Joint Conference of

IPAC

&

CPE

4th – 6th September 2014

Druids Glen Resort, Co. Wicklow, Ireland

Raising Concerns About Poor Performance

- Matching Public Expectations and Professional Practice

Paul Kavanagh, Lorna Farren,

Simon O'Hare, & Caroline Spillane, Medical Council of Ireland.

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Overview

• Why we did this piece of work?

• How did we do it?

• What did we find?

• So, what next?

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Overview

• Why we did this piece of work?

• How did we do it?

• What did we find?

• So, what next?

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Safe, high quality care

Good doctors

Good systems

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Responding to concerns

Setting expectations for doctors

Developing and maintaining good

practice

Controlling entry to practice

Good Professional

Practice

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

What is the Medical Council going to do

about this? - Performance

assessment and remediation

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

One or more concerns

Whole of performance

Why did we do this?

• What do the public and doctors think about professionalism – discourse about “what it means to be a good doctor”

• Understand attitudes and behaviours related to “responding to concerns”.

• Inform strategy 2014-2018

• Enhance our role in concern response

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Overview

• Why we did this piece of work?

• How did we do it?

• What did we find?

• So, what next?

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

How did we do it?

• Three consecutive omnibus public survey waves 2011-2013.

• Single doctor survey 2013. - Simple random sample of 2,500 doctors with valid

emails (89%) present survey via online system.

- Response rate was 28%.

• Questions content drawn from work by Roland et al BMJ Qual Safety 2011

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Table 1: Characteristics of respondents to doctors’ survey 2013

Characteristic Survey Responses Annual Retention 2012

Male 61.5% 60.3%

Female 38.5% 39.7%

Mean age (standard deviation) 44.5 years (11.5 years) 45.1 years (12.7 years)

Irish graduates 65.8% 65.1%

Working full-time 80.9% 83.1%

Practising in Ireland only 80.6% 74.7%

Specialist Division 49.1% 44.3%

General Division 36.1% 42.0%

Trainee Specialist Division 13.8% 12.2%

Working in general practice 26.1% 31.0%

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Doctors survey respondents

Overview

• Why we did this piece of work?

• How did we do it?

• What did we find?

• So, what next?

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Trust

Experience

Building blocks of trust

Figure 1: For each different type of people, would you tell me whether you generally trust them to tell the truth or not (% “trust to tell the truth”, 2011-2013)?

91%

88%

85%

80%

76%

75%

75%

62%

58%

58%

44%

42%

42%

40%

18%

92%

89%

78%

70%

77%

64%

76%

52%

67%

53%

37%

35%

41%

40%

15%

88%

79%

72%

61%

63%

71%

64%

50%

41%

45%

25%

32%

37%

27%

12%

0% 20% 40% 60% 80% 100%

Doctors

Teachers

Professors

Scientists

Television News Readers

Judges

The Gardai

Clergymen/Priests

The Ordinary Man/Woman on the street

Civil Servants

Pollsters

Trade Union Officials

Journalists

Business Leaders

TDs

2013 2012 2011

20

14

Join

t Co

nfe

ren

ce o

f IPA

C &

CP

E

Figure 2: How would you rate the experience you have with the doctor that you attend most often, 2011-2013?

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Communication Shared decision

making Confidentiality

Open disclosure Raising concerns Maintaining

competence and quality assurance

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Figure 3: In relation to the doctor you attend most often how confident would you be that ... (very confident and fairly confident combined, 2013)?

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Figure 4a: To what extent do you agree or disagree that doctors should report all instances of significantly impaired or incompetent colleagues to relevant authorities (completely agree %)?

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Figure 4a: “Responding to concerns” versus “safeguarding confidentiality” (% completely agree)

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ireland UK USA

"Responding toconcerns"

"Safeguardingconfidentiality"

Figure 5: In the last 3 years, have you had direct personal knowledge of a doctor who was impaired or incompetent to practise medicine in your hospital or practice?

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

14%

19%

17%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Ireland UK USA

Figure 6: If you did have direct personal knowledge of a doctor who was impaired or incompetent to practise medicine in your hospital or practice, in the most recent case did you… (% Yes – more than 1 option allowable)

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

18%

36%

41%

17%

66%

73%

72%

60%

65%

0% 20% 40% 60% 80%

Stopped referring my patients

Had a personal discussion withthe doctor

Reported the doctor to arelevant individual/body

USA

UK

Ireland

Figure 7: If you did not report the doctor was it because… (% Yes – more than one option allowable)

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

44%

19%

25%

14%

26%

34%

14%

20%

12%

0% 10% 20% 30% 40% 50%

I thought nothing would happen

I thought it was someone else'sjob

I was afraid of retribution

USA

UK

Ireland

What did we find?

• Public expect “responding to concerns” as an attribute of medical professionalism − Expectation varies by concern type.

• “Responding to concerns” is an attribute of professionalism among doctors − but more disputed and some contextual variation.

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

What did we find?

• “Responding to concerns” behaviours among Irish doctors less “patient-centric” − Behaviours vary by context.

• Perception that nothing will happen is a perceived barrier among Irish doctors − Perceptions vary by context.

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Overview

• Why we did this piece of work?

• How did we do it?

• What did we find?

• So, what next?

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

So, what next?

• Good doctors practising in good systems – safe, high quality care

• Professional attitudes & behaviours are shaped by context …. Professional attitudes & behaviours shape context

• Limit focus of medical regulator to individual practice … limit effectiveness

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

Training and practice setting

Healthcare team

Patient-doctor

relationship

Wider political, social & cultural environment

Lesser et al, JAMA. 2010

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

So, what next?

• Informing good practice through defining expectations − Revise Professional Code

• Fostering good practice through education, training and lifelong learning − Oversight of educational bodies and programmes

• Inform and engage on informal and hidden curriculum − Learning and practice environments

− Wider policy agenda

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E

2

01

4 Jo

int C

on

fere

nce o

f IPA

C &

CP

E