Last week, the governing council of the College of Physicians and Surgeons of Ontario (CPSO) voted unanimously in favor of changing its bylaws to allow for public reporting of the results of inspections of Out-of-Hospital Premises, such as private colonoscopy and plastic surgery clinics.
This change was made following reporting by the Toronto Star, which raised important concerns that the public was being put at risk by a policy of not identifying clinics that receive failing grades or conditional passes.
To date, the inspection program has identified some clinics with serious quality deficiencies, including a colonoscopy clinic in Ottawa with inadequate sterilization procedures. Since the beginning of the inspection program in 2010, nine of Ontario’s 251 clinics failed inspection, and a further 64 passed with conditions.
The CPSO will now post inspection results on their website.
There is wide agreement that this policy change represents a positive step in improving the transparency of the CPSO, and its Registrar, Rocco Gerace, agrees that Ontario’s self-regulatory bodies must continue to become more transparent. However, there have also been recent calls for the CPSO and other regulatory bodies to go much farther, and begin publicly reporting ‘cautions.’ Cautions are remedial, in that they are intended to correct a problem in a professional’s practice. Cautions are not legal findings of professional misconduct.
Would publicly reporting cautions help protect patients from medical errors, or could this practice have unintended consequences that might undermine patient safety?
Ontario’s self-regulated health professions
Doctors in Canada are a self-regulated profession, meaning that the profession itself is responsible for ensuring that doctors meet professional standards of competence and conduct, in order to protect the public from incompetent or unethical practitioners.
Self-regulation is used in many parts of the world to govern professions that possess unique combinations of knowledge and skills, which make effective external regulation difficult.
In Ontario, there are 21 self-regulated health professions, including nurses, pharmacists, and dentists. Each of these professions has their own regulatory college, which are responsible for establishing and enforcing professional standards for their members, ensuring their members meet training and educational standards of the profession, and investigating complaints against members.
The central mandate of all of Ontario’s regulatory colleges is to serve and protect the public. All of these regulatory colleges operate under Ontario’s Regulated Health Professions Act.
All self-regulated health professions in Ontario are required to have a complaints and discipline process in place to investigate complaints from both the public and other members of the profession. Some of the colleges also have active quality assurance processes, such as inspections for pharmacies and Out-of-Hospital Premises.
Complaints and Discipline at the CPSO
When complaints are made against doctors (either by patients or by other health professionals), they are investigated by CPSO staff. The findings from these investigations are then presented to the CPSO’s Inquiries, Complaints and Reports Committee, which is made up of doctors and government appointed public members. This committee’s hearings are not public.
If the committee finds that a doctor’s conduct or care provided was appropriate, it will take no further action. However, if it finds that the complaint has merit, it has several options.
One option is to issue a caution, if the committee believes a doctor would benefit from some advice or direction about future conduct. The caution can be in writing or the committee may require the doctor to appear in person to be cautioned, in order to discuss steps the doctor must take to avoid future problems. Doctors who are cautioned in person are usually expected to prepare for the meeting by making practice changes or reviewing relevant medical literature.
The committee may also choose to direct the doctor to participate in training or educational programs to improve his or her practice. If the doctor is believed to be suffering from a health condition that impacts his or her ability to practice medicine, the committee will refer the doctor to a special panel for assessment.
Particularly serious complaints are referred by the Inquiries, Complaints and Reports Committee to the CPSO’s Disciplinary Committee. This committee is made up of both doctors and public members. Unlike the proceedings of the Inquiries, Complaints and Reports Committee, the Disciplinary Committee’s decisions are public and posted on the CPSO’s website.
Disciplinary Committee hearings are adversarial, with each side represented by lawyers. If the committee finds that a doctor has committed an act of professional misconduct or is incompetent, it can revoke or suspend the doctor’s license to practice medicine, or impose terms, conditions or limitations on the doctor’s practice. In cases of professional misconduct the committee may also issue reprimands and fines up to $35,000. In cases of sexual misconduct, it may further require a doctor to cover the costs of counseling and therapy for the patient.
Protecting the public from medical errors
“Every doctor makes mistakes,” says Brian Goldman, an emergency room doctor and host of CBC Radio’s White Coat, Black Art who has called for greater openness around medical errors. “We don’t discover or disclose the vast majority of mistakes that happen around us every day,” he continues, “but anyone who says they don’t make mistakes is living in dreamland.”
The obvious and serious concern for patients is that when doctors make mistakes, it is patients who suffer. Patients want to be able to know if their doctor is deficient in some way, so that they can make an informed decision about whether to see the doctor or seek medical care elsewhere.
