Transcript Are you competent?

Are you competent?
Developing competent general
level pharmacists.
Ian Coombes, SMPU, Queensland Health,
Graham Davies, King’s College London,
Peter Halstead, Pharmacy Board, South Australia.
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Content
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Introduction
Brief introductory comments:
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Peter Halstead
Ian Coombes
Graham Davies
Setting the scene
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CPD issues
Competency,
standards and safety
Performance
Peter Halstead
Scene 1 – an informal chat
Scene 2 – a formal chat
Addressing the issues – a way forward
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Introductory
Comments
CPD
Peter Halstead, Pharmacy Board, South Australia.
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Content

What are PBSA’s expectations and experiences
with regard to competency assurance?
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What are PBSA’s expectations with regard to
CPD
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Are you competent?
Understandably a regulators approach to ensuring
competency assurance will bear the impact of a broad
range influences
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Are you competent?
PBSA understands - a commitment to professional
development does not guarantee professional
competency but a failure to have such a commitment
does guarantee professional incompetence
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Are you competent?
“The responsibility of individual pharmacists for systematic
maintenance, development and broadening of knowledge,
skills and attitudes to ensure continuing competence as a
professional throughout their careers.”
FIP Definition of CPD
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Are you competent?
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Acceptability – pharmacist driven
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Sustainability – regulator driven
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Transparent – community driven
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Equitable – procedural fairness
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Are you competent?
Acceptability
2003/2004 whole of profession introduction:
Draconian
• Impediment
• Forced retirement
•
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Are you competent?
Sustainability
Regulators have to mindful of the resources available.
Resources in SA are provided by the profession and
have to operate on the basis of professional and
commercial responsibility
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Are you competent?
Transparent
The
community have only one interest and it is not
negotiable - pharmacists must be competent.
It
is not possible to be partially competent (because
one only works part-time)
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Are you competent?
Equitable or in legal terms – procedural fairness
Australia is a vast land. Availability, ease of access
and cost imposition need to be considered by a
regulator
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Are you competent?
PBSA examined courses, written examinations,
objective structured clinical examinations (OSCEs),
multiple choice questionnaires, workbooks, portfolios
and practise observation
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Are you competent?
However 2003/2004 is not only 5 years ago but an
age in terms of technology, mind-set and
sophistication with regard to the profession
understanding competency
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Are you competent?
PBSA chose not to limit the scope or nature of
activities suitable for inclusion in the ENRICH
program.
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Are you competent?
PBSA expects that CPD will provide demonstrable
outcomes i.e.
The consumer, client or patient benefits through
the improved practice of pharmacy as a result of
undertaking the professional development activity
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Competence, Standards
and Patient Safety
Ian Coombes
SMPU, Queensland Health
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Clinical competence
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Professional competence
the habitual and judicious use of communication,
knowledge, technical skills, clinical reasoning, emotions,
values, and reflection in daily practice for the benefit of the
individual and community being served
[Epstein and Hundert, 2002]
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Conveys competence as
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Developmental
Impermanent
Context-dependent
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The Competency iceberg
Effective and
persistent
behaviour
Knowledge
Skills
Abilities
Values, attitudes
and beliefs
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Theory into practice… (outcomes)
…the competent and reflective practitioner
Approach to practice
(attitudes; ethics; values; decisions;
judgements; reasoning; etc)
Professionalism
(role in HC system;
personal development)
Technical skills
(clinical; MI; management; etc)
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Why a competency approach?
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Policy
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Fitness-for-purpose in Qld in the post Forster
era
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Competence, like truth, beauty and contact
lenses, is in the eye of the beholder
Laurence J Peter
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Former Kaiser Hospital surgeon
was highly recommended by
colleagues in U.S
•Australia's 'Dr. Death’ linked to
fatalities
• From a patient’s perspective
Professionals’ competence is not negotiable
[Bundaberg Hospital Enquiry, Australia]
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Why a competency approach?
