Practice X has a duty of care to the public (patient safety) as well as the GPs working in practice X (GP safety). Consequently, practice X has a responsibility to:
- the standard of performance and behaviour of its GPs
- ensure that every GP understands and complies with their responsibilities
- manage performance concerns regarding its GPs.
With respect to managing performance concerns, practice X’s role is to:
- ensure that processes for performance management are transparent, fair and equitable
- provide a supportive environment that allows performance management to take place without putting patients or the identified GP at risk.
To outline the process for managing performance concerns of GPs at practice X.
- applies to all GPs at practice X, regardless of the terms of their employment
- provides a framework for addressing performance concerns.
Note: With general practice registrars, performance concerns are managed, in the first instance, by their supervisor. Significant performance concerns will be referred to the registrar’s Regional Training Organisation (RTO), but may also require involvement from practice X.
This policy is guided by the following principles:
- the safety of patients and the public
- the needs and wellbeing of the GP
- the integrity of practice X
- the requirement to take a comprehensive approach
- processes that are fair and transparent
- confidentiality for the GP (this need for confidentiality will, however, be balanced against the need to ensure that information is passed to colleagues where appropriate, and patients are properly informed before giving consent to care from a practitioner who has restrictions placed on their practice)
- personal and professional support for the GP and the team that they are working in
- drawing on external expertise to facilitate processes and ensure better outcomes for all.
Managing underperformance is also termed ‘remediation’. It is a process that begins with identifying a concern, followed by investigation, assessment, decision making and, finally, implementing a management plan. A range of possible interventions, or remedial activities, may be implemented, from simple advice and support through to formal supervision and retraining. These interventions encompass:
- reskilling or retraining: the process of addressing deficits in knowledge, skills and/or behaviours to enable the GP to practise safely
- rehabilitation: the process of supporting the GP with ongoing health issues and/or disability to
- surmount the difficulties that hinder them from practising safely
- assist with making adjustments in the workplace to enable them to practise safely.
Once a performance concern is identified, assistance from various individuals or agencies may be necessary at any or all stages of the performance management process. Those who may be involved in the performance management process include the following.
The governing body of practice X (practice principal/chief executive/board of directors):
- has overall responsibility for ensuring that identified cases of underperformance are properly managed
- leads the performance management panel, but delegates these responsibilities to an appropriate person when there is a conflict of interest
- nominates the members of the performance management panel
- convenes discussions regarding performance concerns with the performance management panel
- obtains advice and/or assistance, as relevant, from AHPRA, the RACGP, practice X’s MDO and experts in performance management.
The performance management panel:
- is responsible for managing identified performance concerns
- makes decisions regarding performance concerns
- comprises the governing body (or their representative), the practice manager and a GP of the clinic.
The practice manager:
- is responsible for ensuring policy implementation and compliance
- is responsible for enabling the early identification of performance concerns
- refers concerns about patient safety directly to the governing body
- participates in discussions regarding performance concerns
- may participate as a member of the performance management panel.
The GP is responsible for ensuring their safety to practise. The onus is therefore on the GP to:
- continually reflect on their practice
- maintain the required level of knowledge and clinical skills appropriate to that practice (prevention)
- demonstrate that any identified performance concerns are addressed and resolved.
The GP may also be called on to assist:
- as a member of a performance management panel
- the identified GP in a supervisory, mentoring and/or educational role.
The clinical supervisor (a suitably experienced GP from within the practice):
- is a doctor in the practice who may be asked to supervise a GP about whom there are performance concerns. Supervision may be formal or informal and will depend on the context that assists the GP with their learning plan (development and execution)
- monitors the GP’s progress
- reports to the governing body and makes recommendations about the GP’s progress and any concerns they may have
- evaluates the outcomes of the Remediation Plan.
- provides personal support
- challenges and promotes the development of reflective skills.
Mentoring is a developmental process whereby a more experienced GP (‘mentor’) helps a less experienced GP (‘mentee’) in their personal and professional development.
