DGD12-042
Policy
Reviewing the Clinical Competence of a Doctor or Dentist
following Receipt of a Complaint or Concern
Policy Statement
Complaints or concerns about the clinical competence of a doctor or dentist (clinician) are to
be managed with appropriate attention to the safety of the community, the privacy, rights
and well-being of the clinician and the integrity of the Health Directorate (HD) and relevant
legislation.
Executive Directors, in conjunction with relevant Clinical Directors, are responsible for the
conduct and documentation of the management of complaints or concerns.
Purpose
This policy outlines the guiding principles and approach to the management of complaints
and concerns about the clinical practice of a clinician within the HD and Calvary Public
Hospital.
This policy is to be read in conjunction with the associated Standard Operating Procedure
(SOP) – Reviewing the Clinical Competence of a Doctor or Dentist following Receipt of a
Complaint or Concern which outlines the procedures to be followed in the management of a
complaint or concern.
Scope
This policy applies to the management of complaints regarding the clinical practice of a
clinician appointed within the HD or Calvary Public Hospital. For the purpose of this policy,
“complaint” will be used to mean both complaint and concern.
The term “clinician” will be used to refer to junior doctors, senior doctors and dentists. The
policy applies to clinicians:
 with permanent, short or fixed term appointments or contracts, including locums; or
 appointed on an urgent basis, such as in an emergency or a disaster situation.
This policy does not apply to the management of disciplinary matters (such as
underperformance or bullying and harassment) which are dealt with according to the
provisions of the Public Sector Management Act 1994, HD Enterprise Agreements and
policies.
All staff within the HD must adhere to this Policy and corresponding SOP.
Doc Number
DGD12-042
Version
1.0
Issued
October 2012
Review Date
October 2015
Area Responsible
MDPSU
Page
1 of 4
DGD12-042
Background
Although use of the term ‘competence’ is generally directed towards technical expertise and
practice, a clinician needs a range of additional knowledge, skills and attributes to provide
safe and quality patient care including, but not limited to: attitudes and interpersonal skills;
ability to communicate with patients and colleagues; ability to work as part of a
multidisciplinary team; leadership skills; and knowledge of the health system within which
the clinician works.
An essential focus of a competence review is the maintenance of clinical safety and quality,
and avoidance of poor patient outcomes.
Making a complaint
Anyone is free to make a complaint about clinical competence (see SOP). Anonymous
complaints may not be pursued, although this will depend upon the nature of the complaint
made. Initial enquiries will be made to evaluate all complaints and complaints from staff
members considered vexatious will be referred to the People, Strategy and Service Branch
(PSSB) for consideration of disciplinary action, where appropriate.
Response to complaint
The management of a complaint about clinical competence will have a graduated response
dependent on the nature, severity and/or frequency of alleged incidents.
Wherever safe and practicable, and subject to the requirements of any relevant legislation
or standards, complaints will be managed without disruption to the clinician’s work pattern.
If necessary, the matter may, however, be escalated to an appropriate forum or scope of
clinical practice committee approved under the Health Act 1993 (the Health Act). It is a
requirement of employment or engagement with the HD and Calvary Public Hospital that
clinicians comply with an appropriately established scope of clinical practice review process.
The CanMEDS 2005 Physician Competency Framework (“the CanMEDS Framework”) is to be
used in the assessment of clinical competence (see Attachment 1 to the SOP: Complaints
and Concerns regarding the Clinical Competence of a Doctor or Dentist).
In the conduct of competence reviews, the HD will meet all requirements of the Health Act
and the Health Practitioner Regulation National Law (ACT) Act 2010.
If the Director-General/Deputy Director-General (Canberra Hospital and Health Services) or a
scope of clinical practice committee consider that “the clinical practice of a doctor or dentist
at a health facility poses a threat to the safety of members of the public1”, the scope of
clinical practice of the clinician may be amended or withdrawn immediately. Salaried
clinicians may be required to take leave with pay for the duration of the review.
Principles of review
Any review process is to be managed as expediently as possible, bearing in the mind the
need to mitigate the risk of the recurrence of the issue which may have led to the complaint,
and the impact of the process on the clinician and the clinical service. Wherever appropriate,
HD will work with the clinician to achieve remediation of any substantiated concerns.