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Policy
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Fitness-for-purpose in Qld in the post Forster era
Interest Based Bargaining (IBB) process and
job evaluation Framework
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A career structure link to patient
outcomes – Pharmacy Interest
Based Bargaining QH 2005-2008
Career
Structure
Recruit
and
Retain
Remuneration
Workforce
Size and
Structure
Training
And
Development
Capacity to
deliver improved
client and
patient
outcomes
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Why a competency approach?
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Policy
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Fitness-for-purpose in Qld in the post Forster era
Common A-H pay spine – IBB process and job
evaluation Framework
Research Evidence
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Patient Consultation Factor (Medical)
Borja-Lopetegi A*§, Webb DG*, Bates I§, Sharott P
Low Activity
High Activity
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120
W
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W
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W
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Mortality
110
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W
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WW
W
W
W
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100
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W
W
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W
W
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W
W
W
W
W
W
W
W
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W
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90
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Low factor 1 performance
R2=0.10, n=22, p=0.146
W
W
W
W
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W
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80
W
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High factor 1 performance
R2=0.62, n=11, p=0.004
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70
R-Square
=0.62
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1.00
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2.00
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3.00
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W
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4.00
Clinical Pharmacy FTE per 100
beds
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Rate of pharmacy review - Site Comparison
What if this Ndoesn’t
happen?
= Number of patients audited
Percentage patients
Qld
Target =“reviewed”
100%
n=20, 2004
100%
80%
60%
40%
20%
0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Sites
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Rate of patients with incomplete ADR documentation by
pharmaceutical review, 2003
Number of patients: Reviewed N = 60, Not Reviewed N = 101
Reviewed
100%
80%
Not Reviewed
63.33%
63.37%
60%
40%
20%
0%
Patients with incomplete ADR documentation
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Miller’s pyramid
Does
performance assessment in vivo
Shows how
performance
OSCE
style assessment in vitro
Knows how
clinical
contextPBL
assessment
Case
studies/
/Portfolio
Knows
factual/ Exams
assessment
MCQ
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QH pre-reg comp data
Candidate (n=21)
Jan-07
Oct-07
Drug History Taking - patient
86%
73%
Drug History confirmation - GP
76%
32%
Review and Identification of problems
76%
59%
Dosage Conversion
52%
45%
Identification and Prioritise Interventions
57%
27%
Resolution of problems with Medical Staff
67%
27%
Patient Counselling
86%
68%
Discharge Reconcilliation and Counselling
81%
77%
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Demonstrating competence is
integral to providing safe
patient care
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Performance, in
search of the………..
Some initial thoughts
Graham Davies
King’s College London
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Yes, many species can learn competences…
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Miller’s pyramid
From UG to post-registration
development
Does
performance assessment in vivo
Shows how
competence assessment in vitro
Knows how
clinical context assessment
Knows
factual assessment
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Performance
“Performance is the consistent provision of care to meet
the required standard.”
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Patients are interested in performance:
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Employers are interested in performance:
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It’s what you do that matters
Instills confidence
Information on what staff do (vs expected)
Protects patients – via poor performance system
Can be used to reward (pay) or promote (career)
Individual pharmacists are interested in performance:
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Provides a check on quality of care they provide - motivates
Reveals “hidden curriculum” & guides CPD
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Miller Cambridge Pyramid
competency
System factors
Human Factors
Performance
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Some evidence…………..
Pre-Registration "Performance"
(n=21)
9
8
OSCE Stations Passed
7
6
5
4
3
2
End of 10 month
training
Post Induction OSCE
1
0
1
2
Time Period
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Learning modality linked to time/career pathway
Predominantly
Flexible & Distance
Learning and emodes
Higher
General
FDL, e-modes
off-site, experiential
Independent
Career driven
Interns
UG
Predominantly
face-to-face modes
Cohort learners
Lone learner
On-site (HEI)
learning
Off-site (work)
learning
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Learning and working……a
different culture
Undergraduate Learning
Environment
Guided study
material
Tutor Access
Defined curriculum
Learning
Support
Peer contact
Regular Appraisal
Employees learning in the
workplace
Unable to identify
Limited Tutor
learning needs
Support
Limited
Opportunity to
Infrequent
learn
Appraisal
Individualised
Curriculum
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Self directed learning?
