WORKFORCE CSIRO PUBLISHING
Australian Health Review, 2015, 39, 483–485 http://dx.doi.org/10.1071/AH14222
Perspective
A step towards evidence-based regulation of health practitioners Marie M. Bismark1,4 MBChB, LLB, MBHL, MPH, FAFPHM, FAICD, Senior Research Fellow Martin Fletcher2 BSocStud, BA(Hons), MMan, Chief Executive Matthew J. Spittal1 BSc(Hons), MBio, PhD, Senior Research Fellow David M. Studdert1,3 LLB, ScD, MPH, Professor of Law and Medicine 1
Centre for Health Policy, University of Melbourne, 207 Bouverie Street, Carlton, Vic. 3010, Australia. Email: [email protected] 2 Australian Health Practitioner Regulation Agency, 111 Bourke Street, Vic. 3000, Australia. Email: martin.fl[email protected] 3 Center for Health Policy/PCOR, Stanford University School of Medicine and Stanford Law School, 291 Campus Drive, Stanford, CA 94305, USA. Email: [email protected] 4 Corresponding author. Email: [email protected]
Abstract. In 2010 Australia established a national registration and accreditation scheme, covering more than 620 000 health practitioners. The data held by the Australian Health Practitioner Regulation Agency is a remarkable platform for research aimed at improving health practitioner regulation, health care quality and workforce planning. Received 13 November 2014, accepted 19 January 2015, published online 23 March 2015
Unrealised potential of regulatory data
Australia’s changed regulatory environment
In a recent address to a meeting of leading medical regulators from over 50 countries, Dr Joanna Flynn, Chair of the Medical Board of Australia, urged her colleagues to move from being ‘regulatory philosophers’ to ‘regulatory scientists’.1 Her call followed days of discussion regarding the importance of building regulatory policy on a platform of sound data and evidence-based research. At the meeting’s conclusion, attendees cast their vote for ‘the single biggest opportunity facing medical regulation’; two-thirds of them chose better use of data. The opportunity looms particularly large in relation to the oversight of health practitioners. In many countries, practitioner boards dominate this regulatory space. Although boards sit atop a mountain of data regarding the practitioners they regulate, they have long struggled to unlock its research potential.2–4 The result is missed opportunities to improve healthcare5 and inform debates on pressing policy questions, such as revalidation.6 In Australia, there is a new imperative for more and better use of data to guide regulation of practitioners. Until recently, answers to national-level empirical questions about health practitioners required state-by-state and profession-byprofession data collection, followed by a complex reconciliation process to combine the different sources of information; in practical terms, it was infeasible. That is no longer the case. The introduction of a national scheme of health practitioner regulation in Australia has created unprecedented opportunities for researchers, policy makers and regulators to move towards evidence-based regulation.
Established in 2010, Australia’s national registration and accreditation scheme for health practitioners encompasses 14 professions: Aboriginal and Torres Strait Islander health practice, Chinese medicine, chiropractic, dentistry, medical radiation, medicine, nursing and midwifery, occupational therapy, optometry, osteopathy, pharmacy, physiotherapy, podiatry and psychology. There is a national board for each profession. With support from the Australian Health Practitioner Regulation Agency (AHPRA), the boards undertake a suite of regulatory functions, including assessment for registration, approval of education programs and management of concerns about practitioners. The national scheme’s core mission remains the same as its state-level predecessors: to protect the public from harm.
Journal compilation Ó AHHA 2015
A new data resource A collateral benefit of the move to a national scheme has been the establishment of a comprehensive national dataset on Australia’s registered health workforce, totalling more than 620 000 practitioners. This is a remarkable and underappreciated accomplishment. The dataset has tremendous potential to strengthen research into health practitioner regulation, health care quality and workforce planning. The national scheme collects information from four main sources: practitioners themselves; independent assessors; notifiers (employers, educators, peers and community members who lodge concerns); and the boards and tribunals that adjudicate www.publish.csiro.au/journals/ahr
