Policy Reviewing the Clinical Competence of a Doctor or Dentist following Receipt of a Complaint or Concern



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DGD12-042


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Policy

Reviewing the Clinical Competence of a Doctor or Dentist following Receipt of a Complaint or Concern

Policy Statement

Complaints or concerns about the clinical competence of a doctor or dentist (clinician) are to be managed with appropriate attention to the safety of the community, the privacy, rights and well-being of the clinician and the integrity of the Health Directorate (HD) and relevant legislation.

Executive Directors, in conjunction with relevant Clinical Directors, are responsible for the conduct and documentation of the management of complaints or concerns.

Purpose

This policy outlines the guiding principles and approach to the management of complaints and concerns about the clinical practice of a clinician within the HD and Calvary Public Hospital.

This policy is to be read in conjunction with the associated Standard Operating Procedure (SOP) – Reviewing the Clinical Competence of a Doctor or Dentist following Receipt of a Complaint or Concern which outlines the procedures to be followed in the management of a complaint or concern.

Scope

This policy applies to the management of complaints regarding the clinical practice of a clinician appointed within the HD or Calvary Public Hospital. For the purpose of this policy, “complaint” will be used to mean both complaint and concern.

The term “clinician” will be used to refer to junior doctors, senior doctors and dentists. The policy applies to clinicians:


  • with permanent, short or fixed term appointments or contracts, including locums; or

  • appointed on an urgent basis, such as in an emergency or a disaster situation.

This policy does not apply to the management of disciplinary matters (such as underperformance or bullying and harassment) which are dealt with according to the provisions of the Public Sector Management Act 1994, HD Enterprise Agreements and policies.

All staff within the HD must adhere to this Policy and corresponding SOP.



Background

Although use of the term ‘competence’ is generally directed towards technical expertise and practice, a clinician needs a range of additional knowledge, skills and attributes to provide safe and quality patient care including, but not limited to: attitudes and interpersonal skills; ability to communicate with patients and colleagues; ability to work as part of a multidisciplinary team; leadership skills; and knowledge of the health system within which the clinician works.

An essential focus of a competence review is the maintenance of clinical safety and quality, and avoidance of poor patient outcomes.
Making a complaint

Anyone is free to make a complaint about clinical competence (see SOP). Anonymous complaints may not be pursued, although this will depend upon the nature of the complaint made. Initial enquiries will be made to evaluate all complaints and complaints from staff members considered vexatious will be referred to the People, Strategy and Service Branch (PSSB) for consideration of disciplinary action, where appropriate.


Response to complaint

The management of a complaint about clinical competence will have a graduated response dependent on the nature, severity and/or frequency of alleged incidents.


Wherever safe and practicable, and subject to the requirements of any relevant legislation or standards, complaints will be managed without disruption to the clinician’s work pattern.
If necessary, the matter may, however, be escalated to an appropriate forum or scope of clinical practice committee approved under the Health Act 1993 (the Health Act). It is a requirement of employment or engagement with the HD and Calvary Public Hospital that clinicians comply with an appropriately established scope of clinical practice review process.

The CanMEDS 2005 Physician Competency Framework (“the CanMEDS Framework”) is to be used in the assessment of clinical competence (see Attachment 1 to the SOP: Complaints and Concerns regarding the Clinical Competence of a Doctor or Dentist).


In the conduct of competence reviews, the HD will meet all requirements of the Health Act and the Health Practitioner Regulation National Law (ACT) Act 2010.
If the Director-General/Deputy Director-General (Canberra Hospital and Health Services) or a scope of clinical practice committee consider that “the clinical practice of a doctor or dentist at a health facility poses a threat to the safety of members of the public1”, the scope of clinical practice of the clinician may be amended or withdrawn immediately. Salaried clinicians may be required to take leave with pay for the duration of the review.
Principles of review

Any review process is to be managed as expediently as possible, bearing in the mind the need to mitigate the risk of the recurrence of the issue which may have led to the complaint,

and the impact of the process on the clinician and the clinical service. Wherever appropriate, HD will work with the clinician to achieve remediation of any substantiated concerns.
The clinician is to be provided with procedural fairness in the management of complaints about his/her clinical competence. This includes notification in writing of:


  1. The anticipated process;

  2. The nature of the allegation in sufficient details to enable the clinician to respond to it;

  3. The fact that the clinician is entitled to be accompanied by a support person in all formal forums;

  4. The right of the clinician to request a reasonable time to become familiar with any relevant matters (minimum of 24 hours);

  5. The right of the clinician to be given a fair hearing prior to decision-making, and

  6. That the decision will be made without bias and based on evidence.




Evaluation


Outcome Measures

100% of concerns and complaints regarding the clinical competence of a doctor or dentist are managed according to this Policy.


Method

  • All competency reviews will be evaluated on conclusion by the Director of the Medical and Dental Professional Standards Unit, utilising:

  1. A customer satisfaction tool provided to all stakeholders.

  2. A record of duration of the review with explanation of inappropriate delays.

  3. A record of the outcome of the review.

  4. Summary information from each review will be provided at six month intervals to the Quality and Safety Committee.

  5. Close liaison about management and evaluation will be maintained with the Executive Director, Medical Services, Canberra Hospital and Health Services.




Related Legislation, Standards and Policies


Related Legislation

Health Records (Privacy and Access) Act 1997

Human Rights Act 2004

Health Practitioner Regulation National Law (ACT) Act 2010  

Discrimination Act 1991

Territory Records Act 2002

Public Interest Disclosure Act 1994

Health Act 1993
Standards

ACHS EQuIP 5

ACSQHC Standard 1 - Governance

ACSQHC Standard 2 - Partnering with Consumers

Australian Charter of Healthcare Rights

The CanMEDS 2005 Physician Competency Framework. Better Standards. Better Physicians. Better Care. Ottawa, Canada: The Royal College of Physicians and Surgeons of Canada.
Related Policies

Health Directorate Workplace Safety Policy (CED10-040)

Health Directorate Open Disclosure Policy (CED10-008)

Health Directorate Consumer and Carer Participation Framework (DGD11-094 )

Health Directorate Engaging and Consulting with the Aboriginal and Torres Strait Islander Communities in the ACT, The Health Directorate Guide (DGD12-008)

Health Directorate Consumer Feedback Management in the Health Directorate Policy and SOP

Health Directorate Public Interest Disclosure Policy


Definition of Terms


Clinical practice - means the professional activity undertaken by doctors and dentists for the purposes of investigating patient symptoms and preventing and/or managing illness, together with associated professional activities related to patient care.

Clinician – means all doctors and dentists, including interns, resident medical officers, registrars, career medical officers, Fellows, staff specialists and VMOs and does not include nursing and allied health staff. Differentiation of sections applicable to particular staff subgroups is specified in the text.

Competence - means the demonstrated ability to provide health care services at an expected level of safety and quality (ACSQHC, 2004).

Credentials - means the qualifications, professional training, clinical experience, and training and experience in leadership, research, education, communication and teamwork that contribute to a doctor’s or dentist’s competence, performance and professional suitability to provide safe, high quality health care services.

Scope of clinical practice – means the approved extent of an individual doctor’s or dentist’s clinical practice within a particular organisation based on the individual’s credentials, competence, performance and professional suitability, and the needs and the capability of the organisation to support the doctor’s or dentist’s scope of clinical practice.

Vexatious – means without sufficient grounds and serving only to cause annoyance



References




  • The CanMEDS 2005 Physician Competency Framework. Better Standards. Better Physicians. Better Care. Ottawa, Canada: The Royal College of Physicians and Surgeons of Canada.

  • Australian Medical Council Limited Good Medical Practice: A Code of Conduct for Doctors in Australia http://www.amc.org.au/index.php/about/good-medical-practice




Attachments

Standard Operating Procedure: Reviewing the Clinical Competence of a Doctor or Dentist following Receipt of a Complaint or Concern




1 Health Act 1993, Section 66 (1)

Doc Number

Version

Issued

Review Date

Area Responsible

Page

DGD12-042

1.0

October 2012

October 2015

MDPSU

of




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