June 2013

Issue 5

• Note from the Chair 
• Position statements on providing health information and paediatric care 
• Evidence-based practice (EBP) 
• Murdoch University EBP study – invitation to participate 
• Quarterly data update 
• Notifications information for practitioners 
• Notifications matters: case studies 
• Registration matters: case studies   
• Audit pilot: compliance with registration standards 
• CPD log book 
• National Boards’ review of common registration standards 
• Update your contact details 
• Keep in touch with the Board 

Note from the Chair

July 2013 marks three years since operations began under the National Registration and Accreditation Scheme (the National Scheme). As National Boards undertake the scheduled review of their standards and guidelines it becomes increasingly apparent that what is new is no longer new. The need to embrace the change to the National Scheme, and the educative and helpful approach required to achieve this, is less now and the National Boards are refocusing to develop more cross-professional consistency and stronger guidance for practitioners.

Much has been achieved in the transition to the National Scheme, with many of the objectives of the scheme such as portability and consistency either achieved or well underway. There is still much work to be done, and the Australian Health Practitioner Regulation Agency (AHPRA) and the National Boards remain committed to fulfilling the requirements and objectives of the Health Practitioner Regulation National Law, as in force in each state and territory (the National Law).

The Chiropractic Board of Australia (the National Board) sets the standards, codes, and guidelines and will continue to work to ensure that practitioners are aware of the requirements of the National Board. The National Board has clear expectations around practitioner conduct and performance, and practitioners will be held to account if they do not meet these standards.

It is critical that practitioners understand their professional obligations. The National Board is currently consulting on a number of standards, codes and guidelines, including a further revision of the Code of conduct for chiropractors. For practitioners, reviewing these documents and perhaps even providing feedback to the Board is a fantastic way of understanding your obligations and assisting the National Board in finalising the content of these standards. The National Board welcomes feedback from anyone in relation to its standards, including members of the public.

Since the last newsletter the National Board has released two position statements, one on the provision of health information and one on paediatric patients. These have been issued to ensure that the National Board’s position is clear on these issues to both the profession and the public.

Dr Phillip Donato OAM
Chiropractor
Chair, Chiropractic Board of Australia

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Position statements on providing health information and paediatric care

The role of the National Board is to protect the public consistent with the National Law.

In regulating the chiropractic profession, the Board is responsible for registering practitioners and setting the professional standards they must meet to make sure the public has access to safe and competent services from the profession.

The Board has recently published two position statements:

Providing health information (including vaccination)

Chiropractors have a responsibility to promote the health of the community, and are obliged to give balanced, objective and evidence-based information to patients, to help them make informed health decisions.

Practitioners may be asked to provide information not directly relevant to their competency or the scope of their practice; in such cases patients should be referred to someone with sufficient expertise in that field to have their questions answered.

Advice about vaccination is not typically within the usual area of practice for a chiropractor. Current evidence indicates that preventive measures such as vaccination are a cost- effective and clinically effective public health procedure for certain viral and microbial diseases.

Practitioners should consider the balance of benefit and harm in all clinical decisions, based on best available information.

Paediatric care

Chiropractors need to deliver effective health care within an ethical framework. Like all health practitioners, chiropractors must take particular care to gain informed consent when managing the care of children and young people.

While individual chiropractors have their own beliefs and values, the Code of conduct for chiropractors makes it clear that those values must be secondary to the wellbeing of their patients and the promotion of health in their patients and the community. The Board expects chiropractors to offer balanced, non-biased health advice to their patients. When treating children and young people, this includes parents and guardians, as appropriate.

In maintaining good practice, practitioners should consider the balance of benefit and harm in all clinical decisions. Any care options or recommendations made to patients should be based on the best available information. If the care needs of a patient are beyond the skills, knowledge or experience of a practitioner the Board expects them to appropriately refer that patient to another healthcare provider.

We encourage you to read the position statements, which are available in the FAQ and fact sheets section on the Board website.

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Evidence-based practice (EBP)

The National Board is committed to ensuring that chiropractors conduct their professional practice in an evidence-based manner. The use of an evidence-based approach is universally agreed as the most appropriate model for the contemporary practice of any profession and is consistent with the expectations of the patients whom chiropractors care for.

Evidence-based practice (EBP) is also known as evidence-informed practice, evidence-based treatment, evidence-based healthcare, and even evidence-influenced practice. Regardless of the name, as it relates to clinical decision-making by chiropractors, the proper integration of three elements is critical. These elements are:

1. the best available evidence 
2. the clinical expertise of the practitioner, and 
3. the patient’s values and expectations.

