Chairman’s NewsletterSeptember

2011

New South Wales Regional Committee of the Royal Australasian College of Surgeons177A Albion Street, Surry Hills 2010 Telephone (02) 9331 3933 Fax (02) 9331 3145

Credentialling process to be more reasonable

Vascular Surgery 2011

Welcome to the September Chairman’s Newsletter. It is of great interest and importance to all public hospital visiting medical officers and particularly Fellows that the credentialing and reappointment process is being reviewed and will become more reasonable. This was a significant recommendation made by Garling SC in his report into the New South Wales health system in 2009.

Professor John Harris has provided an article on the state of vascular surgery in New South Wales.

Professor Denis King is well known and

respected for his achievements and this

is one that will benefit current and future

surgeons.

Professor Cliff Hughes reminds us about

the importance of supervision of junior

medical officers.

As Deputy Chairman of The Collaborating

Hospitals Audit of Surgical Mortality

(CHASM) I encourage all Fellows in New

South Wales to participate in CHASM as

part of our duty to Trainees and patients.

Finally, I report on the important role that

surgeons play as peers and experts.

Dr Joseph Lizzio

Chairman

Vascular surgery has been

represented on the RACS NSW

State Committee since it emerged

as a separate specialty and NSW

Vascular formed as a state based

society under the auspices of the

ANZ Society for Vascular Surgery

(ANZSVS) in 2005.

NSW Vascular continues to run a well attended journal club for trainees and surgeons held regularly during the year, organised by Ramon Varcoe. The inaugural scientific meeting was convened by Alan Bray in Newcastle in 2007 and co-convened there with Bernie Bourke in 2008. The 2009 meeting was held in Wollongong, convened by David Huber and the 2010 meeting held in Terrigal. In 2011 the meeting was again held in Newcastle attracting over 200 attendees and strong trade support. A high-light of

the meeting remains live demonstrations of innovative endovascular techniques broadcast to the conference centre and allowing audience interaction. Holding the NSW Vascular Meetings at a major regional centre has proved to be a successful formula, complementing the contribution

that NSW vascular surgeons make to the annual national ANZ Society for Vascular Surgery (ANZSVS) meetings and to the Annual Scientific Meeting of the Royal Australasian College of Surgeons.

A major innovation was the introduction in 2008 of compulsory participation in a national audit as a prerequisite for a membership of the ANZSVS. This has been broadly embraced by vascular surgeons in Australia and New Zealand with 42,653 operations entered during 2010 by 181 consultants from 179 hospitals. The results to-date confirm the high standard of vascular surgery in Australia New Zealand with the audit emerging as a model for other specialties to consider.

John P Harris AMChairman, NSW Vascular

Vascular Representative NSW State Committee

Inside: Clinical Supervision at point of care – Page 3

Dr Joseph Lizzio

Professor John Harris

Dear Fellows

Credentialling and Appointments

Page 2 RACS Chairman’s Newsletter September 2011

In NSW, Visiting Medical Officer (VMO) arrangements have recently been reformed so as to:

• remove unnecessary paperwork, red tape and bureaucratic processes;

• enhance effective performance review and promote high clinical standards.

In the past the consequence of this situation has been that every 5 years VMOs providing services in NSW public hospitals have been required to re-apply for their positions. These quinquennial appointment processes generated large amounts of paperwork, and took up considerable staff resources. The process was regarded by many VMOs as demeaning and by VMOs and health administrators alike as complex, involved, unduly time-consuming and often relatively pointless, in that more than 99% of all VMOs were reappointed at each round. At the same time, there were concerns that the standards and extent of clinical and performance review of VMO staff were variable across the NSW public hospital system.

The new reforms were designed to address both these issues. Early in 2011, new VMO performance review arrangements were introduced for all specialist VMOs providing services in NSW public hospitals. It is important to note that performance review has always been part of the requirements of a VMO appointment. In the new assessment process the capacity for feedback to the hospital has been added. Under the new arrangements, each specialist VMO is required to undergo a ‘Level 1’ performance review each year. Where a VMO’s performance is assessed by the reviewer as satisfactory, there will usually be no further action needed. Where the reviewer considers that it is appropriate,

further action may be needed, such as an interview.