In the case of very serious clinical errors and abuse of patients this is possible; because the CPSO’s disciplinary process is public. However, in the case of less serious errors, there is currently no way for a patient to know if their doctor has been cautioned in the past. Nor is there currently any routine follow-up by the CPSO after a caution is issued to verify whether a doctor has made changes to his or her practice.
For very minor errors that posed no danger to a patient, this may be of no consequence, but “if there is an egregious action by a doctor that didn’t reach the threshold for the Discipline Committee,” asks Gerace, “should there be an ability of the public to know that? Maybe there should.”
The role of cautions
While decisions by a regulatory college’s Disciplinary Committee can result in sanctions, such as the revoking of a doctor’s license to practice, cautions are designed to be educational, rather than punitive. They are not used in cases of intentional wrongdoing, but only when the CPSO believes an unintentional mistake has been made. “They’re designed to tell doctors how they should handle issues of a similar nature in the future,” says Gerace.
The advantage of cautions is that an educational approach allows complaints to be addressed relatively rapidly (most complaints take between three and ten months, versus disciplinary actions which can drag on for much longer); with an emphasis on ensuring that the error is not repeated in the future.
“Obviously there’s a question about when that education should be public knowledge… but it’s disappointing that what we’re hearing [from the media] is just ‘make cautions public,’” says Gerace. “This doesn’t even begin to speak to the complexity that should go into making a decision like this.”
The government agrees. Zita Astravas, a spokesperson for Ontario’s Minister of Health Deb Matthews, says “the minister has asked the colleges to continue to review their policies to find places where transparency can be increased, but she has not requested the colleges make cautions public.”
“Cautions are a valuable educational tool for the colleges,” she says, and the minister recognizes that “any changes should be very carefully considered.”
“Unintended Consequences” of reporting cautions
Goldman believes that public reporting of cautions is not an effective way to improve patient safety. “There is a certain segment of the public who has a thirst to name, blame and shame,” he says, “and they think that this somehow demonstrates to us that the system is safer. But it doesn’t work that way.”
Goldman believes that “naming and shaming is not a recipe for improving the system.” Instead, he argues “we need to get doctors to talk more openly about their mistakes in real time… that’s how you reduce errors.”
Goldman’s concern is that publicly reporting cautions will have “unintended consequences.” Chief among these is transforming an educational experience into a legal process. “If the consequence of a caution is going to become a loss of professional reputation, then doctors are going to fight it. They’ll lawyer-up and the process will grind to a crawl.”
But more important for Goldman is that “if the consequence of talking about medical errors is naming and shaming, then no one is going to talk about medical errors. We won’t get any better.” In his view, doctors must promote a culture of openness, not reinforce a culture of silence.
There is some evidence to back up Goldman’s concerns. In 2011 the state of Utah introduced financial penalties for medical errors and preventable hospital acquired infections. In the year that followed only 17 medical errors were reported in the entire state (down from 81 the year prior). Since it is estimated that between 40,000 and 98,000 medical errors occur every year in the United States, many in the medical community believe Utah’s health care professionals have simply stopped reporting errors. There is also research that suggests similar punitive policies in other states for preventable infections had no effect on the actual rate of preventable infections.
If Goldman is right, the public reporting of cautions may have little effect on actual error rates, and could result in the exact opposite of what it is meant to achieve: less transparency, not more.
Following up on serious and serial cautions
One option to preserve the confidentiality of cautions, while enhancing patient confidence in the system, would be for the CPSO to introduce a follow-up system for doctors who receive serious or multiple cautions.
The CPSO does not currently do routine follow-up on cautions to ensure changes have been made to a cautioned doctor’s practice. The college does occasionally follow-up in the case of written cautions, but this is not common practice according to Kathryn Clark, Senior Communications Coordinator for the CPSO.
From the patient standpoint, the lack of routine follow-up for serious cautions raises concerns that doctors may repeat past mistakes. While following up on every caution issued could be prohibitively expensive and likely unnecessary (not all cautions involve risk to patients), following up on cautions that involve significant risk to patients may be a way of avoiding the chilling effect Goldman describes, while assuring the public that cautioned doctors have taken adequate steps to correct any deficiencies in their practice.
Striking a balance between transparency and quality improvement
To date, much of the evidence on reducing errors points towards the effectiveness of system improvements combined with education, rather than punishment of health professionals.
