Case studies: Shared Code of conduct

Case summary

Amir is a chiropractor who believes Rowan, a more experienced chiropractor at the same practice, has been repeatedly and unfairly critical of his work. Amir has reviewed his work and discussed it with a colleague and they agree that Amir’s practice is at a similar level of competence to his peers. Amir has raised the issue with the other chiropractor but it didn’t help. He considers he is being bullied and is unsure about how to resolve the situation.

Applying the guidelines

Amir reads the code which states at section 5.3 Discrimination, bullying and harassment:

There is no place for discrimination* (including racism), bullying and harassment, including sexual harassment, in healthcare in Australia. Practitioners are expected to contribute to a culture of respect and safety for all. Discrimination, bullying and harassment adversely affect individual health practitioners, increase risk to patients and compromise effective teamwork by healthcare teams. Respect is a cornerstone of good practice and of patient safety. It is a feature of constructive relationships between practitioners, their peers and colleagues on healthcare teams, and with patients. Concerns about disrespectful behaviour are often best handled locally, however where discrimination, bullying and harassment is affecting public safety there may be grounds for regulatory action e.g. consider imposing conditions or accepting an undertaking from the practitioner. 

Good practice includes that you:

4. do or say something about discrimination, bullying or harassment by others when you see it and report it when appropriate
6. escalate your concerns if an appropriate response does not occur
7. refer concerns about discrimination, bullying or sexual harassment to National Boards/Ahpra when there is ongoing and/or serious risk to patients, students, trainees, colleagues or healthcare teams (in addition to mandatory reporting obligations), and

*Discrimination can be against the law if it based on a person’s race (including colour, national or ethnic origin or immigrant status) or gender, sex, pregnancy or marital status, age, disability or sexual orientation, gender identity and intersex status. AHRC (2014) Workplace discrimination, harassment and bullying.

Amir is stressed and upset about the bullying but feels his performance has not suffered and there is no negative impact on patient safety.

Outcome

Amir decides the best option is to follow his workplace policies to address his concern and that there is no need to make a notification to the relevant National Board. A colleague supports Amir to make a complaint to management and the issue with Rowan is dealt with in line with the workplace policies.

The National Scheme’s definition of cultural safety has been included in the revised shared code as well as guidance on how you can ensure culturally safe and respectful practice. This inclusion highlights the important role registered practitioners have in achieving equity in health outcomes between Aboriginal and Torres Strait Islander Peoples and other Australians to close the gap.

Case summary

James is a physiotherapist working as a locum at a multidisciplinary healthcare facility that is the only health care facility in the area. He has not worked in the facility before. He sees a patient, Ruby, a 29-year-old Torres Strait Islander woman who regularly receives care at the facility for chronic injuries. Ruby asks James where the usual physiotherapist is, and he explains that she is unwell and not at work. 

James examines Ruby and decides that she will benefit from therapy she has had before and proceeds with therapy to her hip. Ruby did not feel comfortable with the treatment provided. She did not feel culturally safe as James didn’t explain what treatment he was going to provide or ask if she was happy for him to provide it. Ruby wasn’t comfortable speaking about her concerns with James because she didn’t know him and because she needs ongoing treatment for her chronic injuries from the facility. 

After her treatment, Ruby tells her friend that she felt uncomfortable with the treatment and that she was not given a choice about her care. Her friend suggests that she calls the manager of the facility and tell them her concerns. Ruby isn’t sure at first but calls about her concerns with the support of her friend.

Applying the code

James and the manager review and discuss section 2.2 Cultural safety for Aboriginal and Torres Strait Islander Peoples and the definition of cultural safety in the code. 

Outcome

When the manager tells James about Ruby’s call he realises that he assumed Ruby would be comfortable receiving similar therapy again and failed to consider that she may have cultural and/or personal reasons for preferring to receive some therapies from a female physiotherapist. He didn’t think about cultural and social factors involved in the care he was providing or recognise the importance of self-determined decision-making, partnership and collaboration. By failing to involve Ruby in the therapeutic decision or to ask her if she was comfortable with the proposed therapy he failed to consider his position of power and did not provide culturally safe care to Ruby.

James now understands that the care he provided was not culturally safe and recognises he needs to apply a more patient-centred approach, particularly with patients who identify as an Aboriginal and/or Torres Strait Islander person. James decides to include cultural safety training in his professional development plan.

The healthcare facility supported James to complete education on culturally safe health services for Aboriginal and/or Torres Strait Islander Peoples. The healthcare facility also supported James to provide an apology to Ruby for not ensuring culturally safe care. 

Case summary

Yumiko is an occupational therapist employed as the manager in a small healthcare facility. She notices in the facility’s policy and procedure manual that the procedure for staff to report concerns about risks and incidents has not been updated for some time and it’s not clear how concerns should be raised and dealt with.

Applying the code

Yumiko has recently read the code which states at section 7.1 Risk management: 

Good practice in relation to risk management includes that you:

4. develop and implement risk management processes that identify and minimise risk to reduce harm to patients* and/or to respond to adverse events, if you practise in a setting where local systems are not in place
6. ensure systems are in place for raising concerns about risks to patients, if you have clinical leadership/management responsibilities 

*See ACSQHC NSQHS Standards Risk Management Approach

As a manager Yumiko has a responsibility to ensure that the procedure is kept up to date and that all staff are aware of how to report concerns. 

It is important that reporting and reviewing risks and incidents is timely so they can be dealt with appropriately to help keep patients safe.

Outcome

Yumiko seeks input from relevant staff, reviews industry resources and updates the policy and procedure manual. She arranges for all staff to have training on the updated content. 

Case summary 

Shane is a dentist who practises in a small dental practice. The practice does not have a procedure for reporting and responding to adverse events and near misses that may result in patient harm. 

