22 Mar 2016
An effective and timely system for managing concerns about regulated health practitioners is critical for public safety.
This must provide transparency and accountability and ensure public confidence in the regulatory system for individual health practitioners.
Recognising this, AHPRA commissioned KPMG to undertake an independent review of its system and processes for managing notifications in Victoria. This was designed to examine the effectiveness of changes introduced since 2012 and consider further options for improvement.
The KPMG Review was led by Penny Armytage, Partner, KPMG.
This summary provides an overview of what KPMG did, what they found and what AHPRA is doing in response to these findings.
In October 2015, the Victorian Minister for Health Jill Hennessy made a public statement about potentially preventable deaths of babies at Djerriwarrh Health Service (Bacchus Marsh). In 2013, there were seven stillbirths and newborn deaths at Djerriwarrh and in 2014 there were three stillbirths and newborn deaths. A review of these cases by Professor Euan Wallace, Director of Obstetrics and Gynaecology Services at Monash Health, has found that seven of these deaths may have been avoidable. The Health Minister described this as a catastrophic failure of clinical governance and made sweeping changes to the governance and management of Djerriwarrh.
At the same time, the work of the Australian Health Practitioner Regulation Agency (AHPRA) was the subject of significant media comment and community interest. This was because of the 28-month timeframe to investigate a notification relating to one of the long serving doctors at the health service. AHPRA made a public statement on 16 October 2015 and acknowledged that it took longer than it should have to investigate that complaint, which related to a single case and the follow-up care provided to a mother after birth.
The objective of this review was to examine the design and implementation of processes for managing notifications in the AHPRA Victorian office. The focus was on how well the processes were designed; how well they are being implemented and options for improving systems and processes.
The review involved review of policies and procedural documentation; process walkthroughs and mapping of the notifications lifecycle and testing of the operational effectiveness of processes, systems and internal control including review of a small sample of case files. Consultation was undertaken with AHPRA staff, Boards, a representative of the Department of Health and Human Services, the Health Services Commissioner and an Executive Director of a health service. The Minister for Health was also interviewed. Views of other health service providers and organisations also were considered by KPMG.
The report recommends actions in five main areas.
AHPRA has accepted all the recommendations of the KPMG Report and an action plan has been developed. Although the review only looked at our Victorian operations, many of the solutions apply nationally. Initiatives in response are either underway or planned and are summarised in the table below.
Management of high risk matters
We will provide updates on progress. For further information email AHPRAVic@ahpra.gov.au.
Who does what in the Victorian health system?
Victorian practitioners account for 25.8% of Australia’s registered health workforce.