There are clearly areas where the CPSO and other regulatory colleges can and should make rapid improvements in transparency, with the CPSO’s recent bylaw change regarding inspection results of Out-of-Hospital Premises as a perfect example. The challenge for the regulatory colleges as they consider whether to make some cautions issued to individual practitioners public will be to strike a balance between the rights of individual patients to make informed decisions in selecting their health care providers, with the public’s interest in having a healthcare system which progressively reduces the risk of errors as much as possible.
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Publicizing cautions is a very good way to ensure standards and compliance. It works in Torontos restaurant monitoring by pass fail postings at establishments, why not elsewhere? Twitter is taking us that way as it is. It would be best if there were professional metrics involved in balancing risk management. I’d prefer to see professionally worded information over the inflammatory FUD of twitter.
My complaint was against a Doctor, that I took my pregnant wife to. During the pregnancy, he took her out to the movies and dinners. She told everyone, including my father, that the Doctor was gay and like a girlfriend to her.
After the child was born, she had the baptism at the Drs church and the Doctor picked her up at my home.
I warned the Doctor from contacting my wife but he never stopped. One day, he took my wife to an event that I was participating in. I had them removed and the following day, she called the Police to remove me from my home, saying I was jealous of her gay Doctor friend.
She subsequently divorced me and later married this Doctor.
Years later, the Dr wrote my medical conditions and medications, on a court document and gave his medical opinion on my ability to work.
I asked for an audit on my hospital file and was shocked to find out that the Doctor had logged into my file on 2 occasions.
I complained to CPSO but they made my life worse. The Manager did not want to put anything in writing, using the phone or very short emails.
I continued to ask for written documentation and finally, after over a year, I received a letter saying there was not enough proof in my case. I went through the Appeals Board and was successful.
CPSO finally said that they would issue the Doctor, a warning for giving his Medical opinion on my ability to work, as he was a Gynecologist and had never examined me.
I later found out, that the Doctor was a Board member of the Inquiries, Complaints and Reports Committee to the CPSO’s Disciplinary Committee.
That is a clear conflict and absolutely nothing regarding the case was written on the CPSO website.
I feel like I was emotionally raped and years later, I have absolutely no trust for Doctors. This case cost me over $600,000 over the years.
I really don’t see the reason for CPSO. They are only there to protect the Doctors.
Hi Ris . I’m glad you didn’t give up .
It’s so sad what I read. What about the patients? Why would cpso protect only the doctors and not the patient? I know power speaks but what about justice for harmed patient and their family? Caution only will not heal the patient or the entire family .
I just started to have so much faith in cpso but reading through this thread Im not sure anymore .
This was what happened when you don’t publicize cautions:
http://www.stthomastimesjournal.com/2012/12/25/lawyer-urges-greater-transparency
This physician had agreed to be monitored by another physician in exchange of the college not conducting a public disciplinary hearing, and in your words it’s called a caution. Then among 31 complainants, 3 complainants appealed to Ontario Appeal and Review Board. Guess what? The college no longer could continue to issue another caution. The college had to conduct a public disciplinary hearing. Only after this hearing had this physician ceased to perform surgeries and faced panelties.
%featured%Forget about “striking a balance between transparency and quality improvement”. Transparency is the most effective mean of quality improvement.%featured%
While I agree with much of what Dr. Goldman has stated, I cannot agree with all of it. First, I would suggest that the vast majority of doctors facing any type of complaint at the CPSO, would immediately “lawyer up” anyway. There would be absolutely no disincentive NOT to lawyer up. The Canadian Medical Protective Association is a cadillac service, which has more than $4 billion dollars in reserve, to fight for its physician members (most of that coming directly from tax-payers, I might add). The CMPA provides a “fight to the wall” approach for everything from college complaints, to hospital attempts to limit a doctor’s privileges, to criminal charges, to charges of sexual assault. The doctor doesn’t have to pay a dime out of his or her pocket for representation for any of these services, including fighting of a college complaint. Given that the fear of the CMPA is that a patient filing a complaint with the CPSO would then go on to initiate legal proceedings, the CMPA would take no chances in wanting to secure a beneficial outcome to any such patient complaint. Often, a patient whose complaint is not upheld at the CPSO, will believe that he or she will also not likely be successful in court (and often, medical malpractice lawyers would be of the same view).
Second, it has now been 14 years since the ground-breaking “To Err is Human” from the Institute of Medicine. The crisis in medical errors has not improved, despite from the outset, the perspective imbedded in the IOM report that errors are caused by systems rather than people, and that blaming individuals would be unhelpful.