External factors
Internal factors
Facilitate primary responsibility
for learning
Predisposition to accept
Responsibility for learning actions
Self-directed
Learner
learning
self-direction
Parallels with Adult Learning Theory (Andragogy)
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Novices/beginners………
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Need guidance & structure in which to work
and learn
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Induces a SDL approach, and ultimately
towards Adult Learning habits
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Encourages independence & autonomy
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Post-graduate learning
“Post-graduate pharmacist education
should be a process of managed
participation in a community of practice.”
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In a place far, far
away………
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Background
The place…..
Utopia Hospital, a 500 bed teaching hospital
situated in a metropolitan environment.
Care delivered on 15 wards.
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Pharmacy Structure
Director of Pharmacy
Assistant Director
(Clinical)
Team Leader
Medicine
Team Leader
Surgery
Junior Grade (4)
Assistant Director
(Support)
Team Leader
Critical Care/Paeds
Junior Grade (4)
Junior Grade (2)
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Miss Lucinda B – a profile
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10 months post registration (23 yrs old)
Undertook pre-registration at different site
When recruited:
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Glowing reference from previous employer
 Conscientious
 Hard working
 Quiet but very pleasant girl
Academic Tutor – straight 7s, medal winner in final
year and considered a future “leading light” of the
profession.
Good sportsperson – captain of number of teams
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Scene 1 – an informal meeting
Oswald (DoP) and Tarquin (Assistant Director
{Clinical}) discussing some issues relating to Lucinda’s
work:
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Often late back from wards
Has to stay late to complete work
Rarely attends weekly CE events
Nurses from her ward often bring charts to pharmacy
Residents regard her advice as irrelevant
Often complains when asked to cover additional wards
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Audience participation
Discuss the scenario with your neighbour (2 mins)
and:
1.
Decide whether she is incompetent
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Scene 1 - Solutions
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Needs to receive feedback that work is of an
unacceptable standard
Needs to familiarise herself with protocols
and policies pharmacy service
Must attend departmental CE meetings
Fund to attend SHPA federal conference
Arrange a review meeting for 4 weeks time
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Scene 2: Six weeks later…….
Formal meeting between Sebastian (Director of
HR) and Oswald (DoP) to discuss staffing
issues:
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Lucinda has resigned & now on leave for
remainder of contract
An exit interview took place last week
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Issues from Exit Interview
How she felt:
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Complete loss of confidence
De-motivated
Undervalued
Confused
Not developing or progressing (practice
regressing)
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Reasons for above
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Lack of or inconsistent advice – mixed
messages
Feedback often negative
Felt there was a lack of support
Struggled with providing care within allocated
time and felt under considerable stress
Little link between policy guidance and day to
day practice
No role model to inspire practice
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Summary
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How does this relate to your experience?
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What are the key issues and solutions.
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Miller Cambridge Pyramid
competency
System factors
Human Factors
Performance
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What are the key issues of this
case?
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Lack of direction – what do you expect
Limited supervision or system of appraisal
Little constructive feedback
Inappropriate investment in training
No individualised CPD
Lack of educational culture
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Attaining Competence –
Problems for Pharmacy
The service provided – what does the job entail?
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Clear career strategy with appropriate milestones
A robust standard approach to measuring quality of
practice
Succession planning
Education and Training Support – outdated models?
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Inequality of workforce access to structured, accredited
learning experiences
Driven by academic attainment – divorced from service
need and practitioner development
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General Issues
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General Questions (1)
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How do you know pharmacists can do the job
at interview? Investing in recruitment.
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Would you expect them to be competent to do the
job?
Do you appoint on potential?
What evidence is used?
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General Questions (2)
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How can you identify/monitor performance
issues? i.e. how do you know what your staff
do?
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How does this complement your service
standards or outputs?