484
Australian Health Review
M. M. Bismark et al.
those concerns. Specific information is also collected about trainee practitioners. As part of its registration functions, the scheme routinely collects information on a range of practitioner characteristics, including age, sex, profession, specialty, country of training and practice location. Responses to a voluntary workforce survey, which practitioners complete alongside their annual registration renewal, add more detailed information (e.g. practice type, hours worked, career intentions). In addition, for five states and both territories, AHPRA collects and securely houses data on notifications about health, conduct and performance concerns. For each notification, information is collected on the source and nature of the concern, the process followed and the case outcome. New South Wales (since inception) and Queensland (since July 2014) are ‘co-regulatory’ jurisdictions, meaning at least some of their notification data are handled and stored outside the AHPRA framework. Work is underway with both co-regulatory jurisdictions to further joint research and data analysis. For AHPRA the variables described above are securely stored in an electronic database managed by AHPRA. A range of qualitative data, including letters and reports pertaining to registration decisions, also exist as PDF documents linked to each practitioner’s file. Strict confidentiality provisions apply to these data and their de-identification for research purposes. Untapped research opportunities Three features of the AHPRA data make it well suited to research. First, its scope is broad. As a national resource encompassing all major health professions, the AHPRA dataset may be the most comprehensive dataset of its kind anywhere in the world. A second strength is the depth of the data collected: the mix of variables and textual data permit ‘deep dives’ to investigate specific questions using both quantitative and qualitative research methods. A third strength is the availability and quality of ‘denominator’ data, which allow measures of interest (such as disciplinary sanctions) to be calibrated accurately against a relevant baseline population. The AHPRA data is a particularly powerful resource for addressing research questions that intersect with the agency’s core regulatory functions. For example, how is the role and distribution of different subgroups (such as international medical graduates) changing? Which practitioners are at highest risk of attracting patient complaints?7 How successful are interventions that aim to reduce the risk posed by impaired practitioners? Are disciplinary decisions fair and consistent across different groups of practitioners?8,9
Use of AHPRA data in research has been limited to date, due in part to its newness and the need to establish protocols to protect confidentiality, but a body of work is beginning to emerge. Box 1 provides examples of recent or ongoing research projects that draw on AHPRA data.10–12 Limitations to consider A call for greater research use of the AHPRA database should acknowledge its limitations. Some variables lack specificity and others that may be of interest to researchers (e.g. ethnicity) are not routinely collected. The accessibility and accuracy of some data remain imperfect, although this is steadily improving. Coding of data is also constrained by the lack of consensus regarding how best to classify types of adverse events and categories of patient harm.13 Finally, administrative data only goes so far: understanding the ‘how and why’ of workforce needs, or threats to public safety, may require supplementation with additional data sources. Facilitating use and access Presently, data held by AHPRA may be accessed in three ways: by searching the online national register (which, by law, must be publicly accessible); by purchasing a copy of the national register for an approved research purpose; or by lodging a specific data request. AHPRA records contain highly sensitive health and legal information, so ensuring confidentiality is a paramount concern. Where data are not publicly available, access depends on several factors. The work being done must be by approved researchers, subject to study approval from a human research ethics committee and a robust data protection plan that includes an agreed protocol for data storage and destruction. In addition, the research must have a public benefit and comply with all applicable laws. Applications for access to AHPRA data are rigorously assessed by a Strategic Data Access and Research Committee on a project-by-project basis and all successful applicants are bound by a deed of confidentiality.14 Conclusion Australia is uniquely placed to become a world leader in health workforce policy and regulation research. The national scheme has created unprecedented opportunities to explore the distribution, practice patterns and behaviours of Australian health practitioners. For researchers, the use of AHPRA data can be a cost-effective alternative to manually assembling longitudinal data on health practitioners. For AHPRA and the boards, engagement with researchers can provide valuable feedback about data
Box 1. Case studies Notifications Researchers at the University of Melbourne are analysing 850 de-identified mandatory reports received over a 13-month period regarding the health, competence or conduct of registered health practitioners in Australia. The study will help evaluate the impact of mandatory reporting on practitioners and public safety.10 Assessment and intervention Researchers at the University of Sydney are comparing the complaints investigation and management processes undertaken in New South Wales with those of the Australian Health Practitioner Regulation Agency. The project will reveal complainant experiences and inform best practice in resolution processes.11 Discipline An international project, led by the International Nurse Regulator Collaborative, is compiling de-identified data regarding decisions made about registered nurses’ health, performance and/or professional conduct matters. Analysis of these cases will identify possible inter-country trends and issues, as well as potential strategies to address them.12
Towards evidence-based regulation
Australian Health Review
quality, strengthen internal research capabilities and yield research findings of great relevance to regulatory work. And, most importantly, for the Australian public, expanding research relating to health practitioners, and building capacity to conduct this research, are important pathways towards optimising the quality and safety of health care.
