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SUBMISSION TO THE HEALTH WORKFORCE ADVISORY COMMITTEE ON THE HEALTH PRACTITIONERS COMPETENCE ASSURANCE BILL
29 NOVEMBER 2002
1 INTRODUCTION
1.1 The Association of Salaried Medical Specialists (the Association) represents salaried
senior doctors and dentists, including specialists. The Association was formed in
April 1989 to advocate and promote the common industrial and professional
interests of our members.
1.2 The majority of our members are employed by District Health Boards (DHBs). About
92% of senior doctors and dentists employed at public hospitals run by DHBs are
members of the Association. While most of our membership work in secondary/
tertiary care in the public sector, a number work in primary care and outside DHBs.
1.3 The Association has a close professional working relationship with the New Zealand
Medical Association (NZMA). We have had the opportunity to input into the
submissions produced by the NZMA and their submission has been endorsed by the
Association.
1.4 The Association is affiliated to the Council of Trade Unions (CTU). We have also
been involved with the working group of professional associations collectively
representing the majority of the 70,000 New Zealand health professionals who will
be covered by the legislation. We have had an input into the submissions produced
by the CTU and the health professionals associations’ working group and agree with
them.
2 BACKGROUND
2.1 In 1995 the Medical Practitioners Act (MPA) put in place a certification regime for
medical practitioners. This Act has only been fully implemented since 2000 when
the requirement for oversight of practitioners with out vocational registration came
into force. The MPA is viewed as one of the most forward looking pieces of
legislation governing medical practice anywhere and provides a comprehensive and
systematic registration system for doctors and safety for patients. It provides for
lay representation on disciplinary and registration bodies a quality assurance
system, yearly recertification, a system of competency review and the mandatory
reporting of doctors who are thought to be unfit to practice medicine because of a
mental or physical condition.
2.2 Other health professionals still practice under a licensing regime. The original
concept for legislation covering all health professionals was to extend the MPA
concepts to other health professional groups. The Association supports this
framework and welcomes the collegiality with other health professionals that it
recognises.
2.3 The Association supports the concept of a certification regime for all health
professionals. The MPA has been working well and provides a sensible model. We
believe that the select committee should use the “MPA for all” as a policy model.
3 PROFESSIONALISM (TITLE)
3.1 In April 2002 the Minister of Health, the Ministry of Health and the Association hosted
the Professionalism Conference. The keynote address was given by Professor John
Luce. From the literature he derived five responsibilities for doctors and five for
society.
Doctors responsibilities were:
* to strengthen ties with patients by being their advocates;
* to enhance peer review of themselves;
* to share power with other practitioners, particularly nurses;
* to advance knowledge, including evidence based medicine when evidence is
available;
* to improve the quality of care.
The state or society’s responsibilities were:
* to appreciate the unique nature of professionalism;
* to allow physicians to manage themselves where possible;
* to support the quality initiatives brought forward by professionals;
* to prevent professional frustration within the work environment and
* to let physicians do good work.[1]
3.2 There is an important difference between responsibility and accountability.
Professionals take responsibility for patients by being on the job and constantly
aware that harm is possible. They do all they can to prevent harm or to mitigate
its effects when it occurs.[2] On the other hand, a model that narrowly focuses on
accountability alone is designed to protect those who might be held to blame. This
leads to a “tick box” mentality and denies the value of professional wariness,
teamwork and the need for the requisite variety in human performance.[3]
3.3 The “unfortunate market experiment” of the 1990s health reforms with their reliance
on managerialism attacked professionalism as provider capture and patch
protection. In this context the ideal “practitioner” was seen, in effect, as a cog in a
production process which would produce results if only the correct procedures were
ascertained and assiduously followed. In this model, if someone makes a mistake,
it is because procedures weren’t followed. Either those that allowed the incompetent
to do the work were at fault, the procedures were faulty or the practitioner was
malevolent or impaired. Complaint, punishment, compensation and constant
monitoring were the required responses.
3.4 This is not how patient safety is best served. Patients need to be cared for by
professionals with strongly internalised ethical systems, constantly wary against
harm to the patient and alert to information about possible threats to the patient
because their motivation is “first to do no harm”[4] not because of regulation or
threat. An accountability model is by definition too late. It is constructed better to
apportion blame rather than improve safety.
3.5 Internalised ethical systems and professional wariness to do the best for patients are
not something that one can legislate but they do require a legislative context that
enables, fosters and requires them. These virtues should be the outcome of a
culture in which safety is a shared value and well structured professional
self-regulation underpinned by consistent legislation.
