Dr Jillann FarmerPeter Last

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Around the World in 18 days The Birth of

• Dr Jillann Farmer Peter Last
• Medical Director Assistant Director
• (With acknowledgement to Dr Craig Margetts the
  Safe Doctors Project)

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Where did CliPSS come from?

• Queensland Health Action Plan
• We willdevelop a state-wide approach to
  clinician individual performance assessment and
  the management of concerns about individual
  clinicians performance
• Queensland Health Systems Review (Forster)
• Queensland Public Hospitals Commission of Inquiry
  (Davies)

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Where did CliPSS come from?

• Safe Doctors Fair System Project
• Developed consensus that a new system for
  management of performance concerns was needed.
• Queensland Clinical Assessment Service
• Initial name of the service when I was recruited
  derived from NCAS
• Clinician Performance Support Service

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What we inherited

• QCAS model very closely aligned with NCAS, but
  not well developed
• First impression NCAS model not best choice
• Culturally
• and complexity (bureaucracy)
• Implementation support

5
Help!

• Initial approach to NSWMB
• Discovered that they had been completely ignored
  in the initial environmental scan
• Backpeddle-
• Stakeholders
• Funders
• NCAS

6
The Decision to Travel

• New to field
• Needed to be able to argue for changed model
  authoritatively
• Stakeholders a bit spooked by the change
• Seek Peer review of proposed hybrid model
• QH PDL and PDA, combined with a very short
  opportunity in run-up
• Picked 6 places to visit, and GO!

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First Stop - Sydney

• NSWMB Program
• Since 2001
• Legislative
• Simple Lean
• Reliable
• Acceptable refereed with NSW stakeholders
• Cultural fit
• Familiar model for some stakeholders

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First Stop - Sydney

• Strengths
• Experience
• Forged through adversity lots of opportunities
  to learn
• Weaknesses
• Regulator vs employer
• Design and recommend remediation but dont have
  responsibility for implementing

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Second Stop - Berlin

• Not actually visiting a program
• This made me think about why
• ?? Is there knowledge in this field in the
  non-English-speaking world?
• Kings College review (Published by NCAS) only
  included anglophone countries.
• ?Future opportunity for learning and growth.

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Third Stop London - HCAT

• HCAT is the leading builder of 360 degree
  feedback tools for doctors in Europe, possibly
  the world
• Validated, discipline-specific tools
• Shefpat and SPRAT are the core tools used by NCAS
• Can design and administer 360 feedback (including
  patient perspective) in web-interface or
  telephone based format.

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4th Stop London - NCAS

• NCAS is the behemoth of PA programs.
• 2006/2007 reporting year
• 691 new requests for advice
• 55 resolved with provision of advice only
• 7 of referrals made in the first six years of
  NCAS operation had become assessment cases by
  mid-2007/08
• Average 40 45 assessments per year
• Takes average of more than a year before commence
  assessment

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4th Stop London - NCAS

• Strengths
• Comprehensive
• High degree of professionalism
• Specifications for just about everything
• Defined competencies for assesees and assessors!
• Weaknesses
• Slow
• Expensive - 100K per assessment case
• Dont re-assess to measure progress
• Starting to get bogged in litigation

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5th Stop London - GMC

• Visited because wanted intell on NCAS from the
  regulators perspective, rather than just
  believing the publicity
• Common origins NCAS team drawn from GMC team
• Initially sought to use NCAS assessments
• Now dont bother litigation too hard
• Run own assessments, so have 2 programs in one
  jurisdiction, a bit like if NSWMB program
  operated in Qld.

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6th Stop Albany

• From the behemoth to the Minnow!
• Almost a cottage industry.
• Attached to Albany medical School
• Part-time activity of faculty
• Like all the US programs, chart and invterview
  based, not practice based
• (relatively) heavy use of standardised patients
  6 such patients
• US Board exams for written
• Oral exam as well chart based.

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6th Stop Albany

• Strengths
• Efficient- 8000 per case
• User pays
• Academic base
• More observation than other North american
  programs
• Weaknesses
• Not core business...more like an interest
• Additional to usual full-time jobs
• No attempt to assess health
• No peer matching just use faculty

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7th Stop Philadelphia - NBME

• My contact for setting up all the North American
  visits
• Co-ordinate the Post-Licensure Assessment System
  (PLAS)
• PLAS is a joint activity of the NBME and the
  Federation of State Medical Boards (FSMB) and was
  developed to assist medical licensing authorities
  in assessing physicians who have already been
  licensed.
• The PLAS provides comprehensive objective and
  personalized assessments of physicians for whom
  there is a question regarding clinical
  competence.

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7th Stop Philadelphia - NBME

• No specific assessments of PLAS run out of
  Philadelphia could not achieve viable business
  model
• Design and administer the Board examinations,
  which are used by many of the assessment programs
• MCQ questions
• Computer simulation cases
• SPEX - The Special Purpose Examination,
  administered by computer, is an objective and
  standardized, cognitive examination of current
  knowledge requisite for the general,
  undifferentiated practice of medicine.
• Target re-entry or ??competence practitioners

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8th Stop - NYC

• End of Week 1 time for A break!
• No performance assessment programs in any of the
  5 boroughs (that I could find)
• A chance for time out and a rest.