5
6 7
Competing interests MMB is the recipient of a research fellowship from the Royal Australasian College of Physicians (RACP). The RACP had no involvement in the preparation of the manuscript or the decision to submit for publication. MF is the Chief Executive of AHPRA. The authors have been awarded an NHMRC Partnership Grant to undertake a 3-year study of ‘hot spots’ of risk among notifications to AHPRA.
8
9
10
Acknowledgements This paper was funded, in part, by a Royal Australasian College of Physicians Fellows Career Development Fellowship awarded to MMB.
11
References 1
2
3 4
Bismark MM. The seven qualities of highly effective regulators. Public health, patient voice, good governance. 2014. Available at: http://mariebismark.com/2014/12/01/the-seven-qualities-of-highly-effective-regulators/ [verified December 2014]. Sparrow, M.K., The regulatory craft: controlling risks, solving problems, and managing compliance. Washington DC: Brookings Institution Press; 2011. Bismark M, Studdert D. Realising the research power of complaints data. N Z Med J 2010; 123: 12–17. Bilton D, Cayton H. Asymmetry of influence: the role of regulators in patient safety. London: The Health Foundation; 2011. Available at: http://
12
13
14
485
www.health.org.uk/public/cms/75/76/313/4484/Asymmetry%20of% 20influence.pdf?realName=OPG2bx.pdf [verified February 2015]. Leape LL, Fromson JA. Problem doctors: Is there a system-level solution? Ann Intern Med 2006; 144: 107–15. doi:10.7326/00034819-144-2-200601170-00008 Breen KJ. Revalidation: what is the problem and what are the possible solutions? Med J Aust 2014; 200: 153–6. doi:10.5694/mja13.11261 Bismark MM, Spittal MJ, Gurrin LC, Ward M, Studdert DM. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. BMJ Qual Saf 2013; 22: 532–40. Elkin KJ, Spittal MJ, Elkin DJ, Studdert DM. Doctors disciplined for professional misconduct in Australia and New Zealand, 2000–2009. Med J Aust 2011; 194: 452–6. Grenyer BF, Lewis KL. Prevalence, prediction, and prevention of psychologist misconduct. Aust Psychol 2012; 47: 68–76. doi:10.1111/ j.1742-9544.2010.00019.x Bismark MM, Spittal MJ, Plueckhahn TM, Studdert DM. Mandatory reports of concerns about the health, performance and conduct of health practitioners. Med J Aust 2014; 201: 399–403. doi:10.5694/ mja14.00210 Beaupert F, Carney T, Chiarella M, Satchell C, Walton M, Bennett B, Kelly P. Regulating health care complaints: a literature review. Int J Health Care Qual Assur 2014; 27: 505–18. doi:10.1108/IJHCQA05-2013-0053 Australian Health Practitioner Regulation Agency (AHPRA). AHPRA annual report 2012: the Australian Health Practitioner Regulation Agency and the National Boards, reporting on the National Registration and Accreditation Scheme. Melbourne: AHPRA; 2012. Reader TW, Gillespie A, Roberts J. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf 2014; 23: 678–89. Australian Health Practitioner Regulation Agency (AHPRA). Data access and research. 2014. Available at: http://www.ahpra.gov.au/ About-AHPRA/What-We-Do/Data-access-and-research.aspx [verified December 2014].