1
Health Act 1993, Section 66 (1)
Doc Number
DGD12-042
Version
1.0
Issued
October 2012
Review Date
October 2015
Area Responsible
MDPSU
Page
2 of 4
DGD12-042
The clinician is to be provided with procedural fairness in the management of complaints
about his/her clinical competence. This includes notification in writing of:
1. The anticipated process;
2. The nature of the allegation in sufficient details to enable the clinician to respond to it;
3. The fact that the clinician is entitled to be accompanied by a support person in all formal
forums;
4. The right of the clinician to request a reasonable time to become familiar with any
relevant matters (minimum of 24 hours);
5. The right of the clinician to be given a fair hearing prior to decision-making, and
6. That the decision will be made without bias and based on evidence.
Evaluation
Outcome Measures
100% of concerns and complaints regarding the clinical competence of a doctor or dentist
are managed according to this Policy.
Method
 All competency reviews will be evaluated on conclusion by the Director of the
Medical and Dental Professional Standards Unit, utilising:
1. A customer satisfaction tool provided to all stakeholders.
2. A record of duration of the review with explanation of inappropriate delays.
3. A record of the outcome of the review.
4. Summary information from each review will be provided at six month intervals to the
Quality and Safety Committee.
5. Close liaison about management and evaluation will be maintained with the
Executive Director, Medical Services, Canberra Hospital and Health Services.
Related Legislation, Standards and Policies
Related Legislation
Health Records (Privacy and Access) Act 1997
Human Rights Act 2004
Health Practitioner Regulation National Law (ACT) Act 2010
Discrimination Act 1991
Territory Records Act 2002
Public Interest Disclosure Act 1994
Health Act 1993
Standards
ACHS EQuIP 5
ACSQHC Standard 1 - Governance
ACSQHC Standard 2 - Partnering with Consumers
Australian Charter of Healthcare Rights
The CanMEDS 2005 Physician Competency Framework. Better Standards. Better Physicians.
Better Care. Ottawa, Canada: The Royal College of Physicians and Surgeons of Canada.
Doc Number
DGD12-042
Version
1.0
Issued
October 2012
Review Date
October 2015
Area Responsible
MDPSU
Page
3 of 4
DGD12-042
Related Policies
Health Directorate Workplace Safety Policy (CED10-040)
Health Directorate Open Disclosure Policy (CED10-008)
Health Directorate Consumer and Carer Participation Framework (DGD11-094 )
Health Directorate Engaging and Consulting with the Aboriginal and Torres Strait Islander
Communities in the ACT, The Health Directorate Guide (DGD12-008)
Health Directorate Consumer Feedback Management in the Health Directorate Policy and
SOP
Health Directorate Public Interest Disclosure Policy
Definition of Terms
Clinical practice - means the professional activity undertaken by doctors and dentists for the
purposes of investigating patient symptoms and preventing and/or managing illness,
together with associated professional activities related to patient care.
Clinician – means all doctors and dentists, including interns, resident medical officers,
registrars, career medical officers, Fellows, staff specialists and VMOs and does not include
nursing and allied health staff. Differentiation of sections applicable to particular staff
subgroups is specified in the text.
Competence - means the demonstrated ability to provide health care services at an
expected level of safety and quality (ACSQHC, 2004).
Credentials - means the qualifications, professional training, clinical experience, and training
and experience in leadership, research, education, communication and teamwork that
contribute to a doctor’s or dentist’s competence, performance and professional suitability to
provide safe, high quality health care services.
Scope of clinical practice – means the approved extent of an individual doctor’s or dentist’s
clinical practice within a particular organisation based on the individual’s credentials,
competence, performance and professional suitability, and the needs and the capability of
the organisation to support the doctor’s or dentist’s scope of clinical practice.
Vexatious – means without sufficient grounds and serving only to cause annoyance
References


The CanMEDS 2005 Physician Competency Framework. Better Standards. Better
Physicians. Better Care. Ottawa, Canada: The Royal College of Physicians and Surgeons of
Canada.
Australian Medical Council Limited Good Medical Practice: A Code of Conduct for Doctors
in Australia http://www.amc.org.au/index.php/about/good-medical-practice
Attachments
Standard Operating Procedure: Reviewing the Clinical Competence of a Doctor or Dentist
following Receipt of a Complaint or Concern
Doc Number
DGD12-042
Version
1.0
Issued
October 2012
Review Date
October 2015
Area Responsible
MDPSU
Page
4 of 4