Performance management

Performance concerns may be identified by:

• the GP concerned (self-appraisal)
• a colleague
• the practice employing the GP
• practice staff (eg nurse, reception staff)
• a complaint made by a patient or another individual
• the coroner.

Complaints against GPs may be made to:

• the GP concerned, who should then inform the practice to discuss what action should be taken
• the practice – in this instance, the GP in question should always be informed that a complaint has been made. Depending on the nature of the complaint, it may be
  • addressed directly by the practice. In some situations, where the complaints are of a serious nature, the practice may seek advice or assistance in the matter from someone having more experience, such as their MDO or the RACGP
  • referred to AHPRA or, in New South Wales, the Medical Council of New South Wales under the mandatory reporting regulations
• AHPRA (in all states except New South Wales) – all complaints, or notifications, to AHPRA are triaged and considered by the Medical Board soon after receipt. A significant proportion of notifications are closed with no regulatory action. The remainder are investigated and in that event, the GP can seek assistance with the complaints process from their MDO
• the Medical Council of New South Wales – complaints relating to the conduct, health or performance of a registered medical practitioner or registered medical student are dealt with by the co-regulators, the Medical Council of New South Wales and the Health Care Complaints Commission.

It is important to recognise that complaints against GPs are made for many different reasons and not solely because a clinical error has occurred. This is because the GP’s task is not simply to manage a clinical problem but also to engage with the patient as a person. Interpersonal skills are just as important as clinical skills, with good communication skills and professional behaviour being fundamental to both.

Shortcomings, whether real or perceived, in any of these domains may result in a complaint. Complaints can be made not only by a patient but also by anyone connected to them (a relative, friend or carer), by any health professional involved in the patient’s care or by a health professional that has direct knowledge of the GP in question.

Areas that give rise to complaints

There is very little in the Australian literature about the extent and management of performance concerns in general practice. What is known comes mainly from annual and other reports published by AHPRA. The following are the areas that more frequently give rise to complaints to AHPRA:

• clinical skills
  • communication skills (which are most frequently at issue)
  • prescribing (eg drugs of addiction, off-label prescribing)
  • appropriate documentation
  • informed consent
  • confidentiality
  • privacy
  • patient assessment
  • respect for patients
  • clinical decision making
  • keeping up to date
• professional boundaries, including sexual boundaries.

Possible barriers to identification and notification of a performance problem include:

• minimisation of the problem
• not acknowledging that a problem exists
• uncertainty as to whether there is a problem
• unwillingness to be seen as negative or critical of the GP
• unwillingness or reticence to report
• belief that the problem will resolve itself
• belief that the GP has sufficient insight to self-manage
• fear of repercussion from the GP.

Clinical reasoning

How doctors think and make decisions (clinical reasoning) is a complex process. It entails:

• information gathering
• analysis of the information
• input from the patient
• consideration for context and other pertinent factors
• judgements regarding elements of the gathered information
• decisions regarding diagnosis and management
• evaluation of the outcomes of the decision making.

Clinical reasoning ranges from the simple to the complex. With straight forward, familiar clinical problems, the degree of uncertainty is low and decision making relies primarily on heuristics (medical knowledge, simple actions, learnt schemas such as pattern matching and illness scripts). With problems of greater complexity and problems that are less familiar or new, the degree of uncertainty is greater. Reasoning is more complex, requiring deeper exploration and the use of a greater range of analytical skills. Judgements are also made with respect to probability (the likelihood of one disease occurring over another) and the relative value of individual pieces of information (how relevant it is to the decision making).

Clinical reasoning is facilitated by:

• the GP’s level of clinical knowledge and experience
• the adequacy of the gathered information (history, physical examination, results of investigations and other pertinent information)
• an awareness for what might go wrong (red flags, masquerades, what should not be missed)
• the use of pertinent assessment tools
• advice or assistance from colleagues
• reference to relevant clinical guidelines and evidence-based practice.

Problems with any of the steps in the reasoning process, such as the adequacy of the gathered information, can certainly lead to errors. However, other factors can impact on the reasoning process and must also be considered (refer to ‘Problem definition’, later in this document).