www.publish.csiro.au/journals/ahr
Australian Health Review, 2015, 39, 483–485 http://dx.doi.org/10.1071/AH14222
Perspective
A step towards evidence-based regulation of health practitioners Marie M. Bismark1,4 MBChB, LLB, MBHL, MPH, FAFPHM, FAICD, Senior Research Fellow Martin Fletcher2 BSocStud, BA(Hons), MMan, Chief Executive Matthew J. Spittal1 BSc(Hons), MBio, PhD, Senior Research Fellow David M. Studdert1,3 LLB, ScD, MPH, Professor of Law and Medicine 1
Centre for Health Policy, University of Melbourne, 207 Bouverie Street, Carlton, Vic. 3010, Australia. Email: [email protected] 2 Australian Health Practitioner Regulation Agency, 111 Bourke Street, Vic. 3000, Australia. Email: martin.fl[email protected] 3 Center for Health Policy/PCOR, Stanford University School of Medicine and Stanford Law School, 291 Campus Drive, Stanford, CA 94305, USA. Email: [email protected] 4 Corresponding author. Email: [email protected]
Abstract. In 2010 Australia established a national registration and accreditation scheme, covering more than 620 000 health practitioners. The data held by the Australian Health Practitioner Regulation Agency is a remarkable platform for research aimed at improving health practitioner regulation, health care quality and workforce planning. Received 13 November 2014, accepted 19 January 2015, published online 23 March 2015
Unrealised potential of regulatory data
Australia’s changed regulatory environment
In a recent address to a meeting of leading medical regulators from over 50 countries, Dr Joanna Flynn, Chair of the Medical Board of Australia, urged her colleagues to move from being ‘regulatory philosophers’ to ‘regulatory scientists’.1 Her call followed days of discussion regarding the importance of building regulatory policy on a platform of sound data and evidence-based research. At the meeting’s conclusion, attendees cast their vote for ‘the single biggest opportunity facing medical regulation’; two-thirds of them chose better use of data. The opportunity looms particularly large in relation to the oversight of health practitioners. In many countries, practitioner boards dominate this regulatory space. Although boards sit atop a mountain of data regarding the practitioners they regulate, they have long struggled to unlock its research potential.2–4 The result is missed opportunities to improve healthcare5 and inform debates on pressing policy questions, such as revalidation.6 In Australia, there is a new imperative for more and better use of data to guide regulation of practitioners. Until recently, answers to national-level empirical questions about health practitioners required state-by-state and profession-byprofession data collection, followed by a complex reconciliation process to combine the different sources of information; in practical terms, it was infeasible. That is no longer the case. The introduction of a national scheme of health practitioner regulation in Australia has created unprecedented opportunities for researchers, policy makers and regulators to move towards evidence-based regulation.
Established in 2010, Australia’s national registration and accreditation scheme for health practitioners encompasses 14 professions: Aboriginal and Torres Strait Islander health practice, Chinese medicine, chiropractic, dentistry, medical radiation, medicine, nursing and midwifery, occupational therapy, optometry, osteopathy, pharmacy, physiotherapy, podiatry and psychology. There is a national board for each profession. With support from the Australian Health Practitioner Regulation Agency (AHPRA), the boards undertake a suite of regulatory functions, including assessment for registration, approval of education programs and management of concerns about practitioners. The national scheme’s core mission remains the same as its state-level predecessors: to protect the public from harm.
Journal compilation Ó AHHA 2015
A new data resource A collateral benefit of the move to a national scheme has been the establishment of a comprehensive national dataset on Australia’s registered health workforce, totalling more than 620 000 practitioners. This is a remarkable and underappreciated accomplishment. The dataset has tremendous potential to strengthen research into health practitioner regulation, health care quality and workforce planning. The national scheme collects information from four main sources: practitioners themselves; independent assessors; notifiers (employers, educators, peers and community members who lodge concerns); and the boards and tribunals that adjudicate www.publish.csiro.au/journals/ahr
