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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