Profiling

The issue of whether it possible to identify doctors who are more likely to make errors is contentious. A particular risk profile has been put forward (Spittal, Bismarck and Studdert 2015 – for full details refer to the bibliography); however, it provides predictability only with doctors for whom a prior complaint exists. According to the profile, the factors associated with increased risk of a complaint being made are:

• type of doctor (GPs followed by surgeons being at highest risk)
• location of practice (rural practice being at higher risk)
• the number of previous complaints (risk increases proportionately to the number of prior complaints)
• the amount of time that has elapsed since the last complaint (short time periods between complaints are probably indicative of a doctor who is risk prone)
• the gender of the doctor (males being at greater risk)
• age greater than 35 years (the risk increases with age).

It should be noted that this profile doesn’t take into consideration a number of other factors that have an impact on errors and complaints. These other factors also highlight the complexity that underlies how errors occur and complaints arise. They include:

• individual as opposed to systemic factors
• multiple co-existing factors
• patient factors such as patient demographics and the complexity of presentations
• solo as opposed to group practice
• doctors who are ‘isolated’ (and not necessarily in the geographic sense).

With regard to the crossing of sexual boundaries – which can cover a range of behaviours – doctor groups that are more likely to offend are obstetricians/gynaecologists and GPs. The risk of offending increases with age, and the doctor who is more likely to offend tends to be:

• a socially isolated, middle-aged man experiencing a mid-life crisis
• well functioning, perhaps even eminent in their field
• someone having unmet emotional needs
• someone who over-identifies with the patient (significant counter transference).

The triggers are generally:

• marital/partner discord
• loss of an important relationship (separation, divorce, death)
• professional crisis
• significant stress
• depression.

The ageing GP has also drawn attention as being more prone to making errors. The following factors have been identified as contributing to increased risk in the older doctor:

• age greater than 70 years
• more than 40 years in practice
• the type of practice (the walk-in practice carries higher risk)
• the percentage of billing outside one's specialty (greater than 30% is suggestive)
• unusual prescribing habits (eg excessive prescribing of drugs of addiction)
• solo practitioner
• concurrent health issues and the nature of the impairment (physical or cognitive)
• processes of clinical reasoning that are not well considered (insufficient use of analytical processes carries higher risk).

Physical and cognitive decline occurs with age and doctors are certainly not immune to this. Memory and thinking processes are affected and they may not be as sharp as previously. Knowledge may not be as up to date as it might and generally, there is greater reliance on experience. While experience does facilitate clinical reasoning substantially, reliance on this, at the expense of analytical skills and higher-order thinking, will increase the risk of errors. The ageing GP cannot afford to ignore signs of cognitive or any other impairment. Concerns that are raised by family, friends or colleagues should be taken seriously and acted on appropriately.

Profiles have their uses but they are not absolute, and caution should be exercised in using them. A profile is essentially a set of characteristics and behaviours. It is far more useful for every GP to reflect on the items in each of the profiles and to consider whether any one of those factors might be placing them or their patients at risk. If that is the case, it is imperative to implement corrective and/or preventive measures. There is nothing to be gained by labelling someone purely because they ‘fit the profile’.

With respect to notifications to AHPRA, and as deemed necessary, AHPRA will conduct an investigation, after which the Medical Board will make a determination. This determination includes:

• the reasons for its decision
• the areas of concern
• any undertaking that the GP has voluntarily agreed to enter into
• the conditions imposed on their practice.

In the case of serious offences, the imposed conditions may entail suspension of practice or deregistration or referral to a criminal court. Conditions on registration are imposed by the Medical Board; however, the Medical Board does not have the powers to de-register a practitioner. Only the relevant Civil and Administrative Tribunal has that power. Most issues do not require such serious measures and will generally entail either one or a combination of:

• completion of an educational program
• undergoing an audit of medical records
• undergoing a period of mentoring or supervision.