484
Australian Health Review
M. M. Bismark et al.
those concerns. Specific information is also collected about trainee practitioners. As part of its registration functions, the scheme routinely collects information on a range of practitioner characteristics, including age, sex, profession, specialty, country of training and practice location. Responses to a voluntary workforce survey, which practitioners complete alongside their annual registration renewal, add more detailed information (e.g. practice type, hours worked, career intentions). In addition, for five states and both territories, AHPRA collects and securely houses data on notifications about health, conduct and performance concerns. For each notification, information is collected on the source and nature of the concern, the process followed and the case outcome. New South Wales (since inception) and Queensland (since July 2014) are ‘co-regulatory’ jurisdictions, meaning at least some of their notification data are handled and stored outside the AHPRA framework. Work is underway with both co-regulatory jurisdictions to further joint research and data analysis. For AHPRA the variables described above are securely stored in an electronic database managed by AHPRA. A range of qualitative data, including letters and reports pertaining to registration decisions, also exist as PDF documents linked to each practitioner’s file. Strict confidentiality provisions apply to these data and their de-identification for research purposes. Untapped research opportunities Three features of the AHPRA data make it well suited to research. First, its scope is broad. As a national resource encompassing all major health professions, the AHPRA dataset may be the most comprehensive dataset of its kind anywhere in the world. A second strength is the depth of the data collected: the mix of variables and textual data permit ‘deep dives’ to investigate specific questions using both quantitative and qualitative research methods. A third strength is the availability and quality of ‘denominator’ data, which allow measures of interest (such as disciplinary sanctions) to be calibrated accurately against a relevant baseline population. The AHPRA data is a particularly powerful resource for addressing research questions that intersect with the agency’s core regulatory functions. For example, how is the role and distribution of different subgroups (such as international medical graduates) changing? Which practitioners are at highest risk of attracting patient complaints?7 How successful are interventions that aim to reduce the risk posed by impaired practitioners? Are disciplinary decisions fair and consistent across different groups of practitioners?8,9
Use of AHPRA data in research has been limited to date, due in part to its newness and the need to establish protocols to protect confidentiality, but a body of work is beginning to emerge. Box 1 provides examples of recent or ongoing research projects that draw on AHPRA data.10–12 Limitations to consider A call for greater research use of the AHPRA database should acknowledge its limitations. Some variables lack specificity and others that may be of interest to researchers (e.g. ethnicity) are not routinely collected. The accessibility and accuracy of some data remain imperfect, although this is steadily improving. Coding of data is also constrained by the lack of consensus regarding how best to classify types of adverse events and categories of patient harm.13 Finally, administrative data only goes so far: understanding the ‘how and why’ of workforce needs, or threats to public safety, may require supplementation with additional data sources. Facilitating use and access Presently, data held by AHPRA may be accessed in three ways: by searching the online national register (which, by law, must be publicly accessible); by purchasing a copy of the national register for an approved research purpose; or by lodging a specific data request. AHPRA records contain highly sensitive health and legal information, so ensuring confidentiality is a paramount concern. Where data are not publicly available, access depends on several factors. The work being done must be by approved researchers, subject to study approval from a human research ethics committee and a robust data protection plan that includes an agreed protocol for data storage and destruction. In addition, the research must have a public benefit and comply with all applicable laws. Applications for access to AHPRA data are rigorously assessed by a Strategic Data Access and Research Committee on a project-by-project basis and all successful applicants are bound by a deed of confidentiality.14 Conclusion Australia is uniquely placed to become a world leader in health workforce policy and regulation research. The national scheme has created unprecedented opportunities to explore the distribution, practice patterns and behaviours of Australian health practitioners. For researchers, the use of AHPRA data can be a cost-effective alternative to manually assembling longitudinal data on health practitioners. For AHPRA and the boards, engagement with researchers can provide valuable feedback about data
Box 1. Case studies Notifications Researchers at the University of Melbourne are analysing 850 de-identified mandatory reports received over a 13-month period regarding the health, competence or conduct of registered health practitioners in Australia. The study will help evaluate the impact of mandatory reporting on practitioners and public safety.10 Assessment and intervention Researchers at the University of Sydney are comparing the complaints investigation and management processes undertaken in New South Wales with those of the Australian Health Practitioner Regulation Agency. The project will reveal complainant experiences and inform best practice in resolution processes.11 Discipline An international project, led by the International Nurse Regulator Collaborative, is compiling de-identified data regarding decisions made about registered nurses’ health, performance and/or professional conduct matters. Analysis of these cases will identify possible inter-country trends and issues, as well as potential strategies to address them.12
Towards evidence-based regulation
Australian Health Review
quality, strengthen internal research capabilities and yield research findings of great relevance to regulatory work. And, most importantly, for the Australian public, expanding research relating to health practitioners, and building capacity to conduct this research, are important pathways towards optimising the quality and safety of health care.