The National Board has provided clear guidance throughout many of its codes and standards by directing practitioners towards an evidence-informed approach. The number of advertising offences and issues arising as part of the notifications process clearly indicate that there are some practitioners who are not conducting their practice in this manner.

Therefore the National Board has determined to move to the use of the more explicit term evidence-based practice and produce some supportive material for practitioners around the issue of evidence.

This material will be published as fact sheets and FAQ on the National Board’s website over the coming months.

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Murdoch University EBP study – invitation to participate

Dear Colleague,

We invite you to participate in a study examining evidence-based practice in Australian chiropractic. To date, Australian chiropractors’ views on EBP have not been heard. This is an opportunity for your views on EBP to be recognised.

The study is supervised by Dr Norman Stomski, Dr Randy Beck, Dr Simon French, Dr Jeff Hebert and Dr Bruce Walker at Murdoch University.

Importantly, please read the information letter, placed at the very beginning of the online questionnaire, before you decide to participate.

If you elect to participate, please complete the online questionnaire.

The responses to this questionnaire are anonymous.

If you have any questions about the study please contact Dr Norman Stomski on (08) 9630 6038 or email n.stomski@murdoch.edu.au.

Yours sincerely,

Dr. Norman Stomski
School of Health Professions
Faculty of Health Sciences, Murdoch University
Murdoch WA 6150

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Quarterly data update

The latest data about the profession is now available. As of March 2013, there are 4,637 chiropractors in Australia, of whom 259 are non-practising.

There are 38 chiropractors endorsed to perform acupuncture, all located in Victoria.

Chiropractors: State and territory by registration type

% By age group

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Notifications information for practitioners

AHPRA has published new guides for health practitioners and the community about how notifications are managed in the National Scheme.

The Guide for practitioners and a series of fact sheets explain to practitioners what happens when AHPRA receives a notification on behalf of a National Board. The information complements the direct correspondence that individuals receive if a notification is made about them.

AHPRA has also developed a guide for the community about making a complaint (or notification) about a health practitioner.

Both guides are published online on the AHPRA website in a revised section on notifications and are accessible via the National Board websites. AHPRA collaborated with the professional associations for practitioners registered in the National Scheme to develop the guide for practitioners.

Notifications matters: case studies

The Registration, Notification and Compliance Committee of the National Board meets monthly and considers notifications about chiropractors received by AHPRA on behalf of the National Board. To assist all practitioners to provide safe and effective chiropractic care and to inform the community, the National Board will provide examples and summaries from time to time to highlight certain issues. While tribunal and panel decisions are published by AHPRA, some matters may not progress to that stage yet may contain valuable information for practitioners.

The National Board takes deviation from the required professional standards and conduct expected of chiropractors very seriously and will hold practitioners to account for their professional responsibilities.

As part of AHPRA and the National Boards’ commitment to transparency, information is published about panel and tribunal decisions for all professions. AHPRA has published a table of panel hearing decisions and summaries of court and tribunal decisions for all professions.

In this edition of the newsletter we have included case studies about requests for reports and clinical records and maintaining adequate clinical records.

Request for report and records

Dr U received a request from a law firm for a report and copies of the clinical records for a patient who was Dr U’s client. The request was accompanied by the proper signed authority from the patient.

The practitioner failed to provide a report and a copy of the patient’s clinical records. State-based health records legislation endorses a patient’s right to their healthcare information by requiring practitioners to comply with the request for a copy of the patient’s records.

A Performance and Professional Standards Panel hearing found that the practitioner behaved in a way that constitutes unsatisfactory professional performance in that their knowledge, skill or judgment possessed is below the standard reasonably expected of a health practitioner of an equivalent level of training or experience (section 5 of the National Law). Dr U was required to undertake further education on matters relating to professional conduct and the management of clinical records.

The lessons to be learned from this case are that practitioners have a responsibility to:

• comply with a lawful request for a copy of a patient’s health records 
• promptly provide copies of clinical records when requested by a patient, and 
• comply with any relevant state or territory legislation that applies to chiropractors, particularly health records legislation.

Maintaining adequate clinical records

Dr V was referred to the National Board by a state government workers compensation third-party payer. Dr V was alleged to have:

• failed to keep accurate clinical records 
• kept inadequate clinical records of services performed, and 
• provided treatment that is not in line with that payer’s workers compensation clinical framework for the delivery of health services.