The Medical Board may sometimes require the practitioner to undergo a performance assessment when there is significant concern for patient safety. The aim of a performance assessment is to identify any deficits in a practitioner’s performance, so that a plan can be developed to ensure that the practitioner meets the expected standards as well as to protect the public. It is usually conducted by one or more GPs who are not Medical Board members, but who have been approved by the Medical Board and who have the necessary expertise to assess. As a result of a performance assessment the Medical Board may decide to:

• take no further action
• investigate the practitioner further
• refer the matter to a performance and professional standards panel
• impose conditions on and/or accept an undertaking from the practitioner
• require the practitioner to undergo a health assessment
• caution the practitioner
• refer the matter to a tribunal
• refer the matter to another entity (such as a health complaints entity).

While a GP may self-identify, generally, information regarding a performance problem will come from colleagues in the practice, the practice manager, reception staff and patients. The quality of this information can vary. Seeking the GP’s perspective is helpful but will not necessarily answer the question of whether there are performance issues of significance. In this instance, further investigation and perhaps even formal assessment of clinical skills may be required, particularly where there is uncertainty with regard to:

• the issues affecting performance
• the extent/seriousness of the problem(s)
• whether action needs to be taken
• the required action and support.

The individual GP or the practice may be assisted by someone capable of conducting workplace-based assessments to investigate concerns further, adequately define the issues and make recommendations with respect to a Remediation Plan. Assistance from the RACGP may be sought in this respect.

Investigations and assessments should:

• be done in a timely manner
• be done with sensitivity
• be supportive of the GP and the practice
• be fair and reasonable
• use up-to-date procedures
• safeguard confidentiality
• be non-discriminatory.

Assessing professionalism

Professionalism can be difficult to define, especially when individuals and organisations have different notions about what constitutes professionalism. Nevertheless, the Medical Board’s Good medical practice: A code of conduct for doctors in Australia describes the expected behaviour for all doctors practising medicine in Australia. It sets out the standards against which judgements are made when complaints are made about doctors. Every GP has a duty to adhere to these standards and to comply with the professional behaviour policy of their workplace.

When assessing professionalism, it is easier to consider attitudes and behaviours and whether they are in keeping with workplace policy and/or the Medical Board’s Good medical practice: A code of conduct for doctors in Australia. Information about professional behaviour can come from various sources in the workplace such as colleagues (eg doctors, other health professionals), the practice manager, reception staff, patients and critical incident reports. Questionnaires to patients and key individuals, formal multi-source feedback or 360-degree evaluations are useful tools.

Performance appraisals

Performance appraisals and peer reviews are currently not mandated in Australia. They are useful for identifying issues at an early stage. Appraisals can be conducted informally by:

• in-practice tutorials
• case discussion
• random case analysis
• direct observation of consultations
• review of videotaped consults.

These educational tools are very useful for identifying gaps in knowledge and skills and for providing formative feedback. Audits are another useful tool.

Performance concerns may occur in isolation but often occur in combination with other issues. When a concern is raised, it is important to look beyond the overt problem and to identify all issues that are associated and/or contributory. For example, it is not uncommon to find an underlying physical or mental health concern. It is also not uncommon to find a number of co-existing issues culminating in a significant error. Identifying the issues is not always easy because they can be subtle or disguised; in some situations, the GP in question may not want to divulge personal information.

Some concerns will call for more urgent responses than others. Low-level concerns in isolation may seem insignificant but when considered together, they may indicate a problem requiring action. In a team context it is important to consider whether the individual performance problem might be a manifestation of broader team dysfunction.

Figure 2

The four broad areas for performance concerns

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1. Clinical capability (knowledge and skills), for example:

• inadequate training
• lack of engagement with continuing professional development and/or maintenance of clinical skills
• a lapse in clinical skills (eg taking short cuts, overconfidence, prescribing errors)
• not following guidelines
• poor awareness of limitations (eg doing clinical work that is beyond the GP’s level of skill and experience)
• poor communication skills
• clinical reasoning
• patient factors (eg higher needs, greater complexity of medical problems, challenging behaviour).

