Understanding Risk: towards an evidence based approach to

regulatory policy development

Claire Herbert & Guy Rubin

General Dental Council

IAMRA London 2014

11th INTERNATIONAL CONFERENCE ON MEDICAL REGULATION

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Presentation content

• Introduction

• Policy Context

• Understanding Risk

• GDC Case Studies

• Conclusion

• Questions

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Risk and regulation

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in dentistry….

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Risk factors

Human factors

System Factors

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Understanding risk

• Risk – likelihood that a hazard will occur • Hazard – patient/public protection not

maintained • Risk that Standards are not maintained e.g.

impairment of practice • Risk Factors – variables that give rise to risk

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Risk and regulation

Regulatory tools/

framework Risk

Evidence base

Risk factors

Some questions for regulatory policy

• What are the root causes, causal or contributing factors?

• What are the precursors? E.g. pathway to risk

• How can they be categorised? e.g. conduct, competence, context

• Do the risks apply equally or differently across the register?

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Patient safety and providing dental

treatment directly to patients

• Patients always seen by a dentist first

• Treatment on dentist’s prescription

• 2012 GDC review of “direct access” to dental patients

• Consideration of patient risks

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Literature Review

The Literature Review considered:

• Major impact factors, including risks and benefits of direct access

• Evidence of increased risk to patients from introduction of direct access

• Evidence that patients benefit from direct access

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Findings

• No evidence that widening direct access to dental care to Dental Care Professionals leads patients to be at greater risk of harm than is currently the case

• Some evidence of benefits to patients –

• access to dental services

• limited evidence of at most modest cost savings to patients some

• evidence of high patient satisfaction among dental hygienist and therapist patients

• some evidence of higher relative satisfaction compared with dentists.

• Some limited evidence of higher job satisfaction for dental professionals when working to their full remit and training

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Implications for Regulation

The GDC agreed direct access by dental care professionals in certain circumstances (set out in guidance)

For those who do:

• All registrants must be trained, competent and indemnified for any tasks they undertake.

• All registrants must continue to work within their scope of practice regardless of these changes.

• All registrants must continue to follow the GDC’s Standards for the Dental Team.

Dental care professionals do not have to offer direct access and should not be made to

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Transition to Independent dental practice

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What types of risk are there to patient safety in dentistry and other

healthcare professions with new registrants, what are the reasons for them

and how significant are they?

How do the risks vary across the dental registrant categories and what

are the reasons for this?

What issues and risks are there with confidence, knowledge,

competence and skills levels of new dental and other healthcare

registrants over the four areas of clinical, communication, management

and leadership, and professionalism. How may this vary and what are the

reasons?

Findings (1)

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The literature specifically on risk posed by new registrants is limited and the

studies that do exist are of moderate to low quality

• No evidence of risk from analysis of dental or other regulators fitness to

practice data

• No comparative evidence found on how risk varies across groups and

reasons for it

• Few research studies on dental professionals trained overseas. Little

evidence of risk

Findings (2)

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There are risk factors that could in some circumstances but potential risk factors

Competence: extent of awareness of competence, tasks expected to undertake and the availability of

support and guidance from more senior colleagues.

Confidence: Some areas of low confidence and skill identified

BUT:

Supervision and support mechanisms: Education, training , supervision and support.

Foundation/vocational Training for dentists – highly regarded and generally considered to be successful

in moving the novice towards the status of a competent general practitioner

Implications for regulation

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The evidence has not identified clear risks to patient safety in

relation to newly registered dentists or DCPs

But unable to state categorically that such risks do not exist.

Current evidence is simply not strong enough to support major

regulatory change at this stage

But

• Further work to identify trends in different groups

• Understanding the career paths of those joining the register.

• Systematic monitoring of the different groups of registrants.

• Further scrutiny of FtP data to establish if their are statistically

significant trends.

• Potential to benchmark against information from other

regulators and professions

• Longitudinal research to understand career paths of new

registrants

Risk in Dentistry

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• Understanding risk in dental practice

• Understanding common pathways to

impairment

• Feasibility of analysis of GDC Fitness to

Practise data

Conceptual Framework of Risk

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COMPETENCE

RISKS Factors

related to skills and

knowledge

CONTEXTUAL RISKS

Environmental factors

CONDUCT RISKS Factors

related to behaviour

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Study 3

How is Performance Managed and

Monitored Across Dentistry?

Evaluation of Supporting Evidence Types for

Revalidation

Picker Institute Europe - October 2012

Phase 1: Website search and literature review

Website searches

Literature review

Research questions

RQ1. What are the types of evidence already used across dentistry to

assess performance and quality of the practice of individual dentists?

RQ2. What are the purposes of each evidence type?

Phase 2: Semi-structured interviews

Lend DEPTH

to study

Purposive

samples to

maximise

diversity

8 practising

dentists

18 key

informants

Research questions

RQ1. What are the types of evidence already used across dentistry to assess performance

and quality of the practice of individual dentists?

RQ2. What are the purposes of each evidence type?

RQ3. What is the extent of consistency in application of evidence types and

standardisation in format across the four countries of the UK and practice settings?

RQ4. What contribution could they make to assessing practice in accordance with the

GDC’s standards?

RQ5. What criteria could be used to evaluate compliance with GDC’s standards?

RQ6. Could thresholds of (un)acceptable practice be identified and agreed?

Phase 3: Online surveys

Survey 1:

dental

organisations

(n=26)

Survey 2:

dentists

(n=499)

Lend

BREADTH

to study

Research questions addressed

(Potentially all)

RQ3. What is the extent of consistency in application of evidence types

and standardisation in format across the four countries of the UK and

different practice settings?

Conclusions • Large number of evidence sources in wide & variable use

• Little consistency across countries

• Little standardisation of implementation

• Lack of evidence that participation in such activities is a valid or reliable indicator of good practice

• Dentists working in many different settings so implementing a standardised approach challenging

• Evidence used needs to be relevant to a dentist’s role

Application of evidence type by country

.0% 20.0% 40.0% 60.0% 80.0% 100.0%

CPD

Clinical Audit

Professional development planning

Peer review

Review of significant events

Case-based discussion / assessment

Complaints & compliments

Multi-source (colleague) feedback

Patient feedback

Which of the following have you, or your practice, undertaken in the last year? (Registrant survey)

England (n=171) Scotland (n=111) Wales (n=104) N.Ireland (n=93)

Recommendations

The following evidence types have the potential to make a contribution to revalidation subject to certain conditions:

• CPD

• Clinical audit

• Professional development planning

• Review of significant events

• Case-based discussion/assessment

• Review of complaints and compliments

• Multi-source feedback

• Patient feedback

• Evidence of activity

Risk and GDC policy development

Outcomes - Proactive regulation: preventative as well as responsive Outputs – more concerns identified early and at source; fewer FTP cases; collaborative “regulation” Policy Actions – systems and processes for continuing assurance; targeted/dynamic standards and guidance; pre-registration education outcomes; information gathering

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Questions for Discussion

• What is the purpose of professional regulation in your context?

• What part (if any) does risk play in your organisation’s approach to regulation?

• What does risk mean in your context?

• What approach do you take to identifying and understanding risk factors?

• What are the benefits and challenges to undertaking this kind of analysis for regulatory policy?

• What are the opportunities and challenges of sharing findings in this area, across professional and national boundaries?

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