How Can We Make Health Regulation More Humane? A Quality Improvement Approach to Understanding Complainant and Practitioner Experiences

The regulation of health practitioners aims to serve the public interest by ensuring that only those who are fit to practice safely are registered. One important way regulators seek to achieve this is by responding to complaints or concerns (referred to in this paper as “notifications”— the common terminology used in Australia) about individual practitioners that may raise questions about adherence to professional standards and public and patient safety. This study focuses on the Australian Health Practitioner Regulation Agency (Ahpra), through which more than 730,000 practitioners are registered.1 Ahpra works in partnership with 15 health practitioner boards and manages notifications related to a practitioner's performance, health or conduct that may place the public at risk of harm. In Australia, patients and the public are the largest source of notifications about health practitioners,2 with similar trends internationally.3 

Regulators worldwide are increasingly focusing on the experience of complainants and practitioners. This is in response to high levels of reported dissatisfaction and increasing recognition that the regulatory process can cause unintended harm to those involved.3–7 Few studies to date have considered both the complainant and practitioner experience together.

Public involvement forms the backbone of health regulation, enhances the legitimacy and accountability of the regulator, and gives a voice to community concerns.8,9 Poor experiences by complainants in a regulatory system are likely to erode confidence and reporting of notifications. Community trust and engagement with the regulator is fundamental for an effective reporting culture in which people appropriately make notifications.10–12 

Previous work has highlighted the adverse health impacts, largely stress-related, that being subject to a notification can have on a practitioner.6,13–16 Studies have shown physicians subject to a notification were at higher risk of suicidal thoughts, anxiety and depression compared to their peers,6 reporting anger, guilt, depression and shame following a notification.14 These studies reported practitioners practicing defensively, becoming overcautious and avoiding more complex patients,6 with reduced trust and less goodwill towards patients.14 

The aim of this work was to better understand the experiences of both complainants and practitioners subject to a notification in Australia and use that understanding to make changes targeted at increasing confidence in the regulator. Trust in the purpose and fairness of the notifications process is of critical importance for all professional regulators and complaints processes more widely.

Complainants and health practitioners, with a recently closed notification with Ahpra, were invited to complete an anonymous survey about their experience. This study analyzes data from January 2017 to July 2018. We did not survey practitioners with a health impairment-related notification. No information was collected on the notification itself, its management or the time to closure.

Survey questions included closed- and open-end questions on overall satisfaction with the notification's management and outcome, as well as demographic information. Respondents indicated their level of agreement or disagreement to closed-end questions on a five-point Likert scale. Wilcoxon matched-pairs signed-rank sum tests analyzed the difference between complainant and practitioner responses, significance set at p < 0.05. Practitioners were also asked to give a rating from 1 to 10 about how stressful the process was.

Open-end questions addressed what had worked well and how the respondent's experience could be improved. We performed separate thematic analyses on the complainant and practitioner responses.17,18 First, an original coding frame was developed. When new codes emerged, the coding frame was adjusted, and the survey responses were reanalyzed to fit the new framework. This process was used to develop categories that were conceptualized into broad themes. All conflicts regarding the interpretation of a theme were discussed within the research team until a consensus was reached.

Consent was provided by all survey participants to use the survey information for quality improvement purposes and to publish the results. All survey responses were anonymous. According to the policy activities that constitute research at Ahpra, this work met the criteria for operational improvement activities exempt from ethics review. This quality improvement paper is presented as per SQUIRE guidelines.19 This investigation was conducted in accordance with the Helsinki Declaration (2013).

Survey responses were received from 1,311 complainants and 1,687 practitioners; the response rate for both groups was 22%. We excluded responses from 94 complainants and 83 practitioners, who provided only demographic details. The final sample for analysis included 1,217 responses from complainants and 1,604 from practitioners. Of these, 974 complainants and 545 practitioners provided free-text comments on what could have improved their experience, while 468 complainants and 21 practitioners provided free-text comments on what worked well.