2. Health and personal issues, for example:

• physical conditions (eg misuse of drugs and alcohol)
• psychological conditions (eg stress, depression, disillusionment, burnout)
• cognitive impairment/deterioration
• personal stresses (eg marriage/partnership break-up and other significant life events)
• financial difficulties.

3. Attitudes and behaviour, for example:

• loss of motivation, interest or commitment to medicine and/or the practice
• poor interpersonal relationships with colleagues and staff
• poor leadership/teamwork skills
• not adhering to regulations (eg AHPRA, the practice)
• probity (eg boundary issues, bullying and harassment, altering clinical records, conflicts of interest)
• criminal behaviour (eg Medicare fraud, theft, assault).

4. Work environment, for example:

• team dysfunction and lack of support
• poor managerial relationships
• interpersonal problems with colleagues and staff (eg harassment, bullying)
• work stresses (eg time pressure, interruptions, inadequate resources, poor working conditions)
• employment and contractual issues
• poor or absent systems and processes.

Possible errors with problem definition include:

• insufficient information
• incorrect or misleading information
• assumptions being made
• inappropriate decisions
• lack of objectivity
• preconceived ideas and bias
• an ill-considered approach.

When a performance concern arises in practice, information will be gathered and considered and decisions made at each stage of the performance management process. It is important to follow practice procedure and not to make decisions hastily. For example, decisions about management should not be made before all the relevant information is available or the problems have been adequately defined. Decisions should also be made with due consideration and fairness. Poor decisions have negative flow-on effects, with potentially disastrous end results. Particular care should be exercised with decision making in instances relating to whether:

• a problem exists
• patients need to be protected
• anything needs to be done about the performance problem
• the concern should be reported to a higher authority (eg AHPRA, the police).

While decision making should not be done hastily, it is also important to act in a timely manner because delays will cause unnecessary distress for the GP in question and uncertainty within the practice. Good documentation is also important.

Once all the issues have been defined, a management or Remediation Plan should be drawn up. All issues, whether relating to clinical skills or otherwise, should be included in the plan. Most Remediation Plans will relate to clinical capability and most will be of short duration. Longer plans and those that relate to serious concerns should generally be prepared and implemented with the assistance of an external expert.

Remediation Plans should:

• be developed in consultation with the GP and any important stakeholders, such as AHPRA or the practice
• be tailored to the 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.

Employers and practices may not have the requisite resources and skills to appropriately manage performance concerns. In that event, advice and/or assistance should be sought from an expert in the field of performance management or the RACGP.

Clinical capability (clinical knowledge and skills)

Various clinical skills interventions are available; however, the following points require highlighting:

• The type of intervention will depend on the cause of the performance problem. If the root cause is not addressed, change is unlikely to occur.
• A well-considered, practically oriented and tailored management plan that addresses all the issues is more likely to be successful.
• The learning environment must be supportive.
• The GP needs to be fully engaged. Possible interventions include:
  • tutorials to address knowledge and clinical skills deficits
  • case discussion, including random case analysis
  • audit of clinical notes and prescribing
  • role-play of clinical scenarios
  • direct observation of consultations with feedback.

Rural and remote locations present their own particular challenges with respect to suitable interventions, how they are to be implemented and the provision of mentorship and/or supervision for the GP.

Health and personal issues

When a clinical capability problem has been identified, consider whether a concurrent health issue exists. It is not unusual for a health problem to be either the cause of the performance problem or the result of it.

Any significant illness, whether physical or mental, acute or ongoing, has the potential to:

• affect judgement or performance
• impact on patient care
• impact (to varying degrees) on self, family and friends, colleagues and work capability.

The health problems that affect performance more frequently are:

• psychological disturbances (eg depression, anxiety)
• substance misuse (eg drug and alcohol misuse)
• physical ill health as a result of stress
• fatigue, jadedness and burnout.

Burnout is a complex syndrome that results from the stresses of daily practice, with heavy workload and time pressures being the predominant factors. Burnout consists of emotional exhaustion, cynicism towards patients and low personal accomplishment (encompassing poor motivation, loss of self-confidence and self-deprecation). Burnout can lead to psychological disturbances and substance misuse. Signs of burnout should immediately raise concerns for patient safety as well as the safety of the affected GP.