3.6 Earlier drafts of the Bill used the wording “health professionals” in the title. The Bill
should endorse the concept of professionalism by a name change to Health
Professionals Competence Assurance Bill. This both recognises the special level of
responsibility required and sets a standard for future occupational candidates for
coverage by this legislation.
Preliminary provisions
4 PURPOSE (CLAUSE 3)
4.1 The purpose of the Bill (Clause 3) is to “protect the health and safety of members of
the public”. How does a piece of legislation protect the public? Legislation cannot do
this by threatening or punishing people once the public has been harmed because by
definition that is too late. There is no evidence to suggest that fear of discipline or
punishment leads to safer practice. Legislation best protects the public by helping to
develop a safety culture. A safety culture is a set of attitudes, beliefs, goals, values
and behavioural norms that enhances human performance.[5]
4.2 The source of protection for the public is well-documented in aviation and other
safety critical industries.[6] The factors which create a safety culture are:
* team work;
* a culture that questions (and where it is safe to question and ask for help);
* a culture that promotes confidence but not over confidence.
All of these depend on trust: Trust among those providing the care (the team) and
from those who are being cared for.
4.3 The Bill says that the legislation will protect the public by “providing mechanisms to
ensure that health practitioners are competent and fit to practise their professions”
3(1).
4.4 The “mechanisms” that the Bill proposes will protect the public are:
* consistent procedures for complaints (3 (2)(a));
* scopes of practice and ensuring that no practitioner practises outside their scope
of practice (3(2)(b) and (c));
* restricting certain activities (3(2)(d)) and bringing additional professions within the
scope of the Bill (3(2)(e).
Among the other mechanisms the Bill proposes to protect the public are the sharing
of information among registration bodies, the Health and Disability Commissioner,
employers and ACC (see for instance clauses 33, 34 and 44).
4.5 Consistent procedures for the handling of complaints are a worthy goal however a
system that depends on complaint to remedy adverse events has failed by
definition. There is no evidence that complaints reflect error; they usually reflect
miscommunication.[7] Just as competence differs from performance medical error
may be related to neither (see section 5 below). The only characteristic shown to
distinguish those doctors who are the subject of complaint are poor communication
skills.
4.6 “Scopes of practice” have not been well tested (to our knowledge) in other
jurisdictions. “Scopes of practice” are a concept that is derived from credentialling
in medicine.[8] There is no reason to believe that scopes of practice will
significantly change the risk of harm.[9]
4.7 Research has shown that, although the growth of information technology has made
data easier to collect and compare, the valuable information for learning from one’s
experience is qualitative information not the type collected and produced as “league
tables”. Although “league tables” may, for instance, indicate the possibility of
problems they cannot determine whether variation results from poor individual
performance or other factors such as under-funding or faulty systems.[10] The vain
hope of ascribing incompetence to variations in outcome in the complex stochastic
practice of health care is like mining data banks for fools gold because it excludes
the context in which events occur.
4.8 Neither scopes of practice nor the sharing of information are mechanisms that
guarantee safety from harm.
4.9 Will the Bill if enacted serve its stated purpose of protecting the health and safety of
members of the public? The Association’s view is that it will not because it does not
provide the environment where safety and open questioning are held as values and
instead opts for a system of blame and external control.
4.10 Will the framework, mechanisms and processes set out in the Bill as drafted
jeopardise benefits in the existing system? The Association’s assessment is that it
will because it jeopardises professionalism as an internal value and puts at risk open
learning and adaptive professional behaviour that constantly adjusts to maintain a
safe care environment.
5 COMPETENCE (CLAUSE 5)
5.1 The word competence (which is also in the title of the Bill) is a pivotal concept in the
Bill.
5.2 Competence in its ordinary meaning is an apparent characteristic of human
performance but not a concrete phenomenon or entity. Competence is defined, as
“what the [professional] is capable of doing” but performance is “what the
[professional] does in practice”.[11]
5.3 For doctors there is evidence that competence and performance are not strongly
correlated. A study by Rethans et al[12] showed little correlation between the
performance of general practitioners’ managing simulated patients in the course of
their work and their competence in dealing with the same cases in an examination.