Sometimes individuals ARE to blame. Moreover, sometimes the potential embarrassment and/or litigation which might result from one’s actions is precisely what is needed to keep people careful and thoughtful in their work.
Speaking as a former Medical Laboratory Technologist, I can assure you that the thing always present in my mind and that of many of my colleagues, was the threat of being sued if you made a serious mistake. This led me to be careful and thorough, and to take the extra step needed to avoid a mistake. I cannot see anything wrong in having that looming concern keep health care providers on their toes. And frankly, it keeps people in all other types of employment in check, so why should health care providers get a special pass.
The vast majority of complaints (more than 90%) – if upheld – result in a caution. Forgive me for stating the obvious, but when a health professional makes an error – often one resulting in serious injury or even death – and the best a patient or relative can get is the College to tell the doctor to be more careful in the future, the public can be forgiven for being outraged by this slap on the wrist. I have been in the position, on more than one occasion, of having to explain to client how these cautions are “taken seriously” by the health care providers involved, but no one is looking at this from the perspective of the patient.
Patients want accountability. In fact, that is ALL that the regulatory college can give to them, since they cannot make them whole again, and they cannot compensate them for their injuries. Since less than 5% of complaints ever make it to discipline, then the majority of the public are left with a system that is stacked against them (with the CMPA responding to or assisting with the responses to most complaints) and the few that happen to successfully have their complaint upheld, find out too late that no one else will ever know what the doctor did to them. Moreover, the college itself is not following up on the cautions, so these “repeat offenders” who injure many many patients, are rarely discovered by the college. Almost invariably (as occurred with the need to inspect these independent health facilities) that information is revealed through the media.
This adds to the cynicism of the public who have no reason to believe that the regulated colleges are doing an effective job in policing their own members. Instead, the public understands that the colleges do very little or nothing until prodded by front page coverage of yet another health scandal that should have been picked up long ago by the regulatory authorities, before in morphed into a major media event.
When a patient complains to the College, they are trusting the College to care about what happened to them, and to perform an adequate investigation into their concerns. If the College were to do this, then the doctor’s issues could be addressed at an early stage, and it would save a lot of heartache. When the College dismisses complaints which shouldn’t be dismissed, and/or does superficial investigations into serious matters, there is going to be unnecessary harm. It’s heartbreaking and it’s kept me up many a night.
The CPSO and the CMPA work together to protect doctors, and I believe that doctors need to be protected. %featured%I believe that there needs to be a learning organization, a just culture of safety, and it starts with caring enough about patients to perform an adequate investigation. %featured% Patients should NEVER receive additional harm because they complain to the CPSO.
When “resolving” a complaint causes additional harm, it’s not resolved; not for the patient and their family. Resolution of the complaint in a respectful manner involving the patient would improve the quality of care and would help ensure learning is done. The way that the CPSO performs investigations should be evidence based; if the investigation is seriously flawed, then making the results of that investigation public knowledge could cause more harm than good, in my opinion.
Thank you for the opportunity to be heard.
Thanks for your heartfelt and sincere comments Janice. You make a very good point that many would agree with. I once asked the CPSO if it was possible for them to facilitate a discussion with physicians with a goal to reach agreement about what went wrong and to discuss how the system might be improved– rather than make complaints about individual doctors which usually is a futile, frustrating and indeed, harmful experience. CPSO responded that they did not operate in this manner.
Hi Janice .
Is there additional harm for patient who complain to cpso ? which way will patient and the family members be affected by complaining ?
I’m very concerned , you said the cpso and cpma work together to protect the doctors but then who protect the patients that have been harmed ?
Where can I find additional information on this topic .
Thank you
It would be useful to see examples of issues that might be considered worthy of cautions, both mild and serious.
Hey Gerry, the Toronto Star included a number of examples in the original article it wrote about cautions (here). Of course, since cautions aren't public, it's difficult to say whether these are representative.
Thanks for the reply Jeremy. Indeed, the physician profession as a “brotherhood” is a crucial factor in this debate, and in the reporting of inappropriate care.
But%featured% the fact that physicians have some pre-conceived trepidation about reporting inappropriate care by their colleagues does not completely justify the avoidance of publicly disclosing cautions.%featured% As you said, if public disclosure by the CPSO comes into effect, then already-hesitant physicians may have even less incentive to report on their colleagues.
