• Health policy
• Leadership
• Patient safety
• Risk management
• Safety culture

Performance problems among healthcare professionals can have significant implications for patient safety. Estimates suggest approximately 6–12% of physicians experience performance issues,1 while about one in three healthcare professionals report encountering a poorly performing colleague within the past year.2 Performance problems can arise from individual-level causes including physical illness, substance use disorders, cognitive impairment, mood or personality disorders, and failure to acquire or maintain the knowledge and skills necessary to safely carry out their responsibilities.3 Furthermore, broader systemic issues, including excessive workloads, inadequate resources, lack of institutional support and poor workplace culture, can contribute to or exacerbate performance problems.4 The performance of healthcare professionals is generally evaluated against a set of standards or core competencies of a particular profession that commonly require health professionals to maintain the knowledge, procedural proficiencies, communication skills and professionalism to effectively care for patients. Deficiencies in any of these areas can affect quality and safety, so they must be promptly and effectively addressed.

Remediation—educational or support interventions aimed at addressing underlying issues and improving performance—plays a critical role in addressing performance problems when concerns are raised and ideally before significant patient harms have occurred.5 Remediation may take a variety of forms depending, in part, on the underlying issue: educational content to address knowledge gaps, simulation laboratories to improve procedural skills, mentoring and coaching to provide observation and feedback, counselling and therapy to address mental health and behavioural issues, and comprehensive evaluations that include the work environment to identify systemic issues that may contribute to underperformance.5 When healthcare professional regulatory authorities become aware of serious performance lapses, they must consider the remediation efforts taken by the professional when evaluating their ongoing fitness to practice.

In this issue of BMJ Quality & Safety, Price and colleagues6 explore the influence of remediation in the decision-making of UK healthcare profession regulators when reviewing cases of serious misconduct. Their qualitative study applied framework analysis to data derived from interviews with 21 purposively sampled UK healthcare profession regulators serving in a breath of roles (eg, legal advisors, clinical panellists) and representing eight of nine regulatory authorities overseeing a variety of health professions (eg, chiropractors, nurses, pharmacists and physicians). The study revealed that regulators often view remediation as a proxy for practitioner insight and insight is viewed as evidence of practitioners’ fitness to practice. In the eyes of regulators charged with protecting patients, participation in remediation was seen as evidence of insight, commitment to change and a reduced risk of future performance problems. While the generalisability of the study may be limited by the representativeness of the regulators interviewed—a snowball sample of regulators from a single country—the role of insight and remediation as mitigating factors in cases of misconduct is consistent with a systematic review of processes for assessing health professional impairment across several countries.7

Given the importance of remediation and insight in the decision-making process of healthcare profession regulators considering whether a practitioner is fit to practice, Price and colleagues’ findings invite us to ask whether remediation functions as regulators believe. Is remediation associated with practitioner insight, behaviour change and reduced risk of recurrent performance issues? Insight involves self-awareness, understanding of one’s own actions and recognition of the impact of those actions on others. The literature on the importance of insight in the remediation of health professionals emphasises its crucial role in behaviour change and the prevention of future performance problems.8 A number of remediation strategies can support the development of insight including providing safe spaces for confidential discussion and normative feedback.8 Research indicates that the use of audit and feedback is most effective when it encompasses specific, reliable and actionable data from diverse sources, uses relevant benchmarks and is delivered by a respected colleague in a non-judgmental and supportive manner, with accompanying infrastructure to ensure accountability, follow-up and sustained improvement.9 10 However, as Price and others point out, there is more to learn about the effectiveness of particular remediation strategies in developing insight, whether effective strategies are incorporated into remediation efforts and the impact of those remediation efforts on performance improvement.6 10 The majority of research on remediation outcomes comes from physician remediation programmes in North America and more limited data is available on other health professions and regions.10 Several studies report positive short-term results for remediation targeting substance use disorder with pooled abstinence and return to work rates in 70s per cent range,11 while studies of outcomes for remediation targeting knowledge and skills show more variable results.10 More studies on long-term outcomes of remediation across a diversity of health professions and regions would help to inform healthcare profession regulators’ understanding of the risk of future performance problems.