The practitioner admitted to engaging in unprofessional conduct and agreed to complete a program of further education on matters relating to health records and billing practices.

Dr W was referred to the National Board by a different government third-party payer (transport accident agency). The agency alleged that Dr W’s clinical records for several patients contained minimal information and did not adequately demonstrate:

• worker history, examination and treatment 
• a treatment plan/goals/revision of goals 
• objective and subjective reassessment against treatment goals 
• evidence of functional progression, or 
• informed consent.

The practitioner admitted to engaging in unprofessional conduct and agreed to complete a program of further education on matters relating to health records.

The lessons to be learned from these cases are that practitioners have a responsibility to:

• maintain accurate and adequate clinical records (the National Board’s Guidelines for clinical record-keeping can be found under the Codes and guidelines tab on the website)
• provide care within a third party payer framework that meets the requirements of that framework, and 
• keep clinical records that show a patient’s subjective and objective presentation, care provided and response to treatment/care.

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Registration matters: case studies

The Registration, Notification and Compliance Committee of the National Board meets monthly and considers matters relating to the registration of chiropractors. To assist all practitioners to comply with the registration requirements of the National Law, the National Board will provide examples and case summaries from time to time to highlight certain issues.

In this edition of the newsletter we have included case studies related to CPD variations/exemptions and recency of practice.

CPD variations/exemptions

Practitioners can apply for exemption from or variation to the CPD requirements in exceptional circumstances. This may be full or partial. Generally, exceptional circumstances would be circumstances that would enforce a substantial absence from practice upon a practitioner. These include ill-health, bereavement, maternity leave, acting as a carer or other such circumstances.

All decisions about what constitutes exceptional circumstances will be made on a case-by-case basis. Usually, any event that results in an involuntary absence from practice for a substantial period, such as three months or more, is likely to be considered an exceptional circumstance by the Board. Other events would have to satisfy the Board that these circumstances had a very significant negative impact on a practitioner’s ability to undertake CPD.

Written request for exemption

Practitioners must apply in writing to the Board should they think they are entitled to an exemption due to exceptional circumstances. Applications should be made in advance of the renewal of registration.

A written request for exemption due to exceptional circumstances must explain the nature of those circumstances and practitioners need to provide evidence that their personal circumstances prevent them from doing the required CPD. Depending on the particular circumstances, the type of supporting evidence that would be required might include certified copies of medical reports or death certificate, together with a letter from the practitioner’s employer about the absence from practice.

Additionally, any request for exemption should also include evidence of what activity practitioners have begun or completed along with a proposed plan for their CPD activities. Decisions on the degree of adjustment will be made on the basis of each individual application and its circumstances.

Illness and absence from practice

Dr X suffered a serious illness during 2012 that forced several months of absence from clinical practice. Dr X applied for an exemption before applying for renewal. The application itemised the CPD activity that had already been done (approximately 50 per cent of the requirement) and confirmed that Dr X held a current first aid certificate.

The National Board considered this application and exempted Dr X from the balance of the CPD requirements for the 2011-12 registration period. Dr X was advised that if another variation/exemption for the 2012-13 registration period was needed, another application should be made before renewal.

Dr Y applied for an exemption/variation of the CPD requirements because she was taking nine months off on maternity leave during the 2011-12 registration period. Dr Y made the application before taking the proposed maternity leave and noted that she had already completed some informal learning activities during the 2011-12 registration period.

The National Board accepted this application and exempted Dr Y from the formal learning requirements of the CPD registration standard, but she still had to do the informal learning component and maintain an appropriate first aid certificate. Dr Y was advised that should her period of maternity leave be extended into the 2012-13 registration period, she would need to make another application for variation/exemption.

Declaration of non-compliance at renewal

Dr Z did not apply for an exemption/variation in CPD requirements before renewal but declared upon renewal that the CPD undertaken did not comply with the requirements of the CPD registration standard. Specifically, the practitioner was found not to have done any formal learning in the 2011-12 registration period but had completed the requisite informal learning and held an appropriate first aid qualification.

Dr Z claimed family issues made it difficult to complete CPD requirements. The National Board determined that Dr Z must do double the number of formal CPD activities for the 2012-13 registration period to make up for those hours not done in the previous year and to satisfactorily comply with the requirements of the National Board.

Recency of practice

Absence from practice

Dr A applied for general registration but failed to satisfy the requirements of the Recency of practice registration standard because of an absence from practice of over two years. Dr A had around three years of clinical practice before taking a career break but has maintained a level of informal CPD activity throughout the period of absence.

