Analysing Data for Risk-Based Regulation In Nursing & Midwifery and other Health Professions.

Introduction Who we are Opportunities for new approaches What we needed to learn What we have put in place How we apply it What’s next? Some advice…

Who we are

Australia 23 million people Federal system of government 9.3% of GDP on health Joint government funders 70% public – 30% private mix Good health status overall Major gap for indigenous health Mal-distribution of heath workforce Significant international workforce

Major Consolidation Eight State & Territory based arrangements More than 95 health profession boards 75 Acts of Parliament 38 regulatory operations 1.5 million data items from 94 sources One national scheme 14 health profession boards Nationally consistent legislation (largely) One national organisation (AHPRA) National on-line registers

What we do AHPRA works with the 14 National Health Practitioner Boards to: Set professional standards Register practitioners Maintain national registers Manage notifications Accreditation

Objectives of legislation Protection of the public Workforce mobility within Australia High quality education and training Rigorous and responsive assessment of overseas trained practitioners Facilitate access to services in accordance with the public interest Enable a flexible, responsive and sustainable health workforce and enable innovation

Harmonising Registration Standards Criminal history English language requirements Professional Indemnity Insurance arrangements Continuing Professional Development Recency of Practice Codes and Guidelines Advertising Mandatory reporting Conduct

The diverse nature of the professions ProfessionRegistrants ( ) Proportion of total registrants Notifications ( ) Proportion of total notifications Medical103,13316%4,54154% Nursing and Midwifery370,30358%1,80722% Psychology32,7665%4325% Pharmacy29,0145%4906% Dentistry21,2093%7669% - Other Boards80,79312%3904%

Patient safety and workforce: driving reform of regulation

Opportunities for new approaches

Lessons from the UK Professional Standards Authority Harry Cayton, CEO UK Professional Standards Authority Be clear on the problem Quantify the risk Pay attention to unintended consequences Keep it simple

What we needed to learn

What would Malcolm say? Prof Malcolm Sparrow Detect patterns Understand the problems Develop regulatory solutions Implement solutions Measure effectiveness Tell people about it

Collect information on harm in a systematic manner, and then identify hotspots of risk that are amenable to a regulatory response.

Reducing rule-breaking vs Reducing harm Compliance based Harm based

The value of harm information “Conclusion: Systematic reviews compound the poor reporting of harms data in primary studies by failing to report on harms or doing so inadequately.” Liliane Zorzela, ‘Quality of reporting in systematic reviews of adverse events: a systematic review’ BMJ, 8 January 2014 “[Health] …complaints have considerable sentinel value: for every adverse event complained of, dozens more lie below the waterline.” Marie M Bismark, David M Studdert, ‘Realising the research power of complaints data’, New Zealand Medical Journal,

What we have put in place

AHPRA’s Regulatory Principles While we balance all the objectives of the National Registration and Accreditation Scheme, our primary consideration is to protect the public. In all areas of our work we: identify the risks that we are obliged to respond to assess the likelihood and possible consequences of the risks, and respond in ways that are proportionate and manage risks so we can adequately protect the public When we take action about practitioners, we use the minimum regulatory force to manage the risk posed by their practice, to protect the public. Our actions are designed to protect the public and not to punish practitioners.

NRAS Risk-based Regulation Unit To reduce harm to the public and facilitate safe workforce reform by increasing the use of data and research to inform policy and regulatory decision-making. Moving from a reporting system to a learning system. 20

Using analysis to inform risk-based regulation 1.Quantitative analysis to detect patterns 2.Semi-quantitative analysis to identify issues and themes 3.Case reviews & qualitative methods to understand the problems

Which of the following should be the greatest influence on the regulatory actions of a risk-based regulator? a)The characteristics of high-risk practitioners? b)The patients who are most at risk of harm? c)Which health care settings create the greatest risk? d)Which procedures create the greatest risk?

How we apply it

Key Questions DescriptiveCan we create clear, comprehensive, accurate and timely risk profiles for each health profession? ConsistentAre our regulatory responses consistent across jurisdictions, years and professions? PredictiveCan we predict which practitioners and situations are more likely to cause harm? ResponsiveWhat are the best right touch responses to the hot spots of risks that we identify? EffectiveAre our regulatory responses effective in reducing harm to the public?

Predicting Risk

Taxonomies & Classifications

Examples from risk analysis The proportion of nursing notifications relating to Health Impairment is 4.9 times higher than for all other professions combined. Approximately 10% of all notifications about nurses and midwives result in immediate action. The likelihood of a practitioner originated notification resulting in a caution or reprimand is 1.5 times higher than for a patient initiated notification.

Qualitative analysis on boundaries Professional boundaries fall along a spectrum from under- involvement and neglect to over-involvement all the way to sexual assault. Our data systems seem to be better at capturing the over- involvement end, and these are easier to deal with. An analysis of ‘under-involvement’ cases suggests concerning potential for risk of harm to patients In some cases the regulator only became aware after a pattern of behaviour not dealt with in the workplace In some cases, regulatory action can be an effective tool to change behaviour 30

What’s next?

Future Core Focus Frequently reported practitioners Increased risk of notifications with age Identification of factors most associated with patient harm Risk associated with overseas trained practitioners Evaluating impact of practice restrictions

Regulatory topics for NMBA National Health Impairment: Referral, treatment & rehabilitation services for health professionals How continuing competence is/can be defined & assessed Exploring factors related to nursing & midwifery medication management & prescribing Review of code of conduct and guidelines on professional boundaries Development of new model of IQNM assessment The role of accreditation in risk based regulationhttp://ecommerce.dent.unimelb.edu.au/produc t.asp?pID=91&cID=36http://ecommerce.dent.unimelb.edu.au/produc t.asp?pID=91&cID=36

Some advice…

Reporting → Learning → Action...moving beyond traditional regulatory levers Regulator Registration and notification processes Employers Professionals Educators Accreditation Authorities Awareness raising and advice to employers Registration Standards, codes and guidelines Tools for educators and students Accreditation Standards and processes Escalation of professional responsibility

Lessons Learnt Be clear: are you a risk-based regulator? Set realistic expectations Requires new/different skills Partner with external researchers Data classifications and taxonomy essential Will always need subjective, qualitative Close the loop – response system is more important than the reporting system

Contact Information Australian Health Practitioner Regulation Agency Martin Fletcher, Chief Executive Officer Michelle Thomas, Executive officer – dental Nursing and Midwifery Board of Australia Veronica Casey, Practitioner Member Dental Board of Australia Dr John Lockwood (AM), Chair