Appraisal, Assessment, Revalidation

Heirachy

1. Action: does
   • Work based assessments: outcomes of care, volume of practice, logs, diaries
   • 3-tier approach to work-based assessments
2. Performance: shows
   • Appraisal, assessments
3. Competence: knows how
   • OSCE, simulations, clinical exams
4. Knowledge: knows
   • MCQs

What is a good doctor?

1. No accepted definition of what a "good doctor" is
2. Fitness to practice
   • Civil, not criminal standard of proof
   • greater emphasis on retraining and rehabilitation, whilst preserving patient safety
   • Maintain strong lay participation in FTP procedures
   • separation of investigation and ajudication

Appraisal

1. Structured process of facilitated self reflection
   • Formative: trainee-centred, continous
   • Reviews professional activities, identifies areas of real strength and need for development
   • Formalised means of moving through learning cycle
2. Includes aims and objective, curriculum and knowledge required
   • Use of personal development plan to set aims
   • Regular two-way feedback should be provided on progress
3. Trainees should feel able to discuss the merits (or otherwise) of their training experience

Assessment

1. Observational
2. Examinations
3. Portfolio
4. Trainer's report
5. Audit/research

Revalidation

1. [Duties of a doctor]
2. Proposed relicencisng + recertification

Healthcare commission

1. Exists to promote improvements in quality of healthcare and public health through independent, authoritative, patient-centred assessments
   • Assessment of performance of providers
   • Investigation of serious failures in healthcare services
   • Independent complaints review which have not been resolved locally
   • Rating the performance of NHS hospitals and trusts
   • Publication of an annual report on healthcare performance
2. Wales: Healthcare inspectorate
3. Scotland: NHS Quality improvement scotland
4. Northern Ireland: Health & Personal social services regulation and improvement authority

Creating a patient-led NHS

1. Patient led
2. Everything measured by its impact on patients
3. Health important as sickness
4. Patient-centred community services
5. Mental wellbeign
6. More access to GPs
7. New community hospitals

"A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change" - are we doing the right thing in the right way?

• No research (research is evidence based; tells us if we are doing the right thing)

Audit cycle:

1. Observe clinical practice to determine theme
2. Set standards; guidelines, protocols use existing research or evidence
3. Monitor clinical practice against standards
4. Compare practice
5. Implement change
6. Close audit loop - re-audit

• A continual process
• Multidisciplinary audit analyses the "patientjourney"

Clinical Audit

1. Structure
   • Facilities - equipment, accommodation, staff
2. Process
   • Activities
3. Outcome
   • Morbidity, mortality
   • Satisfaction
   • Surveys

Identify, assess, prioritise & prevent risk

1. National Patient Safety Agency (NPSA)
   • Special authority created to learn from adverse incidents
   • Promote open and fair culture across health service
   • Encourage staff to report incidents and near misses
   • Report incidents without fear of personal reprimand
   • Emphasis is "how" rather than "who"
   • Learns lessons and feeds back into health care
   • Additional roles: safety aspects of hospital design, cleanliness and food (previously NHS estates), ensure safe research, confidential enquiries
2. Clinical Negligence Scheme for Trusts (CNST)
   • All acute trusts belong
   • Costs of schemes met by member contributions
   • Discounts if meet risk management criteria

1. Establish clear standards
2. Statutory duty of quality for providers of NHS services
3. Development of clinical governance systems
4. Programme of inspection and performance review of local services
5. System to collect, analyse and learn from adverse events
6. Mechanismsto ensure more patient-centred services
7. National support services to promote governance and patient safety

Evidence based medicine

Payment by results

1. Service providers paid at standard fixed rate for activities undertaken (can't compete on price)
   • Competition on quality and access, not price
2. Aims to be an incentive for trusts
   • Examine and reduce costs (increased cash surplus)
   • Tackle waiting lists (increased income)
   • Improve throughput (income generation)

