Medical Board of Australia's new Professional Performance Framework to include mandatory peer reviews and health checks for doctors
The Medical Board of Australia (Board) has designed a new ‘Professional Performance Framework’ (PPF) to maintain and enhance the performance of 110,000 registered doctors. The fundamental principles are to ensure trust and confidence in the medical profession and improve public safety in health care in Australia. The PPF is premised on the recommendations of the Expert Advisory Group on Revalidation (EAG)  and has five pillars :
- Strengthened continuing professional development;
- Active assurance of safe practice;
- Strengthened assessment and management of practitioners with multiple substantiated complaints;
- Guidance to support practitioners; and
- Collaborations to foster a positive culture.
The Board will consult with stakeholders, the profession and the community regarding the five pillars and will implement the PPF in three phases, the first two phases to be completed by 2020 and the third phase consisting of a review and evaluation of the effectiveness of elements of the PPF.
We outline the five pillars below with a focus on the second pillar, which we anticipate will be the most contentious.
1. Strengthened continuing professional development (CPD)
During its consultation phase, the EAG found there was widespread support for strengthening CPD. The PPF is designed not to increase the amount of CPD to be undertaken by doctors, but to make CPD more useful and relevant to doctors and to help them to provide safer care – CPD is to be ‘smarter not harder’.
Doctors will choose an accredited ‘CPD home’ (ie a specialist medical college or alternate CPD provider) and participate in its CPD program, undertaking at least 50 hours per year of CPD activities. Doctors will develop a Professional Development Plan (PDP) for each CPD period which outlines their current scope of practice and documents their individual development needs and the activities they plan to undertake.
Those activities are to include educational activities to develop knowledge and skills (such as lectures, conference attendance and reading), performance review including direct observation by peers in the workplace, peer review of medical records and peer discussions, and measuring outcomes by analysing and reflecting on data about their patients’ health outcomes (eg postoperative infection rates for surgeons). Doctors are to reflect on their CPD activities as they prepare their PDP for the next period.
CPD programs/providers will help doctors to develop PDPs that are tailored to their scope of practice, support remediation of doctors with identified performance deficiencies, share information about doctors who pose a risk to patients with employers and other health sector agencies within an established legal framework, and report to the Board doctors who fail to complete their CPD requirements.
2. Active assurance of safe practice
According to the EAG, it is time for the Board and other stakeholders in the medical profession to take steps to proactively identify, assess and manage ‘at risk’ and poorly performing doctors.
The PPF provides for targeted screening of doctors with risk factors for poor performance. The Board expects that most doctors having those factors will be practising safely and will remain in active practice. Where possible, doctors who have markers of poor performance are to be supported and remediated back to safe practice by practical, proportionate and supportive interventions.
The EAG identified, from international literature and practice, three significant risks to patient safety that should be addressed by the Board: age related risk, doctors who are the subject of multiple complaints/notifications and professionally isolated doctors. We focus here on the first identified risk.
The EAG noted that the medical workforce in Australia is ageing. The total number of doctors over 65 has increased by 80% since 2004, and in March 2017 there were 5,596 doctors aged 70 years or more and 865 aged 80 or more who are registered to practise medicine.
The EAG referred to studies which suggest that doctors’ performance, on average, declines with increasing years in medical practice and that age may be associated with reduced patient outcomes. It referred to evidence indicating that some older doctors experience physical and cognitive decline, which may affect their ability to provide safe care. The EAG noted that in parallel to the changes in the general population ageing doctors may be affected by age related sensory and neurocognitive changes, such as a decline in processing speed, reduced problem-solving ability and fluid intelligence (the capacity to process information and reason), impaired hearing and vision, and decreased manual dexterity.
The Board has accepted the evidence to support the EAG’s contention that the age-related risk of poor performance is strong and that this risk must be addressed to keep patients safe. The Board believes this evidence will continue to grow.
The EAG observed that international regulatory practice designed to address risks to patient safety from poor performance and/or undetected physical or cognitive decline in doctors aged 70 and over includes routine mandatory screening of the performance of doctors over a certain age or length of clinical career, most commonly through multi-source feedback and/or a peer review process . It observed also that there is increasing evidence that regular mandatory health checks, including cognitive screening of doctors aged 70 and over, are necessary to protect public safety by identifying and assessing doctors at risk of undetected poor performance.