Every 5 years a more rigorous and comprehensive ‘Level 2’ performance review of each specialist VMO must occur. The new performance review process provide for meaningful review of VMOs, with a focus on key areas of VMO work. Under the new arrangements, the Local Health District Chief Executives are able to reappoint a specialist VMO without advertisement for a further term where:

• the role and responsibilities of the VMO remained largely unchanged since he or she was originally appointed;

• there had been a Level 2 review of the VMO in the two years preceding the expiration of his or her term, and the performance has been found to be such as to warrant renewal without advertisement.

Obviously, when VMOs retire or when departments are expanded, there will be a need to advertise VMO vacancies, but the CE has the option then of advertising only the vacancy, and reappointing the incumbents.

The Credentialling process is also being reviewed. The Garling Inquiry highlighted the importance of the credentialing process in maintaining patient safety and ensuring the integrity of our public hospital system. To achieve this aim, I am currently chairing a Steering Committee established by NSW Health which is overseeing a state-wide credentialing and scope of clinical practice project. At present, credentialing processes can differ from one hospital to another, and the way a practitioner’s “clinical privileges” are defined can also differ from one facility to another. There is uncertainty as to whether an incident that results in a change of clinical privileges at one facility is always picked up by other facilities where the practitioner has an appointment. All decisions about appointment and credentialing will be made locally.

The present state-wide project is developing an information system that aims to overcome these problems. The information system will also contain details about a practitioner’s scope of clinical practice for each facility at which they have an appointment.

Another aim of the information system is to facilitate a practitioner’s credentials being described in a transparent, consistent and meaningful way. Hopefully development of the guidelines will mean that the process of determining reasonable criteria will need to be done only once, and with the relevant group, such as the College of Surgeons, and that there is a greater chance of uniformity across the State. The hospitals will determine what services they will offer, their “role delineation”, and a combination of that and the accepted credentials of the surgeon determine “scope of practice” or “clinical privileges”.

The project is designed to mean that relevant documents related to training and registration need only be presented once, and to that end the system is designed to allow compilation of information for the period of an appointment and from registering authorities where appropriate, so that the same documents don’t need to be presented repeatedly, as does happen at present.

Professor Denis King

Chair of Credentialling Steering

Committee

Professsor Denis King

Diary Dates November 18, 2011

Younger Fellows’ Preparation for Practice Course NSW Regional Office, Sydney

May 6-10, 2012

RACS - Annual Scientific CongressKuala Lumpur Convention Centre, Malaysia

RACS Chairman’s Newsletter September 2011 Page 3

Supervision of junior staff is a key component of clinical training and safe patient care. Effective supervision includes both educative and oversight components and needs to suit the clinical environment and professional groups involved. Currently there is variation across the State and although some models work well, many processes for supervision are not clearly defined or monitored.

The literature indicates clearly that effective supervision, particularly at the point of care, is a key element in improving patient safety.

In the Clinical Excellence Commission patient safety report: “Clinical Supervision at Point of Care”, there were a number of cases identified where deficiencies in clinical supervision contributed to adverse patient outcomes. Contributing factors in RCA reports and Incident Information Management System (IIMS) notifications, which cited issues with supervision, were aggregated and reported.

While it is acknowledged that patient care processes are multifaceted, links were found between sub-optimal supervision and:

• recognition and response to a deteriorating patient

• missed or delayed diagnosis • inadequate treatment• “failure to rescue” when a

complication occurs.

Despite the fact that it was not always possible to identify why senior input was sought late or not at all, the following factors were noted:

• reluctance to seek assistance from a senior clinician, for fear that this may perceived as incompetence

• work practices within the team which influence whether or not assistance is sought. There appears to be a reluctance to contact senior clinicians in some teams

• failure to recognise the need for senior input. Junior clinicians may be “unconsciously incompetent” (Crandall et al 2003) and believe they have the skills to manage the situation. This in turn may result in a

failure or delay in seeking assistance with a clinical problem.

Patients are at risk when clinical supervision is not working well. The important formal educative components of supervision are generally well-structured but:

“Point of care supervision is equally important but takes time, and is best accompanied by a teaching intervention. This benefits long term patient safety not just the immediate outcome for the patient involved”. (comment from a clinician).