Doctors are often reluctant to admit that they have a problem and engaging them is not always easy. In the first instance, concerns regarding a GP’s health and wellbeing should be addressed with the GP, either by the practice or a respected colleague. The GP should be encouraged to seek the necessary help from a doctor and/or psychologist. If they do not have their own GP, they should be encouraged to find one or to contact one of the organisations that provide timely access to medical care for doctors.

It is not appropriate for a GP to have as their treating doctor a friend, colleague, counsellor or psychologist in the practice that they work in.

It may be appropriate for the GP to take time off in order to address their problems, even though they may be reluctant to do so. Rural and remote locations can present particular challenges with respect to taking time off. Referral to AHPRA may be necessary when there is concern for patient safety and the GP does not comply with advice and when the concerns are not addressed.

Rehabilitation

Chronic illness and disability are not contraindications to clinical practice. Once again, patient safety is paramount. Allowances and adjustments can be made so that the GP may function to the best of their ability. Advice and/or assistance in achieving this may be sought from:

• the GP’s treating doctor(s)
• a rehabilitation physician
• an occupational physician
• an allied health professional, such as an occupational therapist or physiotherapist, who has knowledge of the GP’shealth issues and is in a position to advise.

While there is significant overlap between the roles of the rehabilitation physician and the occupational physician, the occupational physician is possibly better positioned to provide independent advice and support for the GP and the practice.

Attitudes and behaviour

Unprofessional behaviour, such as personal grievances and personality clashes, can have a significant impact on the GP’s functioning in the workplace, as well as on the functioning of that workplace. Practices are encouraged to have a professional behaviour policy in place that:

• identifies the expected professional behaviour
• identifies the possible consequences of unprofessional behaviour
• supports the development and maintenance of a culture of professionalism within the practice
• is committed to the early identification of, and response to, professional behaviour problems
• provides suitable mechanisms for monitoring and addressing problematic situations
• provides suitable mechanisms for addressing serious and/or continued breaches of professionalism.

It will be very difficult to manage concerns effectively without a policy that identifies the expected behaviour, including the consequences of serious and/or continued breaches of professionalism.

Work environment and systems

It is not in the scope of this document to provide recommendations for managing issues relating to the work environment; process, systems and other organisational factors; and industrial relations matters, such as employment contract disputes. However, all these issues have the potential to indirectly precipitate a deterioration in performance (either on their own or in conjunction with other problems) and resolution will generally occur by:

• face-to-face discussion between the disputing parties
• a formal mediation process
• seeking legal advice.

Most Remediation Plans will be of short duration (less than two months). Those that are of longer duration should have provision for periodic assessment of progress during their execution. Once the plan has been completed, the outcomes should be evaluated to determine whether they have been achieved and what this means regarding the GP’s continued safety to practise.

Measuring progress or change can be difficult but should be as objective as possible and have consideration for the expected standards of general practice, as well as the scope of practice that the GP is engaged in.

Possible evaluation methods include:

• case discussion
• role-play of clinical scenarios
• direct observation of consultations
• audit of clinical notes and prescribing
• feedback from other doctors in the clinic, the practice manager, reception staff and/or patients
• medical reports from treating doctors and/or psychologists.

When evaluating a remedial intervention, the key questions to ask are:

• Is the GP progressing?
• Is progress sufficient?
• Is the GP capable of achieving the required objectives?
• What further resources are required to assist the GP to achieve the required outcomes?
• Should the GP continue to be monitored and/or supported?

In answering these questions, consideration should also be given to the GP’s:

• level of engagement in the remediation and with the remediator (including such things as attendance on time and acceptance of responsibility)
• ability and willingness to reflect and accept feedback
• degree of insight into the concerns
• ability to apply learnt skills to their work.

Possible outcomes following the evaluation of progress or reassessment of the GP include:

• resolution of the problems/concerns
• the problems/concerns remain the same
• the problems/concerns have worsened.