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Why we need “competency”
frameworks and assessments
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Professional boards require measures before registration
We must be able to demonstrate that we can perform
Exams do not = competence
Patients expect “competent and appropriate performance”
Adults develop by reflection and feedback and tailored CPD
Credentialing – General or Advanced level pharmacists
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How do you assure performance?
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Define what is required
Design assessments which test the breadth i.e.
someone must be competent before they can
perform
Must have standards to measure against
Must have an infrastructure which support
practitioner development
Workplace must develop culture of learning
Performance assessment should be a key activity of
senior pharmacists
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General Level Framework
Delivery of
Patient Care
Personal
Problem Solving
Management and
Organisation
Work-based Performance Tools – Portfolio of Evidence
•
•
•
•
•
•
Clinical Evaluation Tool (mini-CEX)
Team working evaluation (Mini-PAT)
Case Discussion (CbD)
Consultation Skills Assessment (MRCF)
Interventions
Regulatory requirements for registration (CPD)
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Resolution drug related problem-GLF
n =55, mean 11 months base - self
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General Questions

How do you support the training needs of
your staff – i.e. tailored CPD to meet the
needs of:
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
your patients (organisation)
the individual?
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Plan for developing Pharmaceutical care
Personal CPD
{Training +
Development}
Targeted Service
Development
Standards of
practice
Identifying “Gaps”
via GLF
Safe + Effective
Medicine Centred Patient
Focused care
Supporting
practitioner
development
Service
Re-engineering
Performance Assessment – the value
Director of Service
Perspective
Quality Indicators
Value for money
Training needs analysis
Identify poor performance
Developing the
Service
Performance
Review
System
Protecting the
Patient
Performance
Assessment
Developing the
Individual
Individual Pharmacist
Perspective
Regular feedback
Motivation
Identifies CPD needs
Key training targets
73
Pharmacist Development Strategy
Consultant
Pharmacist
Advanced
Level
Pharmacist
General
Level Pharmacist
Registered Pharmacist
Pre-registration Pharmacist
Undergraduate Pharmacist
Research, assessment &
Teaching (explicit requirement)
Contributing
knowledge
& skills
Acquiring
knowledge
& skills
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Are you competent?
Developing competent general
level pharmacists.
Ian Coombes, SMPU, Queensland Health,
Graham Davies, King’s College London,
Peter Halstead, Pharmacy Board, South Australia.
78
QUESTIONS?
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Pharmacist
Development Strategy
……don’t consider competence in
isolation
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Key Ingredients of a Strategy
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Describe the key areas of practice & their associated
outputs or competencies,
Tools to evaluate practitioners,
Describe the curriculum to support development,
Reform education system to deliver curriculum,
Overarching body to award statements of completion
of training.
Workforce Planning Data – how many?
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Pharmacist Development Strategy
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Describe the key areas of practice & their associated outputs or
competencies,
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What are the levels of practice – career pathway
What are the associated competencies for each level
Tools to evaluate practitioners
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Test knowledge and understanding
Test competence
Test performance
82
Pharmacist development model
Training infrastructure
PG enabling programmes
Undergraduate
& preregistration
College/faculty system
General Diploma
General postregistration
Masters Adv Practice
Higher level
Phase 1
Research Degree
Higher Level
Phase 2
Advanced
Practitioner
GLF
Pharmacist
Registered
band 6
Consultant
Pharmacist
ACLF
Pharmacist
Specialist
band 7
Pharmacist
Advanced
band 8a/b
Consultant
Pharmacist
band 8d/d
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What does this
mean?
Revalidation
GPhC
Registration
Professional Body
Educational Infrastructure
Supports & assures quality
Grass Root Practitioners
84
Miller’s pyramid
From UG to post-registration
development
Does
performance assessment
in vivo etc
Practice-based,
MiniPAT, MiniCEX,
Shows how
performance
OSCE
style assessment in vitro
Knows how
clinicalstudies/
contextPBL
assessment
Case
/Portfolio
Knows
factual/ Exams
assessment
MCQ
85