By Dr Clare Morgan and Dr Rob Hendry – 12th December 2022

Dr Clare Morgan, Medical Director at Cognitive Institute, and Dr Rob Hendry, Medical Director at Medical Protection, discuss the options open to independent sector providers to engage clinicians, manage risk and ensure high levels of performance

As an international organisation, supporting healthcare providers in multiple markets, Cognitive Institute is in a privileged position to observe trends in the provision of healthcare. For many years we have observed that, in some parts of the world, there has been a trend to employ clinicians to deliver care within the independent healthcare sector.

There are many factors driving this trend. However, one major theme is a desire to achieve consistently high levels of professionalism, engagement and performance across all clinicians. Crucially, several key events have demonstrated the potential for poorly performing clinicians to continue operating in silos in the absence of a direct employment relationship.

Employment is certainly an option. But for many organisations, employing clinicians is something they either do not have the capacity for, or they lack the expertise to do so effectively.

It is no surprise therefore that there is also considerable interest as to whether direct employment of clinicians is the only way to achieve the highest level of engagement and performance.

The simple answer is no. Healthcare providers can successfully engage medical clinicians – and ensure consistently high levels of professionalism and performance – without employing them.

This, however, requires purposeful leveraging of your organisation’s accreditation, credentialing, and scope of practice determination processes.

Credentialing and accreditation

Credentialing and accreditation processes are the types of agreements and contracts that are used to enable a private practitioner to work with a private healthcare organisation.

Previously, many organisations might have been inclined to treat accreditation and credentialing as a tick-box exercise, where a doctor’s registration and indemnity or insurance were checked and little else.

While registration and indemnity are essential foundational elements and are the starting point for good risk management practices, the whole process of credentialing and accreditation can be much more than a tick-box exercise. If done well, this process allows for transparent conversations that build trust and respect and, ultimately, help to reduce risk for an independent healthcare provider and support better outcomes for patients and staff.

Building from the compliance-driven, foundational steps are additional value-adding elements that healthcare providers can focus on, to create robust processes and opportunities for transparent conversations that build trust and respect.

Broadly, these can be phased through an onboarding period, probationary period, and then ongoing monitoring.

Onboarding period

Onboarding is a time for orienting to various policies and procedures, meeting members of various clinical teams and peers, and having candid respectful conversations about behaviour expectations. As well, it is an opportunity for completion of mandatory or essential learning such as infection control, hand hygiene, basic life support, fire safety, graded assertiveness, and speaking up. ‘Speaking up’ communication training is particularly helpful in ensuring the new practitioner understands the organisational language and processes used when there are concerns about safety.

Probationary period

The probationary period is a time for careful monitoring for any variation in practice and behaviour. The 6-12 month period post-employment is critical. If there has been deliberate behaviour modification to achieve accreditation with your organisation, then this cannot be maintained indefinitely, and is likely to manifest after this time. Evidence from the HR literature suggests that inability to receive feedback or be coached in response to variant behaviour or practice is notably correlated with increased likelihood of an individual leaving an organisation.

Ongoing monitoring

Following the initial probationary period, monitoring for behavioural and/or practice variation is essential. Such variation could come to your organisation’s attention through a range of channels, including patient complaints, co-worker reports, clinical data, or operational data such as late operating theatre start times Variation, or so called ‘red flags’, needs to be transparently and respectfully queried and responded to in a timely manner. Accountability systems such as the Vanderbilt Promoting Professional Accountability (PPA) programme delivered under license by the Cognitive Institute provides training for peers and leaders for the different types of conversations to be had in response to circumstances where there are reports of variant professional behaviour and/or clinical practice.

Not just claims – also be mindful of complaints and unprofessional behaviour issues

As part of both credentialing and ongoing monitoring of visiting doctors, all organisations will encounter medicolegal issues, complaints and claims. In their career, doctors on average will have relatively few claims. However, rather than focussing on the occasional large claim, there is much to be gained by considering the more frequent low-level complaints or behavioural issues.

We know that what are sometimes seen as minor complaints about doctors’ behaviours, attitudes, and their communications styles with patient and colleagues, can sometimes be harbingers of more serious underlying risk.

Indeed, research undertaken by the Vanderbilt University Medical Centre has found that ‘the same 3% of physicians who account for 50% of the malpractice risk also accounted for 35-40% of unsolicited patient complaints’.

There is also a correlation between co-worker reports of unprofessional behaviour and an increase in surgical and medical complications. In a study published by Cooper et al in 2019, the adjusted complication rate was 14.3% higher for patients whose surgeons had one to three co-worker reports in the three-year period prior to the surgery compared with patients whose surgeons had no co-worker reports.

The Vanderbilt PPA programme champions open and timely discussion of feedback from colleagues and patients with the doctor.
In 78% of situations, doctors will usually self-correct their behaviour after it is flagged to them that their actions are out of step with colleagues. The PPA results also suggest that, where an intervention is made, the physician can reduce their medical malpractice risk by 75-85% in some cases.

Self-reporting and building a full picture

In more serious cases, it is important that healthcare providers have clear protocols for when they require doctors to self-report incidents. The development of the revalidation process and the Responsible Officer role can help to improve transparency, which is crucial to mitigate risk.

A failure to share concerns or avoiding taking responsibility to follow a case to conclusion can mean potentially significant issues or indicators can go undetected. One of the key learning points from the Paterson case was that the NHS needed to be faster both in terms of its speed of reporting and speed of taking action.

Only by having full visibility of a clinicians’ practice can we protect patients and the providers caring for the patients. If organisations work in silos, high risk clinicians can move from provider to provider undetected until a serious incident occurs. Information sharing between Responsible Officers is central to this. The need for adequate training and support of Responsible Officers has been recognised in a number of recent reports.

Where private providers use clinicians that also work within the NHS, it is vital to collaborate with the Trust’s Responsible Officer, in order to build a full picture of performance, conduct and behaviour of their team.

Having the challenging conversations

In all of these cases, the skills required for these types of conversations are absolutely critical in creating a high reliability and sustainable safety culture.

As organisations increasingly seek to use clinical and operational data to inform performance and improvement, the ability to have confident candid conversations about unwarranted variation in professional behaviour and/or clinical practice and outcome data is absolutely essential to a culture of continuous learning that drives better patient outcomes and more engaged staff.

This article was originally published by Healthcare Markets and has been republished here with permission.

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