5
6 7
Competing interests MMB is the recipient of a research fellowship from the Royal Australasian College of Physicians (RACP). The RACP had no involvement in the preparation of the manuscript or the decision to submit for publication. MF is the Chief Executive of AHPRA. The authors have been awarded an NHMRC Partnership Grant to undertake a 3-year study of ‘hot spots’ of risk among notifications to AHPRA.
8
9
10
Acknowledgements This paper was funded, in part, by a Royal Australasian College of Physicians Fellows Career Development Fellowship awarded to MMB.
11
References 1
2
3 4
Bismark MM. The seven qualities of highly effective regulators. Public health, patient voice, good governance. 2014. Available at: http://mariebismark.com/2014/12/01/the-seven-qualities-of-highly-effective-regulators/ [verified December 2014]. Sparrow, M.K., The regulatory craft: controlling risks, solving problems, and managing compliance. Washington DC: Brookings Institution Press; 2011. Bismark M, Studdert D. Realising the research power of complaints data. N Z Med J 2010; 123: 12–17. Bilton D, Cayton H. Asymmetry of influence: the role of regulators in patient safety. London: The Health Foundation; 2011. Available at: http://
12
13
14
485
www.health.org.uk/public/cms/75/76/313/4484/Asymmetry%20of% 20influence.pdf?realName=OPG2bx.pdf [verified February 2015]. Leape LL, Fromson JA. Problem doctors: Is there a system-level solution? Ann Intern Med 2006; 144: 107–15. doi:10.7326/00034819-144-2-200601170-00008 Breen KJ. Revalidation: what is the problem and what are the possible solutions? Med J Aust 2014; 200: 153–6. doi:10.5694/mja13.11261 Bismark MM, Spittal MJ, Gurrin LC, Ward M, Studdert DM. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. BMJ Qual Saf 2013; 22: 532–40. Elkin KJ, Spittal MJ, Elkin DJ, Studdert DM. Doctors disciplined for professional misconduct in Australia and New Zealand, 2000–2009. Med J Aust 2011; 194: 452–6. Grenyer BF, Lewis KL. Prevalence, prediction, and prevention of psychologist misconduct. Aust Psychol 2012; 47: 68–76. doi:10.1111/ j.1742-9544.2010.00019.x Bismark MM, Spittal MJ, Plueckhahn TM, Studdert DM. Mandatory reports of concerns about the health, performance and conduct of health practitioners. Med J Aust 2014; 201: 399–403. doi:10.5694/ mja14.00210 Beaupert F, Carney T, Chiarella M, Satchell C, Walton M, Bennett B, Kelly P. Regulating health care complaints: a literature review. Int J Health Care Qual Assur 2014; 27: 505–18. doi:10.1108/IJHCQA05-2013-0053 Australian Health Practitioner Regulation Agency (AHPRA). AHPRA annual report 2012: the Australian Health Practitioner Regulation Agency and the National Boards, reporting on the National Registration and Accreditation Scheme. Melbourne: AHPRA; 2012. Reader TW, Gillespie A, Roberts J. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf 2014; 23: 678–89. Australian Health Practitioner Regulation Agency (AHPRA). Data access and research. 2014. Available at: http://www.ahpra.gov.au/ About-AHPRA/What-We-Do/Data-access-and-research.aspx [verified December 2014].
www.publish.csiro.au/journals/ahr