Applying the code

Shane knows that the code includes information about ensuring systems are in place for managing risks to reduce error and improve patient safety.

Section 7.1 Risk management

Good practice in relation to risk management includes that you:

4. develop and implement risk management processes that identify and minimise risk to reduce harm to patients* and/or to respond to adverse events, if you practise in a setting where local systems are not in place
6. ensure systems are in place for raising concerns about risks to patients, if you have clinical leadership/management responsibilities 

*For a definition of clinical governance see the Definitions section. For additional information see the ACSQHC National Model Clinical Governance Framework and ACSQHC Clinical Governance Standard

Outcome

Shane discusses his concern with the practice owner and they agree that Shane will attend a risk management course and develop a risk management policy for the practice, taking into account material published by the professional association and the practice’s insurers. 

After attending the course, Shane speaks with his colleagues and they agree to hold regular meetings with all practice staff to discuss issues or incidents that have or may have led to patient harm. They agree that the outcome of these meetings is not to attribute blame but to find ways to prevent the same problems happening in future.

Case summary 

Maali is an optometrist working in a remote community. Her sister, who lives in the same community and has glaucoma, asks if she can make an appointment with Maali. 

Applying the code

Maali reads the code and in particular section 4.8 Personal relationships:

Good practice includes recognising the potential conflicts, risks and complexities of providing care* to those in a close personal relationship. Providing care to anyone you have a close personal relationship with, for example close friends, work colleagues and family members; can be inappropriate because of the lack of objectivity, possible discontinuity of care and risks to the practitioner or patient. 

If circumstances require you to provide care to someone in a close relationship, for example in an emergency, good practice requires that you:

1. keep adequate records
2. maintain confidentiality
3. carry out an adequate assessment
4. get appropriate consent to the circumstances which is acknowledged by you and the patient
5. do not allow the personal relationship to impair clinical judgement 
6. maintain the option to discontinue care at all times, and
7. if care is discontinued, ensure that you refer the patient where necessary and/or appropriate.

* For a definition of providing care see the Definitions section

The code advises that providing care to anyone in a close personal relationship can be inappropriate because of the risks associated with a lack of objectivity.

Because of the remote location there are no other optometrists in the area and Maali knows that regular review appointments of the condition are important for effective glaucoma management. She weighs the risks and decides that she will provide care for her sister. 

Outcome

Maali talks to her sister about the additional risks associated with caring for a close family member and lets her know that she will only provide care at her practice during business hours and that her sister is free to discontinue care at any time. 

Maali also explains that if she is concerned that her clinical judgement is affected she will refer her sister to another optometrist for an opinion. Maali ensures that she provides the same level of care to her sister as she would her other patients. She keeps accurate records of her sister’s consent and all care provided.

Case summary

Trang is an osteopath and her patient tells her about the treatment she recently received from another osteopath who works nearby. Trang is concerned that the practitioner may have placed the public at risk by providing treatment that does not meet professional standards. Trang discusses her concerns with the patient, who does not want to make a notification (complaint). 

Trang only has the patient’s account of the treatment provided. As the other practice is close to Trang and the practitioner is in the same profession, she is unsure whether her complaint (notification) might be seen as vexatious. 

Applying the code

Trang reads the Vexatious notifications (concerns) section of the code. 

Section 8.2 Vexatious notifications (concerns)

A vexatious complaint/concern (notification) is one without substance, made with an intent to cause distress, detriment or harassment to a practitioner named in the notification. Legitimate complaints (notifications) are motivated by genuine concerns about patient safety.

Good practice includes that you:

1. raise genuine concerns about risks to patient safety to the appropriate authority (locally and/or the relevant National Board) and comply with mandatory reporting requirements, and
2. do not raise complaints/concerns (notifications) that are vexatious or not in good faith about other health practitioners. These claims may be viewed as unprofessional conduct or professional misconduct and the Board may take regulatory action.

The code states that a complaint motivated by genuine concern about patient safety is not considered vexatious.

Outcome

Trang makes a voluntary notification about the other practitioner to the Osteopathy Board of Australia.

Case summary 

Mohammod is a podiatrist employed in a small podiatry practice. John, the practitioner who employs him, sets a performance target that Mohammod must sell more of the therapeutic products stocked in the practice. Mohammod reviews his patient numbers and informs John that to achieve the target he would need to sell products to some patients who do not have any signs or symptoms that indicate clinical need for the products. 

Applying the code

Mohammod and John read the code and in particular section 8.10 Conflicts of interest which states:

Good practice includes you:

9. do not set performance targets, quotas or engage in business practices that are inconsistent with this code, and/or may negatively impact patient safety, if you employ other registered health practitioners.

Mohammod and John agree that good care includes the quality use of therapeutic products based on the best available evidence and the patient’s needs. 

Outcome

Mohammod and John agree that that this performance target is not appropriate and they remove the target.

Case summary

Rebecca is a medical radiation practitioner working in a hospital. In her work, she has access to personal information about patients. She was curious about a friend who had recently attended the hospital and thought she might look up their records. 

Rebecca did not know if it was okay to do this, particularly as she did not intend to disclose the information to anyone. Rebecca checked the code and the hospitals policies on accessing patient records.

Applying the code

Rebecca checked the code and in particular section 3.3 Confidentiality and privacy which states: 

To protect privacy and confidentiality, good practice includes that you:

3. never access records when not professionally involved in the care of the person and/or authorised to do so

Outcome

Rebecca did not access her friends’ records. She is now aware that unless she was professionally involved in the care of the person, she should not access their records, even if she did not intend to share the information with anyone else. She understands that breaching the code and the hospital’s policy could result in disciplinary action.