Transcript New zealand two

Navigating competence:
Beyond the flat earth, competency
icebergs and career doldrums
David Webb
NZHPA Conference
September 30, 2007
Never ascribe to malice that which can
be adequately explained by
incompetence
Napoleon Bonaparte,1815
East and South East England
Round Earth
□ He came back…..
□ From a patient’s
point of view
□ Professionals’
competence is not
negotiable
[BRI Inquiry]
□ Technical
competence is of
key importance
[Picker Institute]
Fuzzy concepts
□ Competence
□ Overarching capacity
□ Competences
□ Functional, the what
□ Competencies
□ Qualities, the how
Professional competence
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
National Occupational Standard
Critical accounts
□ Competence
approaches
□
□
□
□
□
Reductive
Shopping lists
Job specific
Central control
Adequacy
□ Generic/cognitive
approaches
□
□
□
□
□
Abstract
Subject fragments
Performance deficit
Provider autonomy
Isolated excellence
Competency iceberg
Effective and
persistent behaviour
Knowledge
Skills
Abilities
Values, attitudes
and beliefs
Alternative departures
□ Novice-to-expert
Dreyfus & Dreyfus 1986
□ 5 stage progression
□ From adherence to
intuitive grasp
□ Reliable metric to
identify expert?
□ Reflective practice
Schön 1983
□ Learning from
experience
□ Necessary and
sufficient?
□ Cause or effect?
Components of performance
Deployed
Performance
Experience
Bundled
Competencies
Integration
Developed
Knowledge, Skills and Abilities
Education and training
Innate
Characteristics and Traits
McNamara Fallacy
□ First step
□ Measure what can easily be measured
□ Second step
□ Disregard what can’t be easily measured
or give it an arbitrary quantitative value
□ Third step
□ Presume what can’t be measured easily isn’t
important
□ Fourth step
□ Say what can’t be measured easily doesn’t exist
Does it make a difference?
General Level Framework (GLF)
PERSONAL
Organisation,
Team working,
Communication,
Professionalism
Punctuality
Initiative
Confidentiality
McRobbie et al 2001
DELIVERY
OF
PATIENT
CARE
Drug
use
process
Drug history taking
Interaction identification
Patient counselling
PROBLEM
MANAGEMENT
Gathers information
Knowledge
Analyses Information
Provides information
Follows up and reflects
Assesses information
Accurately provides
Relevant, Timely
GLF structure
Performance improvement
Always
Need for drug
Relevant Patient Background
Drug history
Selection of drug
Drug drug interaction
Drug patient interaction
Drug-disease interaction
Administration of drug
Calculation of appropriate dose
Selection of dosing regime
Selection of formulation
Usually
Sometimes
Never
Evaluation of GLF in hospital
□ Controlled trial
□ 30 control pharmacists
□ 74 intervention
pharmacists
□ Matched for gender,
age, experience,
qualifications
□ Observations
□ Significant changes
□ 25 behavioural indicators
0-month 6 0-month 12
Control 7/25
12/25
Active
24/25
24/25
□ Baseline, month-6,
month-12
□ Delivery of patient care
Antoniou et al 2005
Performance attainment
Cumulative attainment
.7
.6
.5
.4
Group
active
control
.3
.2
.1
(log rank
p=0.0048)
0.0
0
2
4
6
8
10
12
14
Months
Community pharmacy
I would like to thank you all for
your help with this project.
Without it I still wouldn’t have
started my CPD
..identified areas for CPD. Helps to
have competencies as a
prompt...you need to know what
you need to be able to do
I think I was doing lots of the
skills but never put them
together into a sequence step
by step to actually realise that
was how I was working
Mills PhD thesis 2007
Self-assessed performance in the delivery of
patient care cluster (mean + 95% CI)
Performance improvement
4.0
Intervention (n=69)
Non-intervention (n=31)
3.5
3.0
2.5
Baseline 4 months
8 months
12 months
Practice development model
Undergraduate
& preregistration
General postregistration
Higher level
Phase 1
Advanced
Practitioner
General Level
Higher Level
Phase 2
Consultant
Pharmacist
Advanced & Consultant Level
Professional Development Frameworks
Advanced/Consultant Level Framework
□ Development
□ Literature review
□ Expert and consensus development panels
□ ACLF design
□ 34 competencies in 6 clusters
□ Foundation, excellence & mastery
□ Premise
□ Attainment identifies level of practice
□ Generalisable
Meadows et al 2004
Clusters
Expert professional practice
Building working relationships
Leadership
Management
Education, training, development
Research and evaluation
Competencies
Expert skills and knowledge,
Patient care responsibilities,
Reasoning and judgement,
Professional autonomy.
Communication,
Teamwork and consultation.
Vision, motivation, governance,
Strategy, innovation,
Service development.