5.4 What a health professional is capable of doing sets the outer parameter of what they
do in real every day situations but is influenced in reality by “personality, mental
and physical health, professional ethics, the standard of premises, equipment and
support staff… workload… time of day” and many other factors.[13]
5.5 A definition of competence is the key definition missing from the Bill.
6 FLEXIBILITY
6.1 In the Bill’s explanatory notes the government states that changes in technology etc
mean that regulatory statutes must be flexible. Where this flexibility leads to conflict
between different health professions (for example the proposal for nurse
anaesthetists) all parties need to engage in a negotiation process in which all can
have faith and trust.
6.2 The Bill moves such decision making to the Minister of Health and to the regulatory
authorities rather than setting it out in statute. The proponents of the Bill suggest
that this makes the Bill enabling rather than prescriptive. The present Minister has
committed herself to a consultative and inclusive approach. However, the Bill does
not make it a requirement for either the Minister or the regulatory authorities to
consult with the health professions. On a number of important issues ranging from
appointment to regulatory authorities through to quality assurance and disputes over
scopes of practice, the Minister has had her powers increased at the expense of the
power of the professions to self-regulate. This is a serious deficiency that will be
detrimental to safe practice and standards of care. This is not only a major
contributor to a sense of lack of control in their lives, which is a major contributor to
professional burn-out, but will lead to the further politicisation of crucial inter –
professional relationships.
6.3 This legislation may be in place for the next 20 years: - meaning a future Minister of
Health that is still at school will be dealing with this legislation. What may be taken
for granted now cannot be guaranteed in the absence of a legislative requirement.
Consultation and criteria for decision making need to be built in to the legislation
not simply available at the Minister’s pleasure.
Part1: Preliminary and key provisions
7 RESTRICTED TASKS (CLAUSE 9)
7.1 The clause provides for the Minister to declare a certain task a “restricted task” by
Order in Council. The argument has been that doctors have certain tasks (such as
prescribing) protected by other legislation whereas other professions do not and
therefore need this clause to protect the public from unregistered practitioners.
7.2 The Dental Council has proposed a definition of a restricted tasks the following:
* “Invasive Procedures with the potential to cause bleeding including surgical or
operative procedures in or below the surface of the skin, mucous membranes or
teeth;
* Procedures to alter the contour or position of the hard or soft tissues of the
oro-facial complex”.
7.3 Psychologists’ organisations have indicated that they are proposing that a restricted
task also be declared in the area of mental health. Either of these definitions have
potential to have an impact on our members such as surgeons or psychiatrists by
making either part or all of their work a “restricted task”.
7.4 The Association and all other submitters are in the position of commenting on a
clause where the content is unsure and impact potentially great but unknowable. At
present invoking the clause does not require consultation with any of the
professions. We are concerned as to:
* how the list of restricted tasks will be developed initially;
* how it will be developed in the future;
* who will be consulted and;
* how changes will be made.
7.5 The Association’s membership includes dentists. Registration is a requirement for
their employment as hospital dentists and therefore they probably require no
additional protection in terms of restricted tasks.
7.6 We suggest that invoking the clause should require consultation with the professions
involved and there should be a requirement for debate, transparency and
disclosure.
Part 2: Registration of, and practising certificates for, health practitioners
8 SCOPES OF PRACTICE (CLAUSE 10)
8.1 “Scopes of practice” are the building blocks of the Bill. Registering authorities (such
as the Medical or Dental Council are charged to “describe the contents of the
profession in terms of one or more scopes of practice” (10(1)).
8.2 The Medical Council has suggested that the scope of practice for doctors will be wide
and will be supplemented by “vocational scopes of practice” describing the different
branches of medicine. At present they propose to use the few sentences used to
describe each vocational branch as the scope. Our concern is with the way the
concept may develop and evolve over time.
8.3 Some professions are defining their scope of practice far more narrowly and some of
the wording in the Bill (see for instance clause 16) suggests an individualised scope
of practice. Officials have suggested that scopes could become specific to the
individual.
8.4 There is no requirement for the authority to consult with the profession when
describing scopes of practice. The present practice of the Medical Council is to
consult with the Colleges. In the Bill any disagreements over scopes of practice will
eventually be decided by the Minister (clauses 123 and 124) presumably on the
advice of the Ministry. There is no requirement for consultation with the profession
out side of the authority who cannot and do not have a profession wide view.