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9th Stop Denver - CPEP

• Built out of the Medical Indemnity sector COPIC
• Underwritten by COPIC initially
• Now operating as a going concern
• Run referred PAs for Boards
• About ½ Colorado, about ½ interstate
• Started 1990
• 90 100 assessments per year
• Charge around US 10K per case
• Re-assess for discharge

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10th Stop San Diego- PACE

• Big!!!
• 100 to 120 assessments per year
• Also use microcog, exam questions, simulated
  patients and clinical interviews
• Main difference to CPEP is that PACE is attached
  to San Diego Medical School
• If uncertain about PA, put them into 2nd stage
  which is a week of observation in the unit of one
  of the assessors.
• Have suite of educational products that can be
  purchased

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11th Stop Sydney again

• After visiting all those programs, Sydney (NSWMB)
  was looking pretty good.
• Formal exchange of letters between Qld Government
  and NSWMB
• Share methodology
• Train assessors
• Advice and support
• IT product development
• Luxury of expertise in (mostly) the same timezone.

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CliPSS Purpose

• Improving Patient Safety by Supporting Clinician
  Performance

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CliPSS Scope

• Credentialed practitioners employed by Queensland
  Health where there is a concern about performance
  that is sufficiently severe as to present
  concerns about patient safety

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Systems analysis (RCA) systems corrections
Gap
Clinician Performance
MBQ, ESU, Investigation
Disciplinary Action
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A CliPSS Assessment

• is not focussed on the original concerns, but
  does use them to inform what will be assessed
• is not an investigation into what has happened
• does not result in a guilty or innocent
  finding
• cannot be partially undertaken that is, the
  practitioner cannot choose to have only some of
  the assessments performed it is a total package

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A CliPSS Assessment

• is voluntary
• is a global assessment of performance
• includes a diverse range of information sources
• is focussed on determining whether the initial
  concerns have an underlying cause that could
  result in repeat occurrences
• Is about managing future risk

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The CliPSS Pathway
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Deciding on what cases to refer to CliPSS?

• Consider referral to CliPSS where patient safety
  may be at risk as a consequence of suspected
  clinician performance concerns

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S31 Quality Assurance Committee

• ss31 38 of the Health Services Act 1991
• Qualified Privilege
• Cannot provide information out unless for
  purposes of Committee Improving Patient Safety
  by Supporting Clinician Performance
• Cannot be forced to produce documents or give
  evidence
• Confers indemnity statutory, not IRM.

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S31 Quality Assurance Committee

• Members now identified
• QH staff CliPSS, DM, DOMSAC, CNO, HR
• Medical Representatives AMA, SDQ, QPSU
• Consumer Representatives - 2 nominated by
  community groups
• Application for QAC completed and lodged
• Awaiting Ministerial approval
• Once approved, we open for business.

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CliPSS and the Regulators

• Collaborative relationship with regulators to
  assist them to discharge their statutory
  functions. E.g. Medical Board, HQCC and Coroner
• Although confidentiality is paramount, some
  external notifications are consistent with the
  functions of the CliPSS Quality Assurance
  Committee
• Appropriate reporting arrangements to the extent
  necessary for the protection of the public

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Information provided to MBQ

• Referral into CliPSS and when an assessment was
  ceased
• The outcome of a completed assessment
• Summary of findings to date of a partially
  completed assessment
• Concern that there may be Unsatisfactory
  Professional Conduct wilful, unethical,
  criminal behaviour or deliberate patient abuse
• Impairment as defined in Health Practitioner
  Professional Standards Act 1999
• Risk to the public (for example, if practitioner
  works in the private sector where CliPSS
  initiated modifications to practice cannot be
  implemented)
• If practitioner leaves employment of Queensland
  Health before discharged from CliPSS

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Information provided to Districts

• Two levels of information
• Direct line manager relevant person and get all
  information
• Bound by confidentiality as if were member of QAC
• Same protections as if were member of QAC
• EDMS or DM recieves higher level information
  sufficient to inform decision-making to ensure
  safety and quality of health care services
• Strengths
• Areas for development
• Performance Support

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Planning Performance Support

• CliPSS purpose is to improve patient safety by
  supporting clinician performance.
• The only purpose of the Assessment is to form the
  basis of decision-making
• Are patients being cared for by this practitioner
  safe?
• Is a Support Plan needed?
• What type of Support?

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Planning Performance Support

• If a CliPSS assessment identifies areas of
  practice where support is required
• CliPSS will work with the practitioner to develop
  and implement a personalised support plan, which
  can include
• clinical training,
• communication skills,
• technical knowledge
• workplace conflict resolution.

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Evaluating Performance Improvement

• Reviews will be undertaken at intervals that are
  reasonable with reference to the Support Plan.
• We aim to have these done by the same team who
  formed the PSP until completion, but this may not
  always be possible.

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Evaluating Performance Improvement

• When the agreed goals have been achieved as
  evidenced at re-assessment, the process will be
  completed
• Merely completing tasks will not be sufficient
  there must be a demonstrable change in the
  performance issues that were identified at the
  first performance assessment.

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Having Realistic Expectations

• There is not a 100 guarantee of full return to
  work.
• Outcomes will depend, in part, on the nature of
  the issues (if any) identified, as well as on
  practitioner preparedness to participate in any
  recommended support program.
• Where the process does not achieve full return to
  work, or if the practitioner does not make
  substantial progress at a re-assessment, CliPSS
  may recommend reverting to the formal
  Investigation or HR Performance management
  pathway.

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Safe Doctors
Fair System
Improving Patient Safety by Supporting
Clinician Performance