In the latter two instances, the situation has to be reassessed and decisions made about any further action. If the GP continues to work in the practice, monitoring for possible recurrence of the concerns may also be required.

Prevention is an individual as well as a collective responsibility. It is about maintaining:

• a level of knowledge and skills that ensure safety to practise
• an awareness for situations where things can go wrong
• attitudes and behaviour consistent with professional practice.

The situation is not helped when the GP:

• is defensive, either rationalising or minimising the problem
• doesn’t accept that a problem has occurred
• believes that they have the problem under control (when they don’t).

Having insight is important, as is the willingness to change and improve. Insight is developed by reflecting honestly on one’s practice, objectively evaluating consultations that have not gone as expected, and considering what can be improved and how and what preventive measures can be put in place. Attention to self-care must not be ignored. Anything that impacts negatively on the self only increases the propensity for distraction from what matters, thus increasing the likelihood of errors occurring.

The following are early warning signs to a performance problem. When noted, they should be taken seriously and action taken before the issues escalate and more serious situations arise.

• Behaviour:
  • frequently arriving late and/or leaving early
  • absences from work, frequent and/or unjustified
  • negative interactions with colleagues and practice staff (eg poor interpersonal skills, rigidity of opinions, difficulty reflecting, defensiveness, inability to compromise, counter‑arguing, anger outbursts)
  • paucity of interactions with colleagues and staff
  • signs of impairment (eg mental illness, alcohol and substance misuse).
• Clinical practice:
  • significant knowledge deficiencies
  • significant clinical skills deficiencies
  • serious clinical errors (eg diagnosis, management)
  • deficiencies in ethical behaviour.
• Complaints from staff, patients and others (whether formal or informal and particularly when repeated).

Clearly, these are areas for every GP to routinely reflect on and for practices to assist their GPs with. Early problem identification and intervention is to be encouraged because concerns can be dealt with:

• more readily and with simpler interventions
• potentially before patient safety is compromised.

The profiles that were presented under ‘Problem identification’ are useful as checklists for identifying problematic situations requiring corrective and/or preventive measures. While age‑related impairment is a particular problem for a GP to be mindful of, it is not the only one. Stress, in its many forms, impacts on behaviour and cognition, which in turn increases the potential for errors and complaints.

The supportive measures listed here have been identified as being useful for the ageing doctor to reduce stress and enable analytical thinking. They are useful to any doctor at any stage in their life.

• Working hours:
  • reducing working hours, including after hours work
  • more flexible working hours
  • later starting time and earlier finishing time.
• Work stresses:
  • allocating more time for the patient (to be able to think through the problem without feeling pressured)
  • no double booking of patients
  • taking regular breaks through the day (so that stresses don’t mount up but also allowing time for reflection)
  • scheduling administrative breaks (to catch up with paperwork, make phone calls).
  • using memory aids, checklists and guidelines more readily
• Extra support:
  • seeking opinions, advice and assistance more readily, particularly with presentations that are new or unusual or outside of one’s expertise and what one is familiar with
  • working with others (group rather than solo practice; team work).
• Self-care:
  • attention to health problems
  • addressing constraints that come with age
  • managing stresses outside of work
  • developing non-medical interests
  • having retirement in mind and planning for and transitioning to new roles (education, mentoring, consultancy).

While GPs individually have a responsibility to ensure their safety to practise, practices may decide to develop policies and processes for monitoring and managing the performance of their GPs (eg peer review, performance appraisal). It is important that these policies and processes are:

• fair and transparent
• developed in consultation with the GPs of the practice
• implemented, as far as possible, with the cooperation of the GP about whom a concern exists.

A pro forma for a practice remediation policy is available in Appendix C.

The cases found in Appendix A are commonly occurring scenarios that would raise concern, necessitating investigation and requiring the GP to undergo some form of remedial intervention. They are scenarios for reflection from both a personal and a practice perspective. They may also be used in clinical meetings to facilitate discussion on a range of topics having medico-legal repercussions, to encourage reflective practice, and to improve capability and effectiveness at the individual and practice level.