8.5 The implications of basing the professions on this concept in the long-term have not
been debated. Will the scope of practice of a health professional merge with
credentialling or will the concepts remain discrete? Will the scope of practice concept
limit the portability of New Zealand qualifications or New Zealand registered
professionals? Will there be any way of examining or challenging whether the
training/experience or qualifications that an authority proposes for a scope of
practice are sufficient to ensure patient safety? What effects will the concept have
on our ability to recruit health professionals from overseas?
8.6 The Bill should be amended so that the scope of practice remains a generic
description of a profession or a branch of a profession and restrictions on it are
placed on an individual. The clauses that suggest a policy of an individual scope of
practice should be deleted in particular clause 16(1) (b).
8.7 The Ministry appears to have done little work on the implications of the concept
given a very limited response to an NZMA Official Information Act request.
8.8 The long-term implications of the approach need to be debated. The suggestion that
a review after 2 or 3 years be incorporated in the Bill would be a necessary means
to check up how the concept is developing and to monitor and evaluate how it is
being used.
9 PRINCIPLES GUIDING THE PRESCRIBING OF QUALIFICATIONS (CLAUSE 12)
9.1 This clause sets out three principles that a registering authority must use as a guide.
These are that the qualifications must be necessary to protect the public, must not
unnecessarily restrict registration or impose unnecessary costs.
9.2 This will provide a basis for a challenge for a registering authority’s failure to register
a practitioner, which is their right and proper function in the maintenance of
standard. It is likely to mean that the Medical Council’s present policy of requiring a
practitioner to meet the standards of a similarly qualified New Zealand practitioner
will not be sustainable beyond the short-term. The implications of this are unknown
and it is possible that effects on patient safety will only emerge after adverse
events.
Part 3: Competence, fitness to practice and quality assurance
10 MANDATORY REPORTING
10.1 The initial publicity on the Bill focused on earlier drafts’ requirements that it be
mandatory on a health professional that they report a peer who they believe may
pose a “risk of harm to the public by practising below the required standard of
competence”. The present version of the Bill (clause 33) allows such reporting but
does not make it mandatory. There is reason to believe that at least some
submitters to the Bill will want the mandatory element reintroduced.
10.2 Mandatory reporting would lead to the very opposite of a safety culture with an
incentive for practitioners to hide mistakes and cover up error. The Association is
opposed to mandatory reporting.
11 REPORTING BY EMPLOYERS (CLAUSE 33(3) and (4))
11.1 This clause requires an employer to inform an authority should an employee resign
or be dismissed “for reasons to do with competence”.
11.2 “Competence” is not defined in the Bill and appears to be used here in a different
sense than that used in the past in the sense of “review of competence”.
11.3 The wording is imprecise. It could cover competence other than (a) that individual’s
or (b) competencies other than the professional or clinical.
11.4 The consequences are unclear if a dismissal is later found during mediation or by
the Employment Relations Authority or the courts to be unjustified. Resolution of
employment relationship problems through mediation is encouraged by the
Employment Relations Act 2000 (ERA). If a mediated solution is agreed then this
clause is likely to undermine it.
11.5 The requirement to notify if a resignation is on the grounds of incompetence would
also pose considerable difficulty in practice. The employer’s assumption that an
employee resigned on the grounds of incompetence should not be sufficient.
11.6 Clause 33(4) appears to exempt employers from liability to pay compensation, if
they are found to have dismissed a health professional unjustifiably, from any
compensation for humiliation, loss of dignity or injury to feelings or the loss of any
benefit (as provided for under the Employment Relations Act) consequent on their
being reported to an authority.
11.7 The Association believes that these clauses has not been thought through with
regard to their implications in employment law and fit with the Employment
Relations Act.
12 THRESHOLDS (CLAUSE 34, 38 AND 76)
12.1 The Bill uses different thresholds for reporting for no clear reason. Clause 34
requires notification by an authority to the Accident Compensation Corporation, the
Director General of Health, the Health and Disability Commissioner and any known
employer if an authority has reason to believe that the practice of the practitioner
“may pose a risk of harm to the public”. Much of medical practice even of the
highest conceivable standard has a risk of harm to the public. This standard is
clearly too low. The same standard “risk of harm to the public” is used in clause 76
which deals with notification by a Complaints Investigation Committee.
12.2 Among those that are required to be notified that there may be a risk of harm to the
public are employers of the health professional. Should any disciplinary action be
taken by an employer consequent to such a notification we would expect that they
would still have to show substantive grounds for believing that such a risk existed
and would have to follow the due process required by employment law.
12.3 Clause 33 (reporting by peers) and clause 38 (dealing with suspension) use the
standard “risk of harm to the public by practising below the required standard of
competence”.