Planning, performance, change,
Priorities, resources, standards,
Risk.
Mentorship, role model, delivery,
CPD, practice linkage, policy.
Critical evaluation, protocol review,
Evidence creation, development,
Supervision, partnerships.
Self assessment using ACLF
□ Practice levels
□ Specialist-in-training
□ Experienced
practitioner
□ Leading-edge
practitioner
□ Evidence
□ To substantiate
assessment
□ Sample (n=390)
□
□
□
□
□
□
□
Cancer
Mental health
Critical care
Primary care
Paediatrics
MI
Other
69
69
36
84
53
43
36
Building working relationships
Leadership
Management
Education, training, development
Research and evaluation
Expert skills and knowledge,
Patient care responsibilities,
Reasoning and judgement,
Professional autonomy.
Communication,
Teamwork and consultation.
Vision, motivation, governance,
Strategy, innovation,
Service development.
Planning, performance, change,
Priorities, resources, standards,
Risk.
Mentorship, role model, delivery,
CPD, practice linkage, policy.
Critical evaluation, protocol review,
Evidence creation, development,
Supervision, partnerships.
Excellence
Expert professional practice
Mastery
Leading-edge respondents
Building working relationships
Leadership
Management
Education, training, development
Research and evaluation
Expert skills and knowledge,
Patient care responsibilities,
Reasoning and judgement,
Professional autonomy.
Communication,
Teamwork and consultation.
Vision, motivation, governance,
Strategy, innovation,
Service development.
Planning, performance, change,
Priorities, resources, standards,
Risk.
Mentorship, role model, delivery,
CPD, practice linkage, policy.
Critical evaluation, protocol review,
Evidence creation, development,
Supervision, partnerships.
Foundation
Expert professional practice
Excellence
Experienced practitioner respondents
Competency profiles
Consultant pharmacist posts
□ Aims
□ Ensure highest level of
expertise is available
to those patients who
need it
□ Strengthen
professional leadership
□ Retain experienced
pharmacists in
practice
□ Responsibilities
□ Expert practice
□ Research, evaluation
and service
development
□ Education, mentoring
and overview of
practice
□ Professional leadership
Practice beyond initial registration
□ Annotation to the professional register
□ Supplementary and independent prescribers
□ 1,241 SPs
□ 142 IPs
□ Regulation of advanced practice?
□ Risk perspectives?
□ Systems for recognition of expertise
□ Approval of consultant pharmacist posts
□ Accreditation of pharmacists with special
interests
Pharmacist development model
Training infrastructure
PG enabling programmes
Undergraduate
& preregistration
College 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 8b/d
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
Performance assessment
Assessment Strategies
Does
Performance
Mini-CEX, mini-PAT, CbD
Experience
Shows
Competencies
OSCE, simulation
Integration
Knows
Knowledge, Skills and Abilities
Education and training
Characteristics and Traits
after Miller 1990
MCQ, MEQ
Pharmacist development model
Training infrastructure
PG enabling programmes
Undergraduate
& preregistration
College 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
Curriculum design
Land ahoy
□ Professional coherence
□ Higher level practice in community pharmacy
□ Careers in research, teaching and management
□ Higher level practice
□ Consistent and equitable recognition
□ Clarity for, and safety of, the public
□ Infrastructure
□ To bridge education and service provision
□ General professional development for all?
Graham Davies
Denise Farmer
Lizzie Mills
Laura Obiols
Roger Fernandes
Ian Bates
Duncan McRobbie
Sotiris Antoniou
Naomi Meadows
With thanks to
DH Steering Group, GHP, UKCPA, CPP and E&SE
England Specialist Pharmacy Services. Members of
Specialist/Practice Interest Groups and CPP Faculties
Funding
NWL WDC, NSC WDD and Department of Health
(scoping higher level practice)
Bibliography
Antoniou S, Webb DG, McRobbie D et
al. A controlled study of the
general level framework: results of
the South of England competency
study. Pharmacy Education 2005: 5:
201-7
Meadows N, Webb DG, McRobbie D
et al. Developing and validating a
competency framework for
advanced pharmacy practice.
Pharm J 2004; 273: 789-792
Dreyfus HL, Dreyfus SE. Mind over
Machine. Oxford: Blackwell, 1986
Miller GE. The assessment of clinical
skills/competence/performance.
Acad Med 1990; 65(suppl): S63-S67
Epstein RM, Hundert EM. Defining and
assessing professional
competence. JAMA 2002; 287: 226235
McRobbie D, Webb DG, Bates I, et al.
Assessment of clinical
competence: designing a
competence grid for junior
pharmacists. Pharmacy Education
2001; 1: 67-76
Schön DA. The Reflective Practitioner:
how professionals think in action.
London: Temple Smith, 1983
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