Professor of Primary and Prehospital Health Care, Community and Health Research Unit (CaHRU), University of Lincoln, UK
Steve Gillam MD FFPH FRCP FRCGP
Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK
Received date: 14 March 2014; Accepted date: 24 March 2014
Individual practice needs to be developed to improve effectiveness, safety and patient experience. Although good systems can support better individual performance, without personal development, individual practice can be a source of error. This, the final article in our series on the science of quality improvement, describes models of competence and practice and the causes of good or poor practice. We show how quality improvement techniques can be used to improve individual practice and how this can be incorporated into the appraisal process for doctors, nurses and other healthcare professionals.
appraisal, general practice, perform-ance, primary care, quality improvement, revalid-ation
For many healthcare practitioners, it is their indi-vidual practice involving face-to-face contact with patients that is the main focus of their work. They are primarily concerned with how to improve the care they provide at a personal level.
In previous articles, we have considered how quality improvement efforts at a wider macro- (multi-organisational), meso- (organisational) and clinical micro-system affect individual practice, but in this article, we focus on how practitioners can personally improve the care that they provide.
Although systems can be designed to improve quality and safety, a disproportionately large number of errors and failures have been shown to be attribu-table to a small minority of healthcare workers, an example of the Pareto principle.
From knowledge to practice
Improvement at an individual level is essentially based on learning, but this is not simply about acquiring knowledge. It also implies an ability to demonstrate the knowledge through the skill of applying it in practice and then the attitudes that lead to these skills being used consistently in day-to-day practice. This progression, from knowledge to its application and from demonstration of competence to performance, is neatly captured in Miller’s pyramid (Figure 1).
The scope of individual practice
The scope and nature of clinical practice is neatly summarised by Norfolk’s ‘RDM-p’ model, which incorporates relationship, diagnostics, management and professionalism (Figure 2).
Relationships with patients, relatives and carers, professionals and even members of the public are central to clinical work and depend on good com-munication skills, and other attributes such as empathy, which leads to trust.
‘Diagnostics’ refers to gathering, interpreting and prioritising information to decision making, which includes the clinical diagnostic process, but also more widely to decisions we make in day-to-day practice. Management is primarily about how we effectively tackle work processes from the cognitive processes that help us make decisions accurately and safely to scheduled tasks such as prescriptions, tests results and correspondence accurately, and from conducting a consultation efficiently to dealing with multiple(sometimes conflicting) priorities effectively. Man-agement is also about monitoring ourselves effectively, maintaining both our performance and our health.
Finally, professionalism is the glue that binds re-lationships, diagnostics and management together. It defines our commitment to best practice, with an emphasis on showing respect for people, acting re-sponsibly and demonstrating ethical and moral be-haviour.
The causes of poor practice
The RDM-p model identifies the nature of clinical practice and where potential strengths or difficulties may arise, whereas the causes of good (or poor) practice are described in a further model developed by Norfolk through painstaking