12.4 The Association is of the view that the threshold for reporting, suspension and
notification should be “significant risk of harm”.
13 QUALITY ASSURANCE (CLAUSES 50-60)
13.1 It is this section of the Bill that had the greatest potential to protect patient safety.
Safety is enhanced in an environment where practitioners can admit to a near miss
or a mistake and work with their colleagues to minimise the risk of such an error
happening again.[14] This helps establish a safety culture.[15] The MPA (Part VI
66 to 75) provides that the Minister of Health may declare an activity a quality
assurance activity, which protects those engaging in such an activity from civil
liability in respect of giving an opinion. Similar protections do not exist for other
health professionals.
13.2 Sadly the opportunity to enhance patient safety by extending the application of
quality assurance has been missed and the Bill also effectively removes protection
for medical practitioners engaged in quality assurance activities.
13.3 The provisions in the MPA to declare an activity a quality assurance activity have not
been used by the Minister of Health as often as would be desirable to develop a
safety culture. Recently the Ministry reported in that they have tightened up on the
criteria for making such a declaration. Activities such as monitoring of the cancer
screening programmes, which seem to be obvious candidates for such a declaration
have not been declared to be quality assurance activities.
13.4 Clause 51 of the Bill introduces three definitions “protected quality assurance
activity”, “quality assurance activity” and “specific significant incident”.
13.5 A protected quality assurance activity is one that the Minister has declared under
section 51 and has made an appointment under section 53. At present, under the
MPA only a declaration is necessary. The requirement for an appointment by the
Minister is new. This means such an activity could no longer be carried out by
clinicians and is one of the instances where we believe increasing discretion is being
given to the Executive arm of government unnecessarily.
13.6 In order to achieve protected status the activity must meet the definition of a quality
assurance activity. Under (c) of the definition a “specific significant incident” is
excluded from the definition of a quality assurance activity. A “specific significant
incident” is defined as an incident that has adversely affected one or more
individuals and is reasonably expected to be the subject of an inquiry.
13.7 Our members advise us that this will effectively mean that many quality assurance
activities will cease because almost no quality assurance activity can be guaranteed
not to have the potential for covering an adverse event that may be potentially part
of an investigation by a commission of inquiry, an inquiry board or the Health and
Disability Commissioner.
13.8 This inappropriate limitation of a quality assurance activity is completely
unnecessary in any event because the Health and Disability Commissioner, Director
– General of health and the police can now investigate any audit they choose. What
is privileged under the MPA, (section 6) is the findings in a quality assurance activity
that might be sought as evidence similarly to the voice recorder or “black box” in
the case of an aircrew. Without this protection there is no capacity to learn from
events and improve and even maintain a safer environment.
13.9 The Association has been negotiating time for quality assurance into our collective
employment agreements. For example, clause 27 of our Auckland DHB collective
agreement covering senior medical staff states:
“The employer requires employees to participate fully in activities which assist with
the development and maintenance of high quality services, and in particular, in the
systems and processes with their service areas designed to review activities. Where
relevant to duties and responsibilities as set out in the job description, time will be
mutually agreed in the job description for clinical, peer review, professional
development and quality improvement.”
This has been done because we believe that quality assurance activity is crucial to
patient safety and to doctors’ clinical and professional job satisfaction.
Part 4: Complaints and discipline
14 SINGLE DISCIPLINARY TRIBUNAL (CLAUSE 80)
14.1 It has been suggested that separate tribunals for each profession be maintained
partly because of cost. Professions other than medicine are concerned that costs
will go up to the level of the present Medical Disciplinary Tribunal.
14.2 One tribunal will serve to build up expertise in the permanent and lay members of
the panel and fits into the concept of one set of rules for all health professions.
14.3 The Association supports having one tribunal with panels of peers from the
appropriate profession.
15 MINORITY OF PRACTITIONERS ON DISCIPLINARY TRIBUNAL (CLAUSE 84)
15.1 This clause provides for a disciplinary tribunal consisting of the chair or deputy chair
of the tribunal, 2 lay persons and 2 peers of the practitioner. This is a change from
past practice in medicine where such tribunals have had a majority of peers. It is
an important move away from self-regulation which sends the wrong message to
professionals.
15.2 The Association believes that the majority of the disciplinary tribunals’ panel should
be made up of peers of the health professional being disciplined.