A number of recommendations have been made in response to the report. These support the need for changes to work practices, increased emphasis on level of responsibility, and clarity around team and organisation expectations.

The following is a summary of recommendations:

• critically/seriously ill patients are adequately reviewed

• care is reviewed before discharge from emergency department

• new admissions must be seen by the admitting medical officer or senior clinician within 24 hours of admission

• every clinical speciality must have guidelines for point of care supervision by on call clinicians.

• escalation pathways for deteriorating patient should include notification of the admitting medical officer or the consultant

• position descriptions of clinical directors and senior managers must emphasise responsibilities for promoting a safe culture

• position descriptions and visiting medical officer contracts must explicitly outline active clinical supervision requirements

• rostering practices should allow for adequate supervision at the same time as meeting the demands of clinical care and reporting

• ideally as part of providing greater levels of point of care supervision after hours, there should be senior clinicians on duty in selected specialties

• failures in clinical supervision and other failures in safe patient care must be reported and monitored

• all orientation programs must contain information about escalation processes, pathways

• procedures that entail a potential risk to patient safety and which require previous experience should only be performed by staff members who have been credentialed or are under direct supervision

• the Clinical Education & Training Institute’s accreditation standards for prevocational training and supervision policy should be revised to make clear that active supervision is the required standard for point of care supervision of junior doctors in training

• implementation of the “Garling Report” recommendation continues

• consultants must have clear guidelines for junior staff about referrals, which includes protocols related to refused admissions.

Clifford F Hughes AOClinical Professor

Chief Executive OfficerClinical Excellence Commission

Reference

1. Crandall, S.J., George, G., Marion, G.S., Davis, S. Applying Theory to the Design of Cultural Competency Training for Medical Students: A Case study. Academic Medicine 2003. June 2003 Vol 6 pp 588-594.

Clinical Supervision at point of care

Professsor Clifford Hughes

Page 4 RACS Chairman’s Newsletter September 2011

Peers and ExpertsIt is an honour and a privilege to be regarded as a peer and an expert by your colleagues and by other professionals. However being asked to act as a peer or expert carries very significant responsibilities. Experts are often asked to examine patients and give an opinion regarding a disease process or injury, the management and the prognosis. Reports regarding patients may be requested by various insurers such as workers’ compensation, motor vehicle accidents and income protection. Appropriate experts must have the necessary training and experience in the relevant field of medicine to qualify them as competent experts. The expert is expected to carry out a thorough examination of the patient and review the investigations and management. The essential skill is based on medical knowledge and experience rather than on the ability as a writer. Surgeons are often asked by lawyers to provide medico-legal reports in civil claims for compensation where a surgeon is being sued. A plaintiff lawyer must have a medical expert report indicating that the care was below standard to allow the lawyer to file a statement of claim in court. Filing a statement of claim without an expert report critical of the standard of care is a breach of statuary court rules that would expose the lawyer to disciplinary action for unprofessional conduct. The solicitor must sign a paragraph at the back of the statement of claim certifying that there is a reasonable prospect of success in the claim. However, the quality of the report does not have to be very high for the solicitor to be able to comply with the requirements and occasionally inappropriate reports are filed. An appropriate report would be one that is provided by a peer within the same field as the defendant doctor. For example, an emergency physician or general practitioner would not be an appropriate peer to comment on the standard of care provided by a surgeon. An appropriate peer is one that has similar training and experience as the defendant doctor and practices in similar circumstances. A teaching hospital surgeon is not a peer for a rural surgeon.In medical negligence cases the plaintiff must prove on the balance of probability that the care provided was below standard and therefore a breach in the duty of care occurred. A report from an expert is required to address this issue of liability. The plaintiff must also prove on the balance of probability that the breach of the duty of care caused the poor outcome and an expert report is required to address this issue of causation. The expert will be given an assumption of facts, the medical records and copies of reports from other experts. There will be no patient to examine but the whole clinical case will need to be examined carefully so that the expert can understand what may have occurred and will be able to provide