While monitoring health professionals after remediation is crucial for assessing the intervention’s effectiveness and protecting future patients, it is clearly preferable to identify at-risk professionals earlier and help them gain insight and address deficiencies before serious misconduct or patient harm occurs. Emerging research offers promising ways to identify at-risk professionals. In a recent study of 44 290 US surgeons who applied for board certification (a credentialing examination verifying a doctor’s expertise in a specific specialty that is required by many US hospitals, insurers or employers), Kopp et al12 found that surgeons who failed to obtain board certification were three times more likely to subsequently receive severe disciplinary action compared with surgeons who obtained certification. Research by Papadakis and colleagues13 had previously demonstrated a link between medical school performance and later disciplinary actions by medical boards. Similarly, a study of 725 US nurses reported to regulatory authorities for performance problems found that 60% had a negative job history (ie, termination or disciplinary actions by prior employers).14 A study of 6898 recently trained US hospitalists found that board certification scores in the top quartile were associated with an 8% reduction in 7-day mortality rates and a 9.3% reduction in 7-day readmission rates compared with scores in the bottom quartile.15 In a study of patient complaints and learner milestones, Han et al16 found that among 9340 newly trained US physicians, those with the lowest trainee milestone ratings in professionalism and interpersonal/communication skills were more likely to receive disproportionately high numbers of patient complaints once in independent practice. Taken collectively, these studies and others17 provide an opportunity to develop processes for the early identification of at-risk health professionals and early intervention to improve performance.

To effectively address underperformance, we must also broaden our focus beyond the individual to include system-level factors. Workload and organisational factors significantly affect performance. Research shows that high levels of occupational stress, poor work organisation and inadequate staffing are linked to increased psychological distress, absenteeism and reduced job performance.4 To achieve optimal healthcare professional performance, healthcare organisations must ensure adequate staffing and resources, provide access to professional development and promote a culture of teamwork.

Calls for a systematic approach to early identification and intervention of at-risk healthcare professionals are not new. In a 2006 seminal paper on the topic of underperforming physicians, Leape and Fromson3 called for an objective, fair (ie, open and unbiased) and responsive system to regularly monitor physician adherence to accepted standards of behaviour and competence and protect patients from harm. Such a system could make use of the emerging research on early indicators of performance problems to provide additional support to at-risk professionals early in their careers. By integrating available data from patient complaints, coworker observations and evaluations, quality of care measures, compliance with documentation, billing and patient safety procedures, local leaders can gain insight into emerging performance problems at the individual and unit or service-line level. By identifying and targeting significant outliers in underperformance, remediation efforts can be more focused and effective, helping to avoid the potential downsides of overly intensive clinical governance, such as inefficiency, excessive bureaucracy and staff demotivation. The literature on patient complaints and coworker observations of unprofessional behaviour shows that early sharing of normative data—delivered by trained, well-respected colleagues in a confidential and non-judgmental manner—with underperforming healthcare professionals supports insight and most professionals (>70%) can self-correct.9 18 As part of a tiered intervention strategy, professionals that do not respond to ‘awareness interventions’ proceed to more intensive interventions and may benefit from formal assessment and leadership-guided remediation.19 A systematic approach requires committed leadership willing to enforce standards consistently and equitably without regard to status, policies and procedures to govern processes and support reliability and fairness and avoid bias, resources to support and recover underperforming professionals, and accurate performance data normed to relevant peers or benchmarks.3 19 If the system works as intended, underperforming professionals will be identified and supported before serious harms occur and referrals to healthcare profession regulators will decline.

Professional regulatory reform can facilitate the adoption of effective clinical governance structures to systematically address underperformance, but it requires careful consideration to avoid exacerbating administrative burdens and workloads on healthcare professionals. For instance, the introduction of medical revalidation in the UK in 2012, which requires UK doctors to periodically demonstrate their fitness to practice, has been criticised for its onerous requirements, leading to increased physician workload and, in some cases, prompting physicians to leave practice.20 To avoid such unintended consequences, regulatory authorities should collaborate with healthcare organisations to develop streamlined, evidence-based standards and performance metrics that leverage existing performance data and efficient IT systems for data abstraction and analysis and require that they be implemented alongside robust systems for identifying and addressing significant underperformance.

In conclusion, addressing performance problems among healthcare professionals is critical for ensuring patient safety and maintaining high standards of care. Remediation efforts are viewed as a vital step in helping practitioners gain insight and improve their performance, but their effectiveness needs further investigation. Early identification and intervention for at-risk professionals, supported by systematic approaches and committed leadership, may prevent serious misconduct and patient harm. By leveraging data from multiple sources and fostering a culture of continuous improvement, healthcare organisations can better support their professionals and protect their patients.