Insight and a Remediation Plan After a Notification NZ

Insight, to a Council or Board, a Professional Conduct Committee or the Health Practitioners Disciplinary Tribunal, means that you can say accurately what happened, why it happened, which standard it fell short of and what you have changed so that it does not happen again. Regret is not insight. You show insight in two documents: a written reflection, which explains, and a remediation plan, which proves. The reflection follows the order what happened, why, what you understand now, what you have changed. The plan lists each shortfall, the step you have taken to answer it and the evidence: courses with dated certificates, supervision with a named supervisor and a log, an audit with results, a change to how your practice is organised. Both go in with your response, written against the record and read by your adviser before they are sent.

What the authority means by insight

The Health Practitioners Competence Assurance Act 2003 (the HPCA Act) exists to protect the public. When a Council or Board decides what to do with a notification, the question under that purpose is whether you are safe to practise now and whether the concern will recur. Insight is the word the authorities and the Tribunal use for the evidence that answers it. A practitioner with insight has understood the concern as the authority sees it, not only as they see it; can describe the cause without excuse; and has changed something specific as a result.

In its published decisions the Tribunal has described insight and remediation as mitigating factors in penalty and a lack of insight as an aggravating one. A Professional Conduct Committee reads a response with the same questions, as the guide to how a Professional Conduct Committee process runs describes, and an authority deciding whether a matter can close at the first stage reads for it as well. The same evidence serves at every stage, which is why it is worth building early.

Regret and insight

The difference is between a statement about how you feel and a statement about what you understand. Each of the following pairs describes the same event.

Regret. "I am very sorry that the patient was upset and that the outcome was not what anyone wanted." Insight. "I did not record the consent discussion, so there is no evidence that the risks were explained. The patient's account that they were not is the only account on the file. I now record each consent discussion before the procedure begins, and my audit of the last forty records shows that it is done."
Regret. "I deeply regret that my relationship with a colleague affected the team." Insight. "I allowed a personal relationship with a colleague I supervised to continue without telling my manager, which was a dual relationship I should have declared or ended. I have ended the supervisory role, declared the relationship, and completed a course on boundaries with patients and colleagues."
Regret. "I was under enormous pressure that day." Insight. "I was running forty minutes late and did not check the dose against the chart because I assumed the previous entry was right. The pressure explains the shortcut; it does not justify it. I now check every dose against the chart regardless of time, and I have raised the clinic load with the practice manager in writing."

Each insight statement has the same shape: what I did, why, which standard it fell short of, what I have changed, how it can be checked.

How to write the reflection

What happened. The event in order, with reference to the record and the page. Where the record and your memory differ, prefer the record and say so. Where the record is silent, say that it is silent.
Why it happened. The causes as you now understand them: a habit, an assumption, a gap in knowledge, a system you worked around, a boundary with a patient or a colleague that moved by degrees. State pressure and workload as facts, then move on to your own part.
The standard. Name the paragraph of your profession's code of conduct or ethics, or the authority's statement, that the event fell short of, and say in one sentence how.
What you understand now. What the patient or colleague experienced, what the risk to them was, and what you would do differently with the same information on the same day.
What you have changed. Each change as a specific action, with a date and a way it can be checked. This paragraph leads into the remediation plan.

Keep it to two or three pages. Write in the first person and the past tense for the event, the present tense for what you do now. The guide to writing a response to a Council or Board notification shows where the reflection sits within the response.

What goes in a remediation plan

A remediation plan is a table or a list. For each shortfall identified in the reflection it gives the step taken, the date, and the evidence attached. The authority reads it for fit, for completion and for proof.

The shortfall. One line, in the authority's terms: consent not recorded; late notes; a dual relationship with a colleague not declared; a prescribing decision outside the guideline; a complaint not responded to.
The step. A course on the topic, with the title and the provider; supervision with a named supervisor, the frequency and the period; an audit of a defined set of records with the result; a change to a process, a template or a roster; a conversation with the patient where that was appropriate and advised; a period of restricted practice you have taken on yourself.
The date. When the step was completed or started. Completed steps carry weight; started steps carry some; planned steps carry little.
The evidence. A dated certificate, a supervisor's letter, the audit table, the new template, the roster change. Attached and numbered.
The check. How the authority can see at a later date that the change has held: a repeat audit at a set date, a further supervisor's report, a log.