The mentor does not have to be from practice X and may be of the identified GP’s choosing.
The assessor/investigator (an external expert having experience with remediation and assessment of clinical skills):
- ensures they are clear about their decision making and any recommendations they make with respect to a Remediation Plan
- assists practice X to
- investigate performance concerns
- assess the clinical skills of GPs and identify deficiencies
- make a determination as to the GP’s safety to practise
- make recommendations for addressing the performance issues
- evaluate the outcomes of the Remediation Plan.
The medical educator (has experience in medical education and remediation):
- assists in the investigation and assessment of performance concerns
- delivers and monitors Remediation Plans
- assists in evaluating the outcomes of Remediation Plans.
Occupational health and rehabilitation services assist when there are concerns regarding the identified GP’s health. Referral to such specialist services may be necessary when adjustments or modifications need to be made in the workplace to assist the identified GP in their practice.
AHPRA must be notified (under legislation) when there is serious concern regarding patient safety. Practice X may have a role in supporting the GP with respect to any determination made by AHPRA.
Practice X’s performance management process
A GP’s clinical capability may be brought into question in the following circumstances:
- concerns expressed by colleagues, staff or students
- complaints made by patients, relatives or carers
- anonymous complaints/allegations
- investigation into a critical incident
- information provided by AHPRA
- information provided by the police
- court decisions
- information provided from other sources regarding clinical capability
- the GP seeks to return to work after a sustained period of absence (from either illness, disability, suspension or deregistration).
All allegations or concerns will be investigated and appropriate action taken; this includes action with respect to vexatious complaints.
Concerns about the capability of general practice registrars are primarily a training issue involving the registrar’s supervisor and the RTO. However, practice X may also be involved in managing the performance concern.
The governing body will decide the appropriate course of action in the first instance for each case. The governing body may delegate authority, as appropriate, after considering the details of a particular case and any conflicts of interest. All concerns will be investigated by the performance management panel, as appointed by the governing body, in a timely manner.
Advice and/or assistance may be sought from external parties, such as the RACGP or an expert in the field of remediation.
A meeting will be convened, as soon as practicable between the performance management panel and the GP about whom the performance concerns have been raised, to discuss the concerns and the appropriate course of action. The GP may nominate a support person to attend that meeting.
Possible outcomes of an investigation are:
- no cause for concern
- concern exists and needs to be addressed (a Remediation Plan will be formulated)
- concern exists but needs to be further investigated or assessed for it to be managed appropriately.
With concerns of a serious nature, the following may apply:
- notification is made to AHPRA
- the GP is stood down from practising at practice X.
With notifications to AHPRA, AHPRA will conduct an investigation and make a determination that includes the reasons for its decision, the areas of concern, the undertaking that the GP is to comply with, and any conditions imposed on the GP’s practise. Practice X may have a role in supporting the GP regarding any determination made by AHPRA.
A performance assessment may sometimes be required when there is uncertainty as to the adequacy of the identified GP’s clinical skills. Practice X will be guided on the need for such an assessment by an expert on performance management. The aim of a performance assessment is not only to identify any deficits in a practitioner’s performance, but also that a suitable management plan be developed to assist the GP in attaining the expected standard.
Management plans will:
- be developed in consultation with the identified GP
- be tailored to the identified GP’s needs
- address all the concerns
- have clear objectives
- have a set time frame
- have provision for evaluation of the outcomes
- have defined actions with respect to the outcomes.
Practice X is committed to support the identified GP throughout the implementation of their management plan.
The outcomes of the management plan will be evaluated upon its completion. Possible outcomes include:
- resolution of the problems/concerns
- the problems/concerns remain the same
- the problems/concerns have worsened.
In the latter two instances, the situation will be reassessed and a decision made about further action, including whether the GP should continue to work at practice X.
Practice X may be assisted with the evaluation by an expert on performance management. Evaluation will take into consideration:
- the GP’s progress and whether it is sufficient
- whether the identified GP is capable of achieving the required objectives if progress has not been sufficient
- whether the GP will require further assistance.