The Health Quality Council of Alberta (HQCA) report on the role of physician advocacy (February 2012, part of a larger report that also addressed the quality and safety of care in the ER and cancer surgery in Alberta), included one recommendation directed specifically at the College of Physicians & Surgeons: the CPSA have clearer lines of separation and clarity between the roles, programs, and services of investigations and complaints versus education and support, and improve how it communicates those roes so that they are well understood by its stakeholders.
One of the national committees I sit on is the working group on physician performance enhancement (PPE), formerly known as revalidation. The goal of this committee is to develop a pan-Canadian strategy for physician performance enhancement to assist:
- All practising physicians in identifying opportunities for improvement
- All medical regulatory authorities (MRAs) in identifying physicians who may benefit from focused assessment and enhancement, and
- All stakeholder organizations in identifying their roles and responsibilities in physician performance enhancement
Several years ago the national organization of MRAs (Colleges of Physicians and Surgeons), known as the Federation of Medical Regulatory Authorities of Canada (FMRAC), adopted the following position statement:
All licensed physicians in Canada must participate in a recognized revalidation process in which they demonstrate their commitment to continued competent performance in a framework that is fair, relevant, inclusive, transferable and formative.
PPE, referred to as ‘revalidation’ in the above statement, encompasses both physician assessment and physician enhancement (education and remediation). The framework as it currently exists defines the responsibility of MRAs to:
- Monitor the overall professional practice and quality of care provided by their members
- Ensure physicians engage in regular, structured performance assessments
- Perform in-depth performance assessments on physicians when patient care issues (and not just patient care issues) are identified, and
- Liaise with other stakeholders for advice about and assistance with physicians
The CPSA has a number of these elements in place:
- We require all of our members to engage in CPD through participation in MOC or MainPro (the national CPD programs of the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada respectively)
- We require participation of members in the PAR program (a form of assessment and feedback, sometimes accompanied by structured education or remediation)
- We monitor physician prescribing practices via our Physician Prescribing Practices Program, looking specifically at the prescribing of opioids and other drugs of potential abuse
- We require physicians who reprocess equipment to meet our infection prevention and control (IPC) standards and to undergo an inspection to ensure compliance with our standards
- We conduct peer reviews of physicians whose practice raises sufficient concern as a result of a complaint review or because of the physician’s prescribing practices, or because sufficient concern has been raised by colleagues
- We require physicians to report health conditions that could impair their ability to provide safe patient care and some of those physicians will undergo a comprehensive assessment of their health and the effect it may have on practice
The future direction of the CPSA is to better integrate these various activities in order to give our members more comprehensive feedback about their practices. We’ve also been given direction by Council to ensure that all of our members have incorporated the College’s Standards of Practice into their practices, and intend to integrate that process with our other competence activities. This will start to take shape over the coming months, in consultation with representatives from the profession.
So how does all of this fit with the HQCA recommendation presented at the beginning of this piece? The bottom line is that the College doesn’t offer programs that don’t require some level of compliance. Even the PAR program, a pure quality improvement exercise, has a mandatory component, that being mandatory participation.
Our usual approach is to work collegially with physicians who are identified to have practice deficiencies and learning needs. In most cases the regulatory arm of the College is never seen. For example, a physician whose prescribing practices may be putting patients at risk will be asked to engage with our Physician Prescribing Practices Program. Depending on what we learn from a review of that physician’s prescribing a peer review of the physician’s practice may follow. And, depending on the results of the peer review, the physician may be asked to undergo some focused education or remediation. All of this can happen collegially: deficiencies are identified; the physician undertakes a learning program and makes practice changes; a follow-up review occurs to ensure improvement in practice.
But if the physician refuses to engage or to undertake necessary education or to make required changes to his or her practice, then the regulatory authority of the College will be exercised.
My point is that we will engage only if a threshold is reached. If it’s not important to the CPSA whether the physician changes behavior or not, we’re not going to get involved. But if we see evidence that a practice may be putting the public at risk, then we will carry through to ensure that improvements have been made. Ideally, and in most cases, that happens with the cooperation and consent of the physician. When we don’t get cooperation and a willingness to engage we will use our regulatory authority.
While the HQCA recommendation highlights the separation between our continuing competence programs and our professional conduct (complaints) program, the work we do in the competence arena is all about quality improvement. When possible, we work collegially with physicians. Lasting change is much more likely if the physician accepts the need for change and commits to make improvements. But failure to engage or to make necessary improvements, or frankly unsafe care, will cause us to use our authority to ensure public protection and quality care.
As always, I welcome your feedback below or by email.
Trevor Theman, Registrar