Part 6: Structures and administration
16 ELECTION OR APPOINTMENT TO REGULATORY AUTHORITIES
(CLAUSE 116(3))
16.1 This clause allows for the election of practitioners to an authority if the Minister of
Health decides to so regulate. The Minister has apparently indicated that she won’t
regulate to allow for elections. This is an important blow to the concept of
professional self-regulation and means the current elections to the Medical Council
are likely to be among the last.
16.2 The Association believes that at least 50% of the professional representation bodies
must be elected. Professionals fund the regulatory bodies and should have the
opportunity to elect their representatives.
16.3 Wholly appointed bodies do not provide the representation and the sense of “buy in”
of an at least partially elected body.
17 SETTING OF ETHICAL STANDARDS (CLAUSE 114(i))
17.1 Presently the profession through the New Zealand Medical Association has the key
role in setting ethical standards. The Bill proposes that this now be done by the
registering authorities.
17.2 The Association strongly supports the setting of ethical standards by the profession
itself through the New Zealand Medical Association.
18 RIGHT OF COMPLAINT TO HUMAN RIGHTS REVIEW TRIBUNAL (CLAUSE 231)
18.1 This clause provides for individuals who, despite a finding of breach by the Health
and Disability Commissioner do not have their complaint referred to or taken up by
the Director of Proceedings, to take a complaint directly to the Human Rights Review
Tribunal. This is likely to be in cases where the Health and Disability Commissioner
or Director of Proceedings believes a complaint is trivial or settled.
18.2 The Association believes that this right of appeal is unnecessary for the protection of
the public, has the potential to multiply avenues for complaint and should be
removed.
19 TRANSITION
19.1 Legislation as significant as this Bill has to have some thought and effort put into
transition. The Medical Practitioners Act only came fully into force in 2000. Those of
us who remember the Parry inquiry will recall the frustration of the complainants
when confronted with confusing parallel structures for complaints that took place
before 1996 and those that took place after. This left an enduring impression that
the medical profession was obfuscating the transparent settlement of complaints.
On the passage of this Bill there will be three regimes for medical practitioners and
two for each other profession though all will ultimately go to the same tribunal(s).
19.2 The Association is concerned that some effort is put explaining the implications of
the legislation to health professionals and to the public.
19.3 The Bill is a complex piece of legislation and many of its impacts on the professions
it will regulate and on New Zealand’s health system are unknown. The legislation
should have a review after 2 or 3 years built into it so that these impacts can be
assessed and the good retained and the bad rejected.
1] “Fundamentals and First Principles of Professionalism in a Modern Health System” John
Luce, MD Professor of Medicine and Anaesthesia , University of California San
Francisco, Address to Professionalism Conference 2002
[2] Reason J 2000 “Human Error: Models and Management” BMJ 320 pp 768-770
[3] Weick,K 1987 “Organisational Culture as a Source of High Reliability” in California
Management Review 39 (2) p 125-127
[4] This phrase is from the Hippocratic oath
[5] Van Cott H 1994 “Human errors: Their causes and reduction” in Bogner Human Error
in Medicine Hillsdale, NJ. Lawrence Erlbaum Associates
[6] Reason 1997 “Managing the Risks of Organisational Accidents” Aldershot, Ashgate
Publishing Ltd and Cook R & Woods D “Operating at the Sharp End: the Complexity of
Human Error” in Bogner, M (ed) Humans Error in Medicine Hillsdale, NJ Lawrence
Erlbaum Associates.
[7] Tracey J and St George I “The competence and performance of medical practitioners”
NZMJ 2001 p167-169
[8] See Toward Clinical Excellence –A Framework for the Credentialling of
Senior Medical Officers in New Zealand, Ministry of Health, March 2001
[9] McArthur C 2001 “Credentialling: a new system for professional practice, Clinical
governance and Quality Assurance in Healthcare” 20-21 November 2001 Auckland
[10] Tracey and St George (op cit)
[11] Tracey and St George (op cit)
[12] Rethans J J, Sturmans F, Drop R et al “Competence and performance: two different
concepts in the assessment of quality medical care” Fam Pract 1990; 7:68-74 quoted
in Tracey and St George (op cit)
[13] Tracey and St George (op cit.)
[14] See Merry A and McCall Smith A 2001 “Error Medicine and the Law” Cambridge
University Press
[15] “In pursuit of a Safety Culture in New Zealand Public Hospitals” Peter Roberts Master
of Public Policy Thesis, Victoria University of Wellington, 2002