Challenges

1. Activity-based payment systems need constant adjustment to ensure they produce improvements
2. Level playing field
3. Tariff increase for 2006/2007 is 1.5% (below NHS inflation costs)
4. True choice = oversupply of capacity

National Programme for IT

1. Choose and book
2. Electronic prescriptions
3. PACS (Picture Archiving and Communications Systems)
4. Support - financial, audit, target, goveranance data
5. Challenges: security, data quality, compatability, cost, time-frame

1. Will MMC make better doctors?
2. Are doctors being selected too early for speciality training?
3. How can we ensure time to train in the context of EWTD?
4. How do you make the most of educational opportunities in your job?
5. How do medical advances affect workforce planning?
6. What can you contribute to training of others?
7. What is competency-based training and how do we deliver it?
8. How can we make sure we are selecting the best candidates for speciality training?

Training changes

1. Calman structured training
   • Calman "structured" training
2. Modernising medical careers
   • All previous grades scrapped
   • Structured education at all levels
   • Principles of: competency, work-based assessments, continous professional development, life-long learning
   • Streamlined: move from experienced-based to outcome-based

Competency training

1. Real and demonstrated ability to carry out an identified activity
2. Focuses on output (and not input)

Service vs Training

1. Time to train
2. All education in work time?
   • Breakfast teaching - US, australia
   • Blocks of training time vs service time
3. Craft skills different to medical
4. Increased private sector usage?

• Integrity, professionalism
• Positive attitude to negative issues
• Asking for help appropriately
• Know limitations
• Respect for others
• Reflection (change in behaviour, working style, attitude)
• Puts patient first
• Recognition of errors and how learned from them

Avoid

• Criticism of others
• Disrespect of others
• Failing to prioritise patients needs
• "Problems"

• Time management, prioritisation, delegation, multitasking
• Deadline management
• Contingency planning
• Risk identification and management
• Seeks improvement
• Evaluates outcomes
• Maintains overview

Avoid

• Negative impact on other progressions
• Excessive detail
• Not learning
• Not looking for alternatives

How do we learn: Kolb's experiential learning cycle

1. Conceptualisation: new ideas (Theorist)
2. Active experimentation (Pragmatist)
3. Concrete experience (Activist)
4. Reflective observation (Reflector)

Teaching:

• Application of adult learning principles
• Clear and achievable goals
• Set in context of global training needs
• Appropriate time and setting for teaching
• Appropriate experience of learners
• Deliver teaching in an appropriate format
• Seek feedback
• Encourage use of tests, appraisals, portfolio, enhance learning cycle

• Continuing professional development
• Lifelong learning
• Doctors should seek out and welcome constructive feedback
• Look for learning opportunities
• Uses self-directed learning to acquire knowledge and skills
• Maintains portfolio to enhance learning cycle
• Seek to "know what he doesn't know" through active use of appraisal, feedback, case-based discussions

Difficult colleague

Approach

1. Difficult colleagues may be colleagues in difficulty
2. Start by appreciating and not blaming
3. Take the first opportunity - don't collude, minimise, complain to others, be overprotective or submissive
4. Ensure doctor understands his impact on: career, colleages, patients
5. Be patient, don't expect instant results
6. Negotiate with clear expectations

Deal with by

• Understanding
• Honesty and boundaries
• +/- disciplinary action

• Illegal - may affect judgement and performance
• Remove from clinical area, patient safety is paramount
• Consider risk management issues if relevant
• Follow trust procedure - report to relevant person
• Don't act as investigator, prosecutor, judge or jury
• Do not collude
• Consider supportive measures if appropriate

Whistleblowing

1. If you have reasonable belief that the following have/are likely to occur
   • Criminal offence
   • Failure to comply with legal obligations
   • Miscarriage of justice
   • Endangerment of health or safety of any individual
   • Environmental damage
2. Information tending to show that one of these has been, is being or is likely to be concealed
3. Raise issue with appropriate consultant, chief of service, clinical director, clinical tutor, medical director, director of postgraduate medical education, the secretary of state for health!

