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The Quebec system of Monitoring and Enhancement of Physicians Performance

Expect the Unexpected: Are We Clearly Prepared?. The Quebec system of Monitoring and Enhancement of Physicians Performance. André Jacques, MD, Director Practice Enhancement Division Collège des médecins du Québec.

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The Quebec system of Monitoring and Enhancement of Physicians Performance

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  1. Expect the Unexpected: Are We Clearly Prepared? The Quebec system of Monitoring and Enhancement of Physicians Performance André Jacques, MD, Director Practice Enhancement DivisionCollège des médecins du Québec Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  2. “ I do not have any affiliation or financial interest of any nature in a business corporation, or I do not receive remuneration, royalties or research grants from a business corporation” Potential conflict of interests disclosureDr André Jacques declare: Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  3. Mission of the College The mission of the Collège des médecins du Québec is to promote a quality medicine in order to protect the public and to contribute to enhance the health of Quebecers Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  4. Governance of the College Bureau (28 Governors) Executive Committee (5 Governors) President Professional Inspection Committee Committee on Budget Committee on Revision Committee on CPD Committee on Admission to practice Committee on Discipline Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  5. Management structure General Division Administrative Services Division Legal Services Division External Affairs Division Medical Education Division Practice Enhancement Division Inquiry Division Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  6. Role of the College of physicians • Admission to practice - registration • Accreditation of training programs and sites • Licensure examination for family physicians (written and oral examinations, OSCE and SOO) • Specialist certification examination (written and oral and/or clinical examination) Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  7. Role of the College of physicians • Supervision of physicians’ practice • Assessment of practice of physicians in : • Offices • Hospital • Nursing homes • Etc. • Interventions to promote quality of practice • CME activities • Training programs • Coaching • Etc. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  8. Role of the College of physicians • Investigation of complaints related to both physicians and illegal practitioners • Disciplinary process (for physicians) • Legal proceedings against illegal practitioners • Alternate resolution of complaints Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  9. Role of the College of physicians • Political role • Physicians and medical organizations • Public and media's • Government and official bodies • Other health professions Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  10. Human and financial resources • Staff of the College: • 23 full time physicians • 78 support staff • Budget : • 18.6 millions (Canadian dollars) Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  11. Quebec medical manpower Based on data of December 2005 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  12. Quebec medical manpower Based on data of December 2005 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  13. Code of ethics Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  14. Code of Ethics of physicians • A physician must practice his profession in accordance with the highest current standards; to that end he must improve and keep his knowledge up to date. (Section 44) Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  15. Professional Code Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  16. By-laws related to supervision of physicians practice • A Professional Inspection Committee is established within each order. (Professional Code, section 109) Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  17. By-laws related to supervision of physicians practice • The committee shall supervise the practice of the profession by the members of the order. (Professional Code, section 112) Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  18. By-laws related to supervision of physicians practice • The committee may recommend that it require a member of the order to serve a period of refresher training or take a refresher course or both and that it restrict or suspend his right to engage in professional activities during the training period or course. (Professional Code, section 113) Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  19. By-laws related to supervision of physicians practice • It is forbidden to hinder in any way a member of the committee, an inspector or an expert in the performance of the duties conferred upon him by this code. (Professional Code, section 114) Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  20. Professional Inspection CommitteeFunctions • Inquiries into the professional competence of a physician • Inquiries into the the quality of the medical care provided in establishments Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  21. Practice Enhancement Division Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  22. Practice Enhancement DivisionMandate The mandate of the Practice Enhancement Division of the College of physicians of Quebec is the monitoring of the practice of physicians and its enhancement in order to protect the public and contribute to enhance the health of Quebecers Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  23. Practice Enhancement DivisionHuman and Financial Resources • Staff of the Division : • 10 physicians • 1 director • 2 assistant directors • 6 inspectors-investigators • 1 physician for sick MD • 1 coordinator • 1 research agent • 11 secretaries • Budget 2006-2007 : 4.3 M $ Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  24. Practice Enhancement DivisionFunctions • Evaluation of the quality of physicians' practice in office as well as in hospital • Evaluation of the quality of the practice of medicine in health establishments • Support to the Professional Inspection Committee Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  25. Practice Enhancement DivisionFunctions • Intervene to enhance the physicians' performance in office as well as in hospital • Support the Continuing Professional Development (CPD) Committee • Maintain the secretariat of the Conseil québécois du développement professionnel continu des médecins Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  26. Who will be the winner ! Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  27. Study of a representative sampling of 100 GPs • Observational analysis of medical records randomly selected • Assessment of some aspects of the quality of general practitioners’ professional practice • Period : 1995-1996 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  28. Study of a representative sampling of 100 GPs • Professional inspection visits to 100 family physicians • Random selection among Quebec’s family physicians : • practicing either entirely or partially in a private office • in the greater metropolitan Montreal region Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  29. Study of a representative sampling of 100 GPs • Two random sample groups : • 52 family physicians licensed before 1980 • 48 family physicians licensed between 1980 and 1996 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  30. Study of a representative sampling of 100 GPs • Professional inspection visits made by • 5 inspectors/investigators from the College • Average of 10 years of experience in assessment of competence • Study of at least 30 patients records randomly chosen • Using of a standard grid listing the criteria, including a scores scale Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  31. Sampling of 100 GPs Criteria of evaluation • Office practices • Record-keeping • Quality and quantity of CME • Quality of practice • Investigation • Diagnosis accuracy • Treatment plan • Relevance of care Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  32. Sampling of 100 GPs Demographic data Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  33. Sampling of 100 GPs Demographic data Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  34. Sampling of 100 GPs Results • Comparisons between physicians of groups 1 and 2 regarding : • Sex • Age • Status in hospital • University of issuance of the medical degree • Average number of consults per week Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  35. Sampling of 100 GPs Results • No significant statistical difference detected between the two groups (except for record-keeping) • No link between demographic variables and quality of care • Strong link between : • record-keeping and quality of care • CME activities and quality of care Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  36. Sampling of 100 GPs Results Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  37. Sampling of 100 GPs Results Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  38. Sampling of 100 GPs Conclusion of the study • Results enable the College to reassure the public with regard to the overall quality of the professional practices of family physicians in Quebec • Study confirms the PIC decision to evaluate the practice of physicians who present a potential risk of deviant profile, based on quality indicators Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  39. Monitoring and enhancement of physician’s performance Step 3 Enhancement Monitoring Detailed needs assessment Remediation programs Monitoring Enhancement Step 2 Assessment of physicians in need or at risk CME programs for groups and/or individuals Monitoring Enhancement Step 1 Screening of all physicians Feedback to all physicians Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  40. Step Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  41. Development of indicators for individual physicians • Choice of indicator • By Professional Inspection Committee and Practice enhancement division, after consultation with different organizations • Responsibility of the development • One staff physician Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  42. Development of indicators for individual physicians • Elaboration with : • Group of «experts» in the domain • Group of interested physicians in a hospital • Research group • Pilot process evaluating feasibility • Validation of the indicator • Diffusion of the indicator with appropriate guidelines • Implementation of the indicator Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  43. The use of PSA levels as a means of detecting prostate cancer The use of PSA level as a means of detecting prostate cancer … When available data does not always allow to document practices and changes inducted by an intervention Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  44. The use of PSA levels as a means of detecting prostate cancer • Medical controversy about extended use of PSA as a means of detecting prostate cancer • Publication of an evidence-based guideline Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  45. The use of PSA levels as a means of detecting prostate cancer • Publication of an information booklet for patients (in French) • Local CME activity (in a single region) • Analysis of physicians' perceptions : • 90% say they are aware of it • 76% agree with it • 58% say it has influenced their practice Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  46. The use of PSA levels as a means of detecting prostate cancer Evolution of prescription profiles in Québec and in the region where a continuing medical intervention was conducted Dissemination of guideline After dissemination After intervention Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  47. The use of PSA levels as a means of detecting prostate cancer • Data analysis … • Significant decreasing of the use of PSA levels as a means of detecting prostate cancer • Incomplete and impossible to analyze data • Especially in Montreal area • Data to be collected locally by archivists (in patient records) • Hard and long job Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  48. Step Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  49. Professional Inspection CommitteeComposition • 2 physicians from the Practice Enhancement Division : • The Director • One Assistant director • 6 physicians in practice, representative of both medical and surgical specialties • 10 meetings per year Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  50. Professional inspection visits Usual procedures • Sending of a notice and a questionnaire to be completed before the visit by the physician or the establishment • Inspection visit, with or without an expert • Writing of a report and of a project of recommendations • Submission of the report to the Professional Inspection Committee Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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