The Public Release of (Your) Medical Performance Data…
Should the medical profession be more open about a doctor’s track record? An issue which has received recent media attention is whether a doctor’s record should be made available to the New Zealand public in order to achieve greater transparency. The MCNZ is currently encouraging those with vested interests such as the medical profession (you) and the public to debate this issue. Relevant questions to consider are what form should such data take, who should have access to it and importantly what is its value?
According to the MCNZ, trustworthy data (derived from both the micro and macro level) may operate to help carry out a number of health related tasks – including, for example:
a. assessing quality outcomes;
b. identifying areas for improvement;
c. informing clinicians and allowing relevant benchmarking of services;
d. informing patients and allowing for better informed choices;
e. creating a meaningful national dataset of risk and benefit;
f. influencing planning and investment in health systems;
g. influencing recertification.
Some would argue that patients have the right to be fully informed when it comes to seeking medical care. Doctors are not ‘special’ and as a general rule should not be immune from having their names made known in respect of medical performance data. The release of data might be one effective way of checking a doctor’s competence which could encourage patient confidence around decision-making related to service provision.
Both the United States and United Kingdom jurisdictions already make available some medical performance data about individual doctors. For example, in Britain under the NHS system “you can read for instance that cardiothoracic surgeon Edward Ernest John Smith’s risk adjusted patient mortality rate of 3.93 per cent was “okay” and “within the expected range”’. And “in the US, the Federation of State Medical Boards, on payment of a $9.95 fee provides members of the public with a ‘DocInfo Profile’ for a named physician – listing qualifications, board certification status, state(s) where licensed and disciplinary history.” By contrast, in New Zealand, there is no publicly available way to check a doctor’s record – apart from those who have been struck off.
In his book, ‘The Good Doctor: What Patients Want’, former Health and Disability Commissioner Ron Patterson states that patients ought to have more complete information made available to them about a particular doctor’s competency. “The public have a right and responsibility to understand and influence the way that health is delivered”.
Patterson suggests that DHBs should make accessible to the public the ability to search an individual doctor online which would include being able to view details such as their disciplinary history. Ultimately Patterson’s argument rests on “respect for autonomy, accountability and quality improvement” and he urges that the ‘veils of secrecy’ be lifted.
There are however, strong arguments against the public release of performance data – some suggest that not only would this data be irrelevant but it would breach personal privacy rights of doctors and ultimately do more harm than good. The release of this type of data would add a level of stress for doctors who already undertake a highly stressful occupation. The last thing that doctors need is to be ‘under the knife’ even more so than they already are. There is also the real (concerning) possibility that “clinicians may avoid doing the ‘right thing’ if the right thing might appear to worsen that doctors ‘statistics.’”
In addition, procedures and patient care almost always involve a team of medical professionals – not just one. There are also other locality factors to consider – for example, in the far South the population is older and during the winter months “more patients may tend to be having chest infections at the time they need operations” and this would result in increased surgical complications. This example illustrates the difficulties in accurately comparing performance data. Data without context could be highly damaging.
And whilst proceduralists could be easy to measure, what (and how) of GP’s or palliative care for instance? Simply releasing numerical or raw data may be misleading if it creates an inaccurate reality of doctor performance. And anyway, shouldn’t the system of medical care as a whole, rather than information pertaining to an individual doctor, be what is most significant? MCNZ Chairman Andrew Connolly states that in his view “the most important information is how the DHBs fared and not how the individual doctors stacked up.”
At this stage it is not entirely clear where the balance lies. However, what is clear is that this matter involves multiple considerations and it will not be resolved in a hurry! Currently, DHBs that do heart surgery cannot produce reliable comparisons of individual heart surgeon’s patient complication and death rates. Even if they could provide such data it would be unlikely that it would be made publicly available. Questions in regards to how data collecting and dispersal could be carried out still need to be answered. Do not panic – the public’s ‘right to know’ alone is not enough to satisfy the release of your medical work history.
NZRDA is attending a symposium on this topic later in the month. We would value your views on the matter before the symposium to further inform us as we go forward.
Contracting out Pathology Services to SCL
Many of you will no doubt have been reading about the contracting of pathology services (AKA “the lab”) throughout the wider Wellington region, both DHB and private, to SCL a private company. Some of you may have also wondered, what will happen to the pathology registrars and their training?
The answer is relatively simple, if only because NZRDA knows the risk trainees can face plus we put some protections into the MECA, just in case….. First off, NZRDA successfully lobbied to keep the registrars as DHB employees largely because not doing so posed too great a risk to the future supply of such a small speciality workforce both at a regional but also a national level.
But how will it all work you might ask now the SMOs, lab scientists and labs themselves are all employed / owned by someone else? This is where the MECA comes to the rescue.
Clause 7.1 and 7.2 of the MECA are relevant here; there are others but let’s stick to these ones for the moment!