The Board plans to require doctors who are providing clinical care to have a formal peer review of their professional performance and a health check which includes cognitive screening at the age of 70 and every three years thereafter. The peer review is to have three core elements: practice observation, medical record review and feedback and discussion. Both the peer reviews and health checks are to be conducted at arms-length to the Board and doctors are to report to the Board their participation in those processes but not the outcomes, unless a serious risk to the public/patient safety is identified. Most remediation to address identified performance issues and most action to address identified health issues to return doctors to safe practice is to be conducted at arms-length to the Board.
The Board proposes to develop a new registration standard related to the health of doctors. It plans to seek legal and clinical advice and consult extensively with stakeholders before proposing the new standard to Ministers.
Over the next 12 months the Board will seek advice on issues, constraints and options for introducing formal peer reviews and health checks, “to establish the legal basis for actively assuring that doctors can continue to provide safe care to patients throughout their working lives” . The Board will collaborate with the profession, specialist medical colleges, medical educators, professional associations, jurisdictions, insurers, the community and other relevant stakeholders to develop and implement models for peer review, and it will commission clinical advice on what constitutes a practical and effective health check, including advice on cognitive screening tools. The Board plans to engage with the Human Rights and Equal Opportunity Commission on these issues.
The EAG anticipated the possibility of “insurmountable legal obstacles” to the implementation of mandatory three yearly peer reviews and health checks for doctors aged 70 and over, recommending that in the event of such obstacles, the Board commission further research to examine the risk of poor performance from doctors in that age group to guide future regulatory practice in Australia concerning the fitness of older doctors .
Perhaps not surprisingly, during its consultation the EAG found the proposal to identify and manage at risk doctors to be contentious, with some individuals unconvinced there is a problem to be solved.
3. Strengthened assessment and management of practitioners with multiple substantiated complaints
Research indicates that approximately three percent of registered doctors account for nearly half of all complaints to the Board. In light of this, the EAG stated that the Board should act to assess potential risks to patients from doctors with multiple complaints. The Board will require practitioners with multiple substantiated complaints to participate in formal peer review of their performance. If performance deficits are found, the Board will request that the results be reported to it together with remediation plans. The Board will work with stakeholders to develop and implement models for peer review of performance.
Although the initial proposal by the Expert Advisory Group was to assess doctors who had three or more substantiated complaints in a five year period, the Board will instead pilot and evaluate the threshold for formal peer review for different areas of practice.
4. Guidance to support practitioners
The Board will continue to develop and publish clear, relevant and contemporary professional standards by revising Good Medical Practice: A Code of Conduct for Doctors in Australia, which outlines the Board’s expectations of doctors. The Board will also refine and develop registration standards and issue guidance where required.
5. Collaborations to foster a positive culture
The Board has a key role in helping to build a strong and respectful culture of medicine that benefits patients and doctors. The Board states that there is a link between patient safety, standards of practice and the health and wellbeing of doctors and therefore intends to:
- Promote a culture of medicine that is focused on patient safety;
- Work in partnership with the profession to reshape the culture of medicine and build a culture of respect;
- Encourage doctors to commit to reflective practice and lifelong learning, take care of their own health and wellbeing (eg by having a regular treating general practitioner) and support their colleagues; and
- Work with relevant agencies (such as Medicare) to promote individual practitioners accessing their data to support practice review and measuring outcomes.
A lot of work to be done
As the Board says, there is a lot to be done before the PPF is fully implemented, some of its elements – no doubt including elements of the second pillar - requiring substantial work. The PPF is, the Board says, deliberately aligned to other work currently under way to strengthen clinical governance and quality assurance and improve patient safety. Clearly the Board has a crucial role to play in the protection of patients from poorly performing doctors.
The Board is to keep the profession informed of the next steps. We wait to hear of these with interest.
 Expert Advisory Group on Revalidation Final Report, August 2017, Medical Board of Australia
 See Building a professional performance framework, Medical Board of Australia
 For example, a requirement for five yearly mandatory peer reviews of doctors aged 70 and over has been in place in Ontario for many years
 Building a professional performance framework, Medical Board of Australia, page 7.
 Expert Advisory Group on revalidation Final Report, August 2017, Medical Board of Australia, pages 15, 22
Anjali Woodford, Special Counsel
Elaine Fabris, Special Counsel