Of the complainants, 60% were female, 39% male and 1% did not specify their sex. The majority were patients or patient representatives (68%). Health practitioners (24%) and education providers (6%) were also represented; the remaining selected “other.” Complainants were mostly aged 35 to 54 years (49%) or over 55 years (37%); 14% were less than 34 years. Practitioner respondents included medical practitioners (50%), nurses (19%), psychologists (9%), dentists (7%), pharmacists (5%) and others (10%).

More than half the complainants agreed it was easy to find information on submitting a notification (56%, Table 1), submitting the notification itself was simple (52%) and that they had been able to submit all relevant information (56%). Similarly, 49% of practitioners felt it was easy to find information about the notification management, 62% felt they were given adequate opportunity to respond and 70% were satisfied with the outcome.

When asked about what aspects worked well, complainants often referred to the telephone communication with Ahpra: “My first contact on the phone was great; she made the process easy.” Where phone contact was made, complainants often described that as being an important humanizing element of the process. Practitioners also noted the value of this: “I thought that my contact person allocated by Ahpra was very understanding and compassionate every time I had to contact her.”

Most complainants were dissatisfied with the overall management of the notification (66%) and the outcome (71%, Table 1). From 974 open-ended responses, four main themes emerged around complainant dissatisfaction: (1) fairness, (2) communication, (3) outcome and (4) timeliness (Figure 1, Table 2).

Only one-third of practitioners felt they were adequately updated on the progress of their notification (32%, Table 1). While practitioners with a matter closed after an initial assessment felt the process was timely (51%), those with matters closed after further investigation were less likely to agree that the process was timely (70%) or managed well (54%, Table 1). From the 545 open-ended responses, four major themes emerged relating to negative practitioner experience: (1) timeliness, (2) stress, (3) fairness and (4) communication (see Figure 2, Table 2).

You were not impartial: Many complainants referred to a perceived lack of impartiality in the management of the notification and decision. This contributed to a lack of trust in the process and “not having a chance.” Many also felt the process unduly protected the health practitioner.

I didn't feel heard: Many complainants commented on their sense that they were not being taken seriously, not being listened to, or not being understood. They questioned why Ahpra had not “followed up” to ask for more information or seek clarification from them.

The process felt unfair: Complainants felt Ahpra had not investigated their concerns properly, relied on inaccurate information and did not verify “false facts” (provided by the practitioner) and did not do enough to “collect all the evidence.”

I had no opportunity to respond: Some complainants were frustrated that they were not given the opportunity to challenge, respond to, or clarify the outcome.

You didn't update me: A substantial number of complainants commented on receiving no or infrequent communication regarding the progress of their notification, leaving them feeling “alienated” and wondering if their matter had been forgotten. Some felt there was a “complete lack of transparency.”

You didn't explain the process: Many complainants felt Ahpra's role and functions were not clear, particularly in understanding the outcomes that can and cannot be achieved via the regulator.

You didn't communicate well: Complainants reported that the communication was at times “inhuman,” “impersonal” and they wanted more face-to-face or phone contact. The tone of written communication was referred to by one complainant as “incomprehensible bureaucratese.”

I didn't understand the outcome: Complainants commonly mentioned a lack of clarity in the outcome letter. The wording in the letters was considered “vague,” “bureaucratic,” “impersonal,” “insensitive,” with “inappropriate assumptions.” Fifty complainants said they did not know that an outcome had been reached, yet due to the anonymous nature of the surveys the reason for this cannot be verified.

I didn't agree with the outcome: The majority of complainants did not agree with the outcome. Comments reflected on the process being a “waste of time,” “the practitioner was not made accountable,” and outcome “failed to act in the public interest.”

You took too long: Many complainants were disappointed with the time taken to reach an outcome. They found this frustrating, unreasonable and stressful, with some describing adverse impacts on their personal and work life.

The process felt unfair: The investigation was described as inadequate and many practitioners believed it did not involve clinical experts. Practitioners often felt the “complaint was not put into context” and did not consider the “stressful environments” of their practice. Comments also reflected on the investigation process being “secretive,” suggesting a lack of transparency contributed to a lack of confidence: “it is hard to have confidence in an anonymous system.”