But say the disclosure requirement comes into effect. Doesn’t this mean that the complaints that actually slip through the cracks (i.e. from patients) become all the more valuable? I’m not saying that the complaints from other physicians aren’t as valuable, but as you mentioned, physicians are not likely to be reporting in the first place, which causes me to question the validity of the whole business of physicians telling on physicians.
One last point Jeremy. I think physicians offer a service to customers (i.e. patients). Really, the whole debate of disclosing note-worthy cautions comes down to the need to communicate a physician’s ability to provide appropriate care to the patient. And I think this is a right patient’s should have. I remember when I was in university, myself and many of my fellow classmates relied on a site entitled “ratemyprofesor.com.” Reading comments from other students about the quality of teaching provided by a particular professor for a particular course was a huge driver for course selection. And I can recall for a particular subject area, it got to the point where professors were motivated to provide quality teaching to obtain a higher rating. Professors that didn’t meet the needs of their students were, rightly so, subjected to being overlooked when it came time to choose courses.
Thanks again for the reply- great article.
I side with increasing transparency with the objective of providing more information to the patient/public. The authors suggest the cautions that pose a risk to patients be made available. Add to that a follow up by the professional college and reporting as to whether the practitioner addressed the caution. It would be an incentive for the practitioner to set the record straight.
I’m struggling with the linkage between the Utah example and the practice of disclosing cautions in Ontario. The authors supposition that medical errors/ hospital acquired infections was reduced due to the imposition of financial penalties makes sense if these errors are self-reported, or if a physician has powers to control which incidents are reported and which are not.
But this doesn’t seem to be the case with the CPSO cautions process. Isn’t the provision of a caution to a physician sourced by a complaint from another health care practitioner and/or patient? I’m also assuming that this reporting process retains the reporter’s anonymity, as such, the other practitioner/ patient cannot really be coerced into NOT sending in a complaint to the CPSO.
The removal of the physician’s power to oversee their complaints/ complaintees validates the process of disseminating and disclosing cautions to me. But I agree with the previous comments that the CPSO should establish some criteria and only disclose incidents with a higher significance (i.e. multiple warnings, etc). The fact that CPSO issues these cautions and does little follow-up to ensure issues have been addressed is particularly concerning.
Hi Navin, thanks for your comment. I'd agree that public cautions wouldn't affect the rate of patient complaints.
However, there is reason to think the Utah example may be relevant with regards to complaints from health care practitioners. In my limited and anecdotal experience, health care practitioners are already loathe to report their colleagues' errors to the CPSO out of a sense of professional loyalty. This reluctance is present even though they know their complaint is anonymous and that their colleagues are unlikely to suffer a significant penalty. If there is suddenly a serious penalty attached in the form of lost reputation, I suspect the reluctance will only get stronger.
Also, some errors can be covered up from patients and other practitioners… the greater the penalty for making an error, the greater the incentive to do the wrong thing and try to conceal it.
I can't say with any certainty whether this will come to pass. However, I think it's worth weighing carefully as we think about the best way to protect the public from medical errors.
Cautions made Public: A consumer of health care services, %featured%I want transparency in order to make informed decisions. I know mistakes are unavoidable and support the current practice mentioned of informing/educating health professionals to reduce errors and give them the opportunity to improve.%featured%
Perhaps 2 approaches can be considered:
1) Have the CPSO follow-up on cautions that involve “significant” risk to patients as suggested above. The health professional is then held accountable to make required improvements knowing the CPSO will verify their willingness & competencies to make them. If improvements are not satisfactory additional analysis and action can be taken by the CPSO – continuous improvement.
2) Make public the “issue” that was cautioned, the frequency of occurance, proposed solution(s),time frame(s) and outcome without revealing those “individuals” cautioned. Knowing the “types” of issues cautioned, how frequently these occur, what is being done and a time frame by when we could expect the issues corrected would provide consumers with more confidence in the health care system and its progress towards improvement.
Sadly, lack of transparency, false starts and many promises not kept over the years has eroded trust that patient issues are being heard, identified and corrected. Additionally, it would enable consumers to highlight an “issue” with their health professional if they are concerned about it, and receive some re-assurance, education from their health care professional.
Learning and improvement is better than a punative approach, better fo the doctor and better for patient safety. Punishment and litigation can lead to an “American style” approach that includes more investigations or difficulty to take on a similar case, not only for the doctor involved. but for other doctors. What are we trying to accomplish? I think it is generally to improve and move forward.
Ever lose a loved one over a doctor’s incompetence? I have. Let us weed out the bad doctors. This is not shaming it’s a fair warning. Not just for the doctor but for the public at large.