Match the plan to the concern. A records concern is answered by a documentation course and an audit, not by a boundaries course. A boundary concern with a patient or a colleague is answered by a course on boundaries and dual relationships, a declaration to the employer and supervision. A concern about how you handled a complaint is answered by a course on dealing with a complaint and a change to how complaints reach you. The concern guides describe what fits each: a clinical records concern, a boundary concern about a patient or a colleague, a prescribing concern.

The mistakes that read as a lack of insight

Disputing the record. An account that the documents do not support is read as a credibility problem before it is read as anything else.
Explaining instead of acknowledging. Three paragraphs on workload and one sentence on what you did. Reverse the proportion.
Blame. The patient was difficult, the colleague was wrong, the system failed. Any of these can be true and none of them is your reflection.
Apology without cause. "I am sorry for any distress caused" names no action and no standard.
Generic certificates. Courses that do not match the concern, with no sentence explaining why each was chosen.
Promises. "I will undertake further study." Complete it first, then write that you have.
Minimising. "A minor documentation lapse." The authority decides what is minor; your reflection describes what it was.
Silence on the person. A reflection that never mentions what the patient or the colleague experienced reads as a reflection about yourself.

Where the concern is about honesty, the authority is also deciding whether the reflection itself can be believed, which changes how it must be written; the guide to an honesty or probity concern covers that. Profession guides describe what the Medical Council looks for from a doctor and what the Nursing Council looks for from a nurse.

Where remediation fits

The courses are built for the two documents this guide describes. Insight for Fitness to Practise covers what an authority means by insight and how it tells insight from regret. Reflection for Fitness to Practise covers how to write the reflection in the order set out above. Remediation for Fitness to Practise covers how to build the plan, match steps to shortfalls and present the evidence. Ensuring No Repeat of Misconduct or Mistake covers the check that shows the change has held.

Each course is NZ$200, takes 2 CPD hours, is self-paced with immediate access, and ends with a dated certificate issued by Healthcare Ethics Courses that you can submit to your Council or Board or put in your remediation plan. The remediation courses for every Council and Board are on the hub page, and the Council and Board investigation process explained shows the stages at which the reflection and the plan are read.

Sources and further reading

Health Practitioners Disciplinary Tribunal: published decisions in which insight and remediation were weighed in penalty.
Health Practitioners Competence Assurance Act 2003: the purpose of the Act, the competence provisions in section 36 and the conduct provisions in Part 4.
Medical Council of New Zealand: Good medical practice and the Council's statements, the standards a doctor's reflection is written against.

Frequently asked questions

What is the difference between regret and insight?

Regret is a feeling about the outcome: you are sorry it happened and sorry for the patient. Insight is an understanding of the cause: you can say what you did, why you did it, which standard it fell short of, and what in your practice or your thinking let it happen. A Council or Board can accept regret and still find no insight. A reflection that says what went wrong and why, and that leads to a specific change, shows insight; one that says how badly you feel does not.

Should I write a reflection if I do not think I did anything wrong?

Yes, but it is a different document. Set out what happened with reference to the record, say why your decision was reasonable on the information you had, and then reflect on the concern itself: what the notifier experienced, what could have been communicated or recorded differently, and what you have changed so that the same concern does not arise again. Insight does not require you to accept an allegation that the record does not support; it requires you to engage with it.

How many courses should a remediation plan include?

As many as match the concern, and no more. A plan is read for fit, not length. A records concern calls for a documentation course; a boundary concern with a patient or a colleague calls for a boundaries course; a complaint-handling concern calls for a course on dealing with a complaint and on insight. Two or three courses with dated certificates, each tied in the plan to a named shortfall, carry more weight than ten certificates with no explanation of why each was chosen.

When should the remediation plan be sent?

With your response, or as soon after as the steps in it are done. A plan that describes what you have already completed, with certificates, supervision logs and audit results attached, is evidence the authority can weigh now. A plan that describes what you will do later is a promise, and a Council or Board has nothing to weigh in a promise. Where a step takes time, such as a period of supervision, send the plan with the step started and report progress at the dates you set.

Does the Tribunal look at insight?

Yes. In published decisions the Health Practitioners Disciplinary Tribunal has treated a practitioner's insight and remediation as factors in deciding penalty, and the absence of insight as a factor that weighs against the practitioner. What the Tribunal reads for is the same as what a Council or Board reads for: an accurate account that matches the record, an acknowledgement of what fell short, and evidence of change completed before the hearing rather than promised at it.