an opinion. This usually involves answering specific questions asked by a solicitor regarding the standard of care or the disease process and treatment. The report’s value and usefulness depend on how well the case is understood and how well the solicitor’s questions are answered. Providing general comment on a medical matters may reduce the report’s relevance to the issues of the case. At a hearing in court it will be the judge who evaluates the evidence presented and determines whether the surgeon may have been negligent. The expert does not have the authority to determine whether negligence occurred.Ideally surgeons who provide medico-legal reports should be well experienced and in active practice or within say 5 years of retirement from active surgery. However, there are many surgeons who provide excellent medico-legal reports long after 5 years from retirement. Often these are reports regarding patients rather than reports in civil actions against doctors. Since only about 5% of civil claims against doctors end up in court, these senior surgeons are most unlikely to ever be cross-examined by barristers. However, in defending civil claims against surgeons most experts chosen by medical indemnity companies would be in active practice or within a few years of retirement.An important and significant role for surgeons is to be asked to be a peer or expert for the Medical Council, the Health Care Complaints Commission (HCCC) or the Coroner. The Medical Council of New South Wales has a list of surgeons who act as experts and peers. These peers look at the conduct of surgeons and provide reports to the Medical Council. They may participate in performance assessments where they will observe a surgeon in practice in the consulting rooms and in the operating theatres and provide a report.The surgeons who act as experts for the HCCC or the Coroner are usually carefully chosen to be appropriate peers as these peers are most likely going to be required to give evidence in court and will be cross-examined by barristers. It is essential that these surgeons have the appropriate training and experience to be qualified as an expert and peer in the relevant field. These experts must be appraised with the facts of the case and the underlying medicine. A poorly prepared expert or a poorly chosen expert will be an embarrassment to the court, to the lawyers and to themselves.It is in this background that on Thursday 25 August 2011 the New South Wales Regional Committee Chairman and the Manager met with the New South Wales Medical Council Executive Officer, Ameer Tadros, and the Medical Director, Dr Jo Hely to review and discuss the list of surgeons that act as experts and peers for the Medical Council. Later on 25 August a similar meeting was held with Kieran Pehm, Commissioner of the Health Care Complaints Commission and Tony Kofkin, Investigation Manager of HCCC to review and discuss the surgeons

that act as experts and peers for the HCCC. In Medical Tribunal matters it is essential that experts are chosen carefully and are appropriately qualified as they will be required to give evidence and will be cross-examined. It is essential that Fellows of the College be prepared to act as peers and experts for other surgeons in order to ensure that high standards and fairness are maintained.

Participation in Mortality AuditsAll Fellows of the Royal Australasian College of Surgeons who are active in surgical practice must participate in mortality audits. All surgeons who operate in public hospitals in New South Wales are expected to participate in the Collaborating Hospitals Audit of Surgical Mortality (CHASM). Some of the large private hospitals in New South Wales will soon be participating in CHASM and eventually surgeons operating in all private hospitals will also be able to participate. All States and Territories in Australia have RACS mortality audits similar to CHASM.

Participation in mortality audits is a mandatory requirement of continuing professional development (CPD) as a Fellow of the College. This requirement is not met by Fellows who participate in other CPD programs that do not contain mortality audits. For example, the Australian Orthopaedic Association (AOA) has a CPD program but it does not include a mortality audit.

The information provided in CHASM forms is confidential and privileged. It cannot be accessed and cannot be used in any action or for any other purpose. The information provided to First Line Reviewers is de-identified. The Second Line Reviewers have access to the medical records but their reports are de-identified and confidential. The identity of the Reviewers is not disclosed to the surgeon submitting the CHASM forms. If a surgeon disagrees with the Reviewer’s report, they can appeal to the Chairman, who will arrange another assessment to further review the reported death. All CHASM reports are also de-identified. The purpose of CHASM is to encourage reflective learning through the feedback mechanism. It also helps monitor trends and systems in order to improve surgical practice and contribute to evidence based medicine. CHASM is not meant to create unnecessary paper trail or attribute blame to surgeons.

Fellows are encouraged to fill in the CHASM forms when the case is reviewed at the hospital morbidity and mortality meeting. This might assist Fellows in filling in the forms and could provide a learning experience for the registrar. Surgical trainees should be involved in filling in the CHASM forms as an essential part of their training as future Fellows of the College.

Dr Joseph Lizzio