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.

Why was this review commissioned by AHPRA?

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.

What did we ask KPMG to do?

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.

What did the review find?

The report recommends actions in five main areas.

Better risk assessment: need to embed a more systematic, data informed approach to risk assessing notifications not only taking account of the information which is outlined in the notification, but also factors such as a practitioner’s history of notifications, their practice context and who made the notification.
Management of high risk matters: more intensively apply resources to higher-risk notifications, so these cases are investigated thoroughly but quickly.
Greater transparency: interpret and use the National Law flexibly, not narrowly, to support information sharing in the public interest and promote greater understanding and transparency of what we do.
Culture: address perceptions of being pro-practitioner and shift this perception through cultural change, with a greater emphasis on service. We need to drive an open and transparent organisational culture with a clear balance between the interest of patients, public safety and the practitioner to ensure our service culture balances the rights and needs of all stakeholders.
Performance: continue to critically evaluate the causes of delays, especially for high risk and complex cases.

What is AHPRA doing to respond?

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.

Issue	What are we doing?
Better risk assessment	We have implemented staffing changes in Victoria which mean that all initial risk assessments are now undertaken by senior AHPRA staff. We now make direct phone contact with the person who has made the notification and practitioners to ensure all relevant information is identified. We are testing a more rigorous tool for weighting risk factors when we receive a notification taking greater account of: history of notifications for that practitioner the source of notification the context of clinical practice. We have established a research partnership with the University of Melbourne to further develop risk based approaches to identification and assessment of practitioners.
Management of high risk matters	We are using risk-assessment to shape regulatory management. We are actively managing timeframes to reduce the times it takes to assess and investigate notifications. We are piloting a different approach to managing the highest risk notifications, to ensure they are investigated thoroughly but more quickly.
Greater transparency	We are using the National Law more flexibly to improve information-sharing with key stakeholders (such as notifiers, employers, DHHS) within the law. We have adopted a broader definition of employer, applicable both for information gathering about employment details from practitioners and information sharing following board decisions to take health, conduct and performance action. We are working with the Department of Health and Human Services (DHHS) to develop a regulatory compact setting out what sensitive information can be shared between agencies, in what circumstances, to make sure everyone can work effectively together to identify and manage high risk situations and keep patients safe. AHPRA has responded to an invitation from the Minister to identify features of our legislation that may not be serving the public well and may require amendment. These would complement the changes pending in the proposed new law for the Health Services Commissioner and would help us do our job of managing risk to patients. This includes requiring registered practitioners to inform AHPRA of their employersand places of practice and providing AHPRA with the power to advise employers and places of practice of any changes to their registration status. AHPRA has offered to work with DHHS to roll out the practitioner information exchange with health services in Victoria to allow health services to have real time automated access to data from the public register.
Culture	We have established a notifications liaison officer in Victoria to spearhead much better and more regular communication with people who make notifications and practitioners. We are surveying practitioners and notifiers on their experience of the notifications process and ways in which it can be improved. We have reviewed and simplified all correspondence with practitioners and notifiers to improve readability and clarity. We are working with DHHS and the Health Services Commissioner on ways to make it easier for the community to raise a concern, including through a shared single ‘front door’ for complaints. We have implemented extensive awareness-raising campaigns to employers and practitioners about their reporting obligations, and to the public about the scheme.
Performance	We are actively managing timeframes to reduce timeframes for assessment and investigation. We have halved the number of days it takes to close matters at assessment if no further regulatory action is required from 142 days to 73 days. We have strengthened case review processes at key milestones and regularly audit all matters open over six months. We publish an annual report for Victoria which summarises data on our regulatory performance. From April 2016, we will be publishing state-specific performance data for each quarter.

Further information

We will provide updates on progress. For further information email [email protected].

Background

Who does what in the Victorian health system?

Regulating individuals: AHPRA and National Boards set the policies and regulate registered health practitioners, including receiving and managing complaints about the health, conduct or performance of practitioners.
Managing health service complaints and mediations: the Health Services Commissioner receives and resolves complaints about health service providers with a view to improving the quality of health services for everybody.
Responsible for the broader health system in Victoria: The Department of Health and Human Services is responsible for supporting service delivery of the health system to meet health needs of Victorians.

Facts and figures about the work of AHPRA and Boards in Victoria in 2014/15

Victorian practitioners account for 25.8% of Australia’s registered health workforce.

There are now 164,324 registered health practitioners in Victoria, compared with 160,286 in 2014.
77% of registered health practitioners in Victoria are women.
On 30 June 2015 there were 97,561 nurses and midwives, 25,029 medical practitioners, 7,182 pharmacists and 4,827 dental practitioners in Victoria.
There are 413 dental, 15,698 medical and three podiatric specialists in Victoria.
14,513 registration applications were received by National Boards in Victoria, including applications to change registration types.
Two Victorian practitioners had their registration limited or refused in some way after a criminal history check.
We received 1,901 notifications about health practitioners in Victoria during the year, including 172 mandatory notifications.
There has been a 10% decrease in notifications in Victoria, compared to a 16% national decrease since 2013/14.
1.2% of health practitioners in Victoria are subject to a notification.
Most concerns (37%) were about clinical care, pharmacy/medications (10%), communication (9%) and health impairment (11%).
Patients and their relatives were the main source of notifications (32% of notifications), followed by the Health Services Commissioner (22%) and employers (8%).
Victorian boards and committees considered ‘immediate action’ 65 times, limiting the practitioner’s registration in some way in 49 cases as an interim step to keep the public safe.
There were 89 notifications closed after a panel hearing and 21 tribunal decisions finalised during the year.
80% of panel decisions and 85% of tribunal decisions led to disciplinary action.
AHPRA is monitoring conditions on registration or undertakings from 948 Victorian practitioners.
Notifications about practitioners in the dental, medical, nursing and midwifery and psychology professions account for 89% of notifications in Victoria.

Page reviewed 22/03/2016

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