7.1 states that “the parties acknowledge that ….. RMOs are training under the supervision of DHB employees and in the case of training programmes, the appropriate professional college or professional vocational training body.”
7.2 goes on to say that “….In so far as it is within the control of the party(s) there will be no change to the manner in which these services are provided unless agreed between the parties and set out in this agreement.”
Contracting out lab services is within the control of the parties to MECA so…… agreement is required. All the pathology registrars will remain DHB employees and their employment will continue uninterrupted with the DHBs under the terms and conditions of the NZRDA MECA. This includes their rights to access training and supervision consistent with and in compliance with their training programme.
The DHBs, SCL and NZRDA will formalise an agreement shortly to ensure continuity of training services including clinical access and supervision. This agreement will also include provisions for associated trainees such as (medical) haematology and infectious diseases registrars who may be dual training.
Of Note! Quarter Change in Week 14
Some of you may have noticed (from your rosters etc.) that the final quarter of the 2015 training year has 14 weeks instead of the typical 13 weeks. As strange as this may seem this is in fact correct! So… you will work for 14 weeks on your final run instead of the usual 13 weeks before change over takes place. The reason for this extended run period is simply because there are slightly more than 52 weeks in a year and so every now and then we have to ‘catch up’. Note that you will move to the next step of pay at the end of the 13th (and not the 14th) week.
Medical Speciality Factsheets
Health Workforce New Zealand has collaborated with the Medical Colleges to bring together information in the form of “fact sheets” that may assist RMOs making career choices. These can be found on http://www.kiwihealthjobs.com/rmo/fact-sheets
Each of the factsheets provides the same information regarding each of the specialties. This information includes:
o A brief overview of the specialty;
o Personal qualities suited to each specialty;
o Specialty training programme information (including how long it takes to train, and what training involves);
o Entry requirements, application process, and selection criteria;
o Demand for vocational training posts, and the number of training positions;
o The need for the specialty in New Zealand.
The factsheets will be progressively updated as more information becomes available.
Understanding Changes to the MECA
It is important to be familiar with your contract – in particular it is helpful to know about the new clauses. These amendments to the MECA resulted from the latest bargaining. In each upcoming newsletter we will include a breakdown of one or two of the new clauses.
Clause 14.7 Registrar Telephone on Call (page 26 of your new MECA) and Schedule Ten Registrar Telephone Call (page 75 of your new MECA)
Clause 14.7 came about so that you receive compensation when you take a patient related call when you are on call. If the issue of patient care can be resolved over the phone and does not result in a call back you are entitled to payment for a minimum of one hour. If you do get called back in you are not eligible for payment in respect of the call.
Eligibility for payment does not require the issue of patient care to be resolved over the phone – the call merely has to be one in which patient care is resolvable over the phone. The clause also covers the situation where you are called by a GP to discuss patient care (if that is part of your run description or role) – so you will be eligible for payment in this event.
The payment will be paid at an additional duty rate. Calls must be logged and details of the phone conversation must be recorded as per normal procedure. Ensure that you log the information as soon as practicable after the phone call.
You cannot receive more than one payment in respect of the same hours – so all calls received within the period covered by the minimum one hour payment will be counted as one call. Likewise, clause 14.7.4 states that any run where the payment for the phone call is factored into the calculation of the run category is not eligible for payment. This makes sense in order to prevent any ‘double dipping’ or ‘double ups’ with payments received.
Clause 14.7.5 and Schedule 10 state that there is a $1 million maximum total amount payable to registrars for phone calls. Note that if this total amount is reached then the payments will be stopped. However, given the figures from an earlier trial, it is most likely that the $1 million will be sufficient to cover calls for the duration of the current MECA term. It is unclear exactly how the DHBs are monitoring and deducting these phone call payments from the $1 million.
Fatigue Education Tool
Some of you may have been approached regarding the online fatigue education tool. This tool is part of the DHB/RDA partnership work addressing unsafe rosters which started over two years ago, but which was held up by the MECA bargaining.
The tool was developed by the Massey Sleep Wake Research Centre with the aim of improving rostering etc. for RMOs. To that end SMOs and anyone that writes an RMO roster is going to be required to complete the programme, so whilst some of the modules and wording may seem basic and obvious to RMOs please bear in mind you are not the only group undertaking this work.
And this is the very work we need to do to get on top of exactly what you have told us is occurring. This is a whole of system issue and one where RMOs find themselves at the bottom, both in your ability to change the system but also in being directly impacted by it. If we continue to accept poor rostering etc., we are part of the problem. With the education tool being undertaken by everyone, the management’s excuse for not understanding is lessened, and our ability to make things better improved. We also hope that armed with more information, including the knowledge that the managers do know, we will collectively be able to shift some mountains.
Finally, it should be done in work time and not when you are focusing on exams for example. We suggest you get all your colleagues together with the management and have a discussion about when you can all take time off to do it. If you have any difficulty getting time away from clinical duties, let us know and we will facilitate.