The notification was minor or groundless: Many practitioners felt that the notification was “inappropriate,” “invalid” or “a waste of time.” Practitioners felt vulnerable to “vexatious” or “groundless” notifications. “...It is time-consuming and stressful to have to reply to a petty complaint in my case…There should be a better way to triage these complaints…”

You were not impartial: There was a common sentiment expressed by practitioners that the process was biased against them, that they were treated like a criminal, and felt “guilty until proven innocent.”

You didn't communicate well: Some practitioners described the communication received as unhelpful. They felt the communication was at times “intimidating,” “defensive” and lacked “empathy” and “humanity.”

You didn't update me: The lack of regular and useful (informative) updates on the progress of the notification was a source of frustration to many practitioners. The lack of information led to feelings of anxiety and stress; “better ongoing communication would have made the matter a lot less stressful.”

You didn't explain the process: Some practitioners felt that the notifications process was not explained and that they “lacked specific information” regarding decisions or the notification itself.

This impacted my health and well-being: When asked how stressful the notifications process was on a scale of 1 to 10 (with 10 being extremely stressful), 89% selected ≥ 7, with 51% selecting 10. Many practitioners felt this stress was not adequately acknowledged by Ahpra. Practitioners noted that the negative effects were often long-lasting and impacted on both their personal and work life. Timeliness and the lack of useful updates often heightened their stress levels.

You took too long: Many practitioners commented on the length of time required to reach a conclusion. A lengthy process prolonged the stress experienced by the practitioner.

You didn't give me enough time to prepare: A subset of practitioners described the time allowed for their response with words like “inadequate” and “unacceptable.” This was contrasted with the lengthy time taken by Ahpra.

This study analyzed survey responses from more than 1,200 complainants and 1,600 practitioners with a closed notification with Ahpra, providing important insights for initiatives targeted to make health regulation more trustworthy and humane for all involved. Three important findings emerged from the data.

First, there was a strong synergy between the concerns raised about the notifications process by complainants and practitioners. Both groups commonly felt the process was not fair or impartial, that there was a lack of transparency, and that the updates were too infrequent and devoid of useful information. Second, the most notable difference between the groups was their view of the adequacy of the notification outcome. Most complainants (71%) were dissatisfied with the outcome. Conversely, most practitioners (70%) were satisfied with the outcome of their matter, yet many felt the regulatory threshold for even considering the notification was too low. Third, the level of stress experienced by practitioners was high and seen as under-appreciated by the regulator.

Designing regulatory processes that are robust and humane is a complex and multifaceted task, which requires attention to both intended and unintended consequences. Trust in the regulator depends in part on the belief that a reasonable outcome has been achieved.20,21 However, the definition of “reasonable” may differ for complainants and practitioners (Table 2, Fairness), depending on their view and understanding of the role of the regulator, the nature of the event, and what they see as the most appropriate outcome.4,10,21–24 Our findings suggest that both complainants and practitioners are unclear about the role of the regulator, the thresholds for assessing or investigating a notification (Table 2), and what can be expected to be achieved through the regulatory process. Regulators need to place greater emphasis on communicating the possible outcomes that can be achieved and the processes by which an outcome is reached.

The high levels of reported practitioner stress aligns with previous findings.5,13–16 Here, many practitioners connected their stress levels to the length of time taken and a lack of information (Table 2). This suggests that some, but not all, of that stress is linked to tangible elements of the notification process which are amenable to change — for example, the timeliness, fairness, transparency and personalization. Practitioners also commonly described feeling that they were seen as guilty by the regulator, often both before and after a favorable outcome (Table 2). We believe this perception impacts significantly on practitioner stress, yet is much harder for the regulator to change.

The identified issues and concerns are not unique to Australia and apply to complaints processes more widely.25 We, thus, suggest that new approaches are required for regulators worldwide.

First, the nature of the desired experience for complainants and practitioners should be clearly defined. In the case of Ahpra, the organization is developing service principles that include respect, listening, transparency, updating, timeliness, apology, improvement and fairness to describe a “good experience.”

