Managing patient care concerns identified during practice assessment and supervision

Preamble

College-appointed assessors and supervisors routinely review patient care in the course of their duties. On occasion, instances arise where the assessor or supervisors’ approach to care differs from that of the assessed physician. As a result, assessors or supervisors may make comments on or offer recommendations intended to improve care. These recommendations are most often of a general nature and do not address any immediate or significant risk to a specific patient. On the other end of the risk spectrum and in very rare occasions, an assessor or supervisor may identify some deficiency in care which, if left unaddressed, may result in serious harm to a specific patient. Similarly, in rare circumstances, an assessor may identify a situation in which a previously unknown and real harm has already occurred as the result of improper care.

This document is intended to guide College staff and agents of the College (Assessors and Supervisors) in addressing patient care concerns, identified during the course of their duties.

General Principles:

• This procedure focuses on differentiating when a “care concern” reaches the threshold for College intervention and if left unaddressed may lead to patient harm or has already led to patient harm.
• This procedure also provides the process to follow given the different levels of concern identified by the assessor or supervisor to ensure the appropriate actions take place to safeguard patients.
• This procedure considers scenarios whereby the physician under assessment or supervision is the Most Responsible Physician (MRP). The majority of College-directed assessment and supervision activities follow this format.
• Other than in rare circumstances, it will be left to the physician under assessment or supervision  to review information provided to them by the assessor, supervisor or College staff, that includes recommendations in context. The physician will be required to make an informed clinical decision, supported if necessary by formal consultations, on subsequent clinical care.
• Wherever possible, the physician under assessment or supervision should receive a copy of all completed assessment/supervision reports (including patient record worksheets, direct observation tools and summary reports etc.) generated in the course of the assessment or supervision.

Overview

When a patient care concern has been identified and if left unaddressed could lead to patient harm, there needs to be clear communication between the assessed physician and the assessor/supervisor and reassurance to the College that action will be taken to ensure patient safety. The aim is to draw the assessed physician’s attention to care recommendations and observations, with the caveat that any patient-specific recommendations are not viewed as a formal consultation, but rather a recommendation for the physician to reconsider the approach to care.

The specific actions taken by an assessor, supervisor or College staff will, to some degree, be dictated by the nature and purpose of the assessment (i.e., Professional Conduct Investigation, Supervision or a Practice Review).

The following is a graded approach to managing care concerns.

1. The assessment includes comments or recommendations of a general or a minor nature.

Examples:

• Greater vigilance required in providing adult immunizations to vulnerable patients
• Physician does not follow established practice guidelines in the use of screening tests
• An antibiotic is prescribed inappropriately, such as for a viral URI.

Action:

• Assessor / Supervisor makes written comments and / or recommendations, and may highlight these in verbal feedback, depending on the purpose of the assessment.
• Physician receives report package with a direction to review and apply recommendations at their discretion.
• Follow-up may be mandated by the College, depending on the purpose of the assessment.

2. The assessment identifies a patient-specific concern with potential for harm if not addressed.

Examples:

• A patient is prescribed a drug or combination of drugs likely to cause harm
• A high-risk patient has not been offered screening for a serious medical condition.
• It appears that a significant medical condition may have been overlooked, improperly investigated or left untreated.

Action:

• Assessor / Supervisor makes a written comment or recommendation for review. Issue is drawn directly to the attention of the reviewed physician, either during a verbal case discussion (i.e., chart stimulated recall) or in follow-up with the reviewed physician.
• Assessor / Supervisor makes note in the report that a patient-specific issue was discussed as well as the physician’s response.
• Assessor / Supervisor may, at their discretion, request College staff to follow up with the reviewed physician.

3. The assessment identifies a potential for harm, which is of a serious nature and cannot be adequately addressed through consultation with the reviewed physician.

Example:

• Patient appears to have a life or limb threatening condition (e.g., Acute coronary syndrome, malignancy etc.), which has not been addressed and the reviewed physician is unwilling or unable to take appropriate action.

Action:

• Assessor / Supervisor verbally communicates their concern directly to the physician (either through case discussion or during the chart stimulated recall interview). The nature of the concern and outcome of the discussion will be written in the report.
• Should the Assessor / Supervisor determine that the reviewed physician is unwilling or unable to take action they will immediately notify the College staff member most directly responsible for the assessment.
• The staff member will bring the issue to the attention of the Registrar or Deputy Registrar.
• Appropriate steps may include an interview with the assessed physician, direct patient notification and / or a Registrar’s complaint.

4. The assessment identifies an apparent patient harm, which is of a serious nature and has  already occurred.

Examples:

• There has been a missed or delayed diagnosis as the result of an overlooked test result.
• There has been a missed or delayed diagnosis as the result of poor judgement or inaction.
• There is evidence of professional misconduct resulting in harm, such as a sexual boundary violation.

Action:

• The Assessor / Supervisor will immediately notify the College staff member most directly responsible for the assessment.
• The staff member will bring the issue to the attention of the Registrar or Deputy Registrar. Appropriate steps may include an interview with the assessed physician, direct patient notification and / or a Registrar’s complaint.