The National Board agreed to grant Dr A general registration on the condition that Dr A completes a period of nine months’ supervised practice in accordance with the Guidelines for supervision of chiropractors published by the National Board.

Throughout that period, Dr A’s supervisor is to evaluate Dr A’s performance and provide at least three-monthly reports to the National Board on Dr A’s progress. Transition though the levels of supervision as set out in the guidelines would be subject to the recommendation of the supervisor and approval of the National Board.

Once Dr A has satisfactorily completed this period of supervised practice and the final report has been accepted by the National Board, the condition on Dr A’s registration will be removed and Dr A will be able to practise independently.

Never practised the profession

Dr B applied for general registration having graduated from an approved program of study over three years ago, but had never practised as a chiropractor. Dr B did not satisfy the requirements of the Recency of practice registration standard and was requested to undergo a competency assessment administered by the Council on Chiropractic Education Australasia. Having successfully passed that competency assessment Dr B was granted general registration.

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Audit pilot: compliance with registration standards

The National Board is taking the next step towards auditing registered chiropractors’ compliance with Board-approved mandatory registration standards.

On behalf of the National Board, AHPRA developed an audit framework for chiropractic registrants for implementation during last year’s renewal cycle.

When renewing their registration in 2012, a number of chiropractors were randomly selected to take part. The selected chiropractors were audited for compliance against the National Board’s registration standards for continuing professional development (CPD), recency of practice (RoP), professional indemnity insurance and criminal history. The National Board took a commonsense and compliance- based approach where appropriate during the audit.

The National Board, along with all other National Boards, is currently undertaking a review of all registration standards, and the findings of this audit will be taken into consideration as part of this review process. We emphasise that it is the responsibility of all practitioners to be familiar with and comply with the requirements of these mandatory registration standards. Compliance is a requirement of the National Law. The National Board’s standards can be found under the Registration standards tab on the website.

Keeping proper records of the CPD you undertake will assist you greatly in proving your compliance with the standards of the National Board. To support this, the National Board has produced a downloadable template form which can be filled out in hard or soft copy. Its structure and guidance will assist you to meet your CPD requirements and report your compliance clearly and easily if you are audited.

Now that the audit is complete, AHPRA is compiling the data for the report and will be publishing it on the National Board’s website. For more information on the audit pilot, please visit the Audit page on the AHPRA website.

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CPD log book

The National Board has published a free, downloadable log book on its website to help chiropractors keep a CPD portfolio that meets their legal obligations. The log book can be used electronically or as a hard copy. To use the template:

1. print or save the log book to your computer 
2. complete your details in the relevant sections
3. update log when activities have been completed, and 
4. retain a copy of the log book for seven years.

You should pay particular attention to the recommendations in the log book about recording your reflection on the activity to help you gain the maximum benefit from your CPD.

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National Boards’ review of common registration standards

The National Boards are participating in an all-Boards review of common, or largely common, registration standards which includes the English language skills registration standard and the Criminal history registration standard.

An all-Boards preliminary consultation forms part of a three-year review of all National Boards’ registration standards introduced with the National Scheme on 1 July 2010 (18 October 2010 in Western Australia). Registration standards, guidelines and codes are due for review at least every three years.

Preliminary consultation involves targeted stakeholders. It provides the opportunity to road test the proposed content to help identify any operational effects, issues or concerns before the document's release for an extended period of public consultation.

The current registration standards for chiropractic are available on the Board website.

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Update your contact details

Please check your contact details and update them if necessary to receive regular reminders from the National Board and AHPRA. Email accounts should be set to receive communications from AHPRA and the Board to avoid misdirection to a ‘junk email’ or ‘spam’ box or account.

If you have not yet provided AHPRA or the Board with your email contact information, please do so as a matter of urgency.

To update your contact details, go to the AHPRA website, click ‘online services’, use your unique contact number (User ID) and follow the prompts. Your User ID is not your registration number. If you do not have a User ID you can complete an online enquiry form, selecting ‘User ID’ as the category of enquiry, or call 1300 419 495.

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Keep in touch with the Board

• Visit the Chiropractic Board website for news about the profession and for registration standards, codes, guidelines, policies and fact sheets. 
• For registration enquiries, call 1300 419 495 (from within Australia). 
• Lodge an online enquiry form. 
• Address mail correspondence to: Dr Phillip Donato, Chair, Chiropractic Board of Australia, GPO Box 9958, Melbourne VIC 3001. 

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