Table 3 summarizes proposed action steps to guide future initiatives targeted at an improved complainant-practitioner experience. The model is focused on clarifying public knowledge around three key aspects of health regulation: (1) the role of the regulator, the complainant and the practitioner; (2) the purpose of the regulatory process and greater transparency around the process; and (3) the limitations of regulatory outcomes and reasons for outcomes (Table 3).

Second, it is important to set clear expectations early in the process. Previous studies have suggested that so-called “expectation gaps” may contribute to the high levels of dissatisfaction observed in complainants.4,11,23,24 Our findings also support this, with many complainants disagreeing with the outcome (Table 1), or potentially arriving at the regulator's door with unrealizable expectations about the outcome (Table 2). Similarly, our findings indicate that practitioners often do not understand the regulator's obligation to assess all notifications that meet basic legal grounds,9 leading to an early belief that the process is flawed and biased against them (Table 2). Further, while a regulatory process may always be associated with stress for many practitioners, the extremely high levels of reported stress appear to be disproportionate to the profile of regulatory outcomes. In Australia, less than 30% of notifications result in any regulatory action and less than 1% end in the suspension or cancellation of a practitioner's registration.2 Clarifying and setting appropriate expectations early may improve confidence in the process and acceptance of the outcome.4,11 There may also be benefit in initiatives to guide complainants to the most relevant organization for their concern.

Third, commit to ensuring fair and impartial processes and communicating these well. Complainants and practitioners shared similar concerns about the overall fairness and the nature of the communications they received, describing the experience as impersonal and dehumanizing (Table 2). A fair process can be recognized, in part, with clear explanations of what can and can't be done, what is being done, what was done and why. Empowering and supporting regulatory staff with the permission, tools and skills to interact in a more personal and empathic way, while maintaining impartiality and efficiency, may also require a cultural change for most regulators.

Ahpra, along with other health practitioner regulators internationally,26 has introduced ongoing staff training in effective communication strategies, including active listening skills, the capacity to respond to people in distress (including threats of suicide and self-harm), managing expectations, communicating outcomes and responding to complaints about the process. Initial feedback from Ahpra staff has been positive, noting the direct relevance for their daily work. However, an evaluation of the impacts of these initiatives is required to ensure staff are adequately equipped.

Fourth, communicate better. Complainant and practitioner feedback in this study highlighted the impact of both oral and written communication for the experience of both groups (see Figures 1 and 2 and results section: positive aspects). Thus, we believe that improving the tone and clarity of correspondence with complainants and practitioners is an important consideration for regulators hoping to improve experiences.26 

Finally, our findings suggest that complainants place a high value on clear and fulsome reasons for regulatory decisions (Table 2). Independent to these survey findings, amendments were recently made to the National Law in Australia (September 2017), allowing national boards to inform complainants of the reasoning behind outcomes.27 This new power is designed to improve the complainant experience and help them to better understand regulatory outcomes.

Due to the study's descriptive nature, no causal conclusions could be made. Response biases must be considered when interpreting the findings, with most survey respondents being dissatisfied. Also, some notifications may have required months to years to reach an outcome. No information was collected on the non-responders. Finally, information on the complainants' initial expectations was not collected.

This study highlights the value of systematically collecting feedback from complainants and practitioners about the notifications process with both groups reporting substantial concerns about their experience. These concerns are not unique to Australia and apply to complaints processes internationally. The symmetry of issues for both parties — expectations, fairness, transparency, communication, timeliness and empathic contact — highlight the importance of understanding the combined complainant and practitioner experience. This experience can and should lead to improvements in the notifications process. Achieving trust and confidence from both the community and regulated health practitioners is fundamental for effective and humane regulation to keep the public safe.

The authors would like to thank the individuals who responded to the surveys for their contribution and Ahpra's notification staff for their commitment to this work. The authors would also like to acknowledge the contribution of Dr. Anna van der Gaag, Dr. Marie Bismark, Dr. Joanna Flynn, AM, Matthew Hardy and Dr. Mary Russell.