Principles of Ethics

1. Beneficience: obligation to provide benefits
2. Non-malficence: avoid causing harm
3. Respect for autonomy
4. Justice: obligation for fairness

• End of life care and how to improve it - euthanasia, assisted suicide, pain control
• Medical errors - obligation to reduce error
• Stem cell research - moral/legal status of embryo vs benefit to patient
• Electronic health - confidentiality

Approach:

1. Acknowledge difficulties, sensitivities of subject
2. Present a balanced arguement
3. Do not cause offence
4. Do not be overly controversial
5. Display maturity and insight
6. Be concise
7. Close with a summary

Know the facts, be up to date

Medical Management

Competencies of the medical manager

1. Communicates, manages and delivers change
2. Credibility
3. Integrity
4. Teamworker
5. Thorough understanding (technical / system)
6. Encourages performance and potential of others (appraisal)
7. Roadmap, personal vision, strategy
8. Influential, networker, committees, regional/national policy

Effective manager and leader

• Range of styles
• Know when to apply them
• Exercise good judgement
• Emotional intelligence / understand people
• Communicate change effectively

Leadership styles

• Affiliative - emotional bonding of team
• Authoritive - overcomes inertia, moves towards a goal
• Coaching - people development for long term benefit
• Coercive - demand immediate compliance
• Democratic - consensus
• Pace-setting - expect excellence and initiative

A group of people with shared objectives and a unique contribution from each other

• Coherent teamwork is crucial for the delivery of good quality patient care
• Efficient and effective services
• Reduces stress
• Effects of shift work
• Effects of changing responsibilities

What makes a good team?

• Clear defined goals for team and individual
• Meets often
• Values the diverse skills of its members
• Mutual confidence
• Communicates effectively. embraces advances
• Non-competitive internally
• Optimum size
• Time & resources

Examples

• Split site cover in an emergency
• "Hospital at night"
• Rota management
• Role of defined competencies in teams
• Particular challenges of community (GP) teamworking
• Ensuring protected teaching / induction / rest periods
• Personal qualities that you bring to the post
• Personal reasons for enthusiasm / motivation
• Personal examples of good teamwork
• "Worst" colleague

Conflict

• Need to recognise the conflict scenario
• Impose a logical management structure

Resolving conflict

1. Diagnosis
   • Recognising areas of understanding and differences
2. Initiation
   • Bringing disagreements to the surface
3. Listening
   • Hearing including non-verbal (emotional) aspects
4. Problem solving
   • Data gathering
   • Consider impact
   • Examining alternatives
   • Identifying solutions
   • Developing a plan of action
   • Reaching consensus

Negotiation

• May be a way to manage a conflict situation
• Eg rotas, treatments, resources
• Be ready to reach a consensus
• What do I want to achieve?
• What are their beliefes (ideas, concerns, expectations)
• What do they want?
• How much do they want it?
• What part might others play in negotiation?
• How can we reach an agreement?
• What can I concede? 
• Can we prioritise?
• Aim for key objectives rather than total solution
• "Agree to disagree" on specific points if necessary
• Reach negotiated settlements

Prioritisation

• Professionals must be able to multitask effectively
• This means prioritisation (and then delegating as appropriate)
• Follow up (Task management) is a key part of the process

Techniques for prioritisation

• Assess priorities 

• Managers vs doctors
• Job planning
• Changing roles of healthcare professionals
• Conflicts with colleagues
• Managing patient expectations
• Complaints from patients
• Disagreememnts with patients
• New consultant / registrat / nurse / midwife
• New guidance / evidence
• Changes in treatment - impact on patients
• New computerised system
• Need to change working practice

• Communicating & managing change is a critical skill for all doctors
• ADKAR
• Awareness
• Desire to change
• Knowledge on how to change - information, training, education, guidlines
• Ability to implement
• Reinforcement to sustain