S

Increasing medical professional accountability:

the benefits and costs of regular practice review

Katharine Wallis RNZCGP conference, Christchurch, 25-27 July 2014

Background

S High-profile medical scandals in recent years have lead to

calls for increased medical professional accountability.

S In response in 2011 the Medical Council of New Zealand

released its policy on regular practice review (RPR), making

regular practice review compulsory for doctors on the

general register and optional but encouraged for doctors on

the vocational register.

What is regular practice review?

S A supportive and collegial review of a doctor’s practice by a peer/s in the doctor’s usual practice setting (MCNZ)

S RPR is a formative, interactive process:

S 1 or 2 reviewers (peers) over 1 or 2 days

S Review CPD activities – PDP, CME, audit, peer review, collegial relationship

S Observe consultations / procedures

S Multisource feedback & interview colleagues

S Records review & case based discussion exploring clinical reasoning

S +/- Review of prescribing and lab test reports

S Constructive feedback

Purpose of RPR

1. Primary purpose is to maintain and improve standards S by facilitating doctor’s professional development

S helping doctors identify areas of performance for improvement

2. May also assist in the identification of poor performance S structured remediation plan

S referral to Medical Council for performance assessment

3. May help to allay public concern about the adequacy of medical professional regulation S More robust recertification programmes help to ensure all practising doctors are

competent and fit to practice

The unknown

The costs and benefits of RPR are not yet fully understood

S Does RPR help to maintain and improve standards?

S Does RPR help to identify performance issues?

S What are the costs?

S (Does RPR help to improve trust & allay public concern or

does it increase distrust?)

Aim

S To explore the costs and benefits of Inpractice RPR

S Potential costs

S Doctor time & money (cost & access to care)

S Doctor stress /anxiety (quality of care)

S Potential benefits

S Help doctors to identify learning needs, prompt change, foster

reflection & self-care (quality of care)

S Help reviewers to identify performance concerns (safety)

Method

S Online survey:

S Inpractice doctors and reviewers, first 27 RPR visits

S Costs & opportunity costs

S Anxiety / stress

S Learning needs identified

S Changes prompted

S Self-reflection & self-care

S Identifying poor performance

Findings

S 27 doctors (100% response rate)

S 21 reviewers / peers

Cost of RPR visit

S No extra charge to doctors for Inpractice RPR visit

S Inpractice annual membership fee $1200 + GST

S paid by DHB or passed on to patients

Opportunity costs Doctor-patient contact time / consultations

Doctor-patient contact time foregone for RPR

Hours (total) Hours

per RPR visit

Consultations

per RPR visit

Doctors (27) 77+ 2.9+ 11.6+

Reviewers (21) 48+ 2.3+ 9.2+

Doctors +

reviewers 125+ 5.2+ 21

21 consultations foregone per RPR visit x 400 RPR visits per year

= 8400 doctor-patient consultations per year

Anxiety / stress doctors

Utility of RPR visit doctors

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Identifying changes

to make

Identifying areas for

improvement

Reminding re self-

care

% D

oct

ors

Very helpful

Quite

Somewhat

A little

Not helpful

Value of RPR tools to help identify learning needs

Learning & changing

S Will try to become a little more patient centred

S Learnt some useful new tools with Medtech

S Attention to better record keeping

S Follow-up of referrals

S Asking for a chaperone

Made changes following RPR visit

Doctors Reviewers

Self-care

S I openly discussed a health problem ... I have been able to decide to reduce my overall hours as part of my self-care. It was good to talk about that.

S We had a frank and open discussion

S Will focus a little less on clinical targets and a little more on self-care

S More breaks, better time management

S Not to double-book appointments, or when patients are double-booked get nurses to triage them

Performance concerns

Utility of RPR visit according to reviewers

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Identifying areasfor improvement

Assuring on-going competence

Identifyingconcerns about

performance

Identifyingconcerns about

professionalconduct

Identifyingconcerns about

health

Very helpful

Quite

Somewhat

A little

Not helpful

Summary of findings: RPR …

Benefits

S Helps doctors identify learning needs

S Prompts change in practice

S Fosters reflection & self-care

S Helps to identify performance concerns

S Not especially stressful

S Increases med prof accountability

Costs

S Adds to the cost of delivering

health care

S Takes doctors away from patients

(access to care)

Questions

S Doctors seem to find RPR useful, but are patients any better

off ?

S Is RPR the best way to ensure all practising doctors are

competent and fit to practise?

S Do we need increased medical professional accountability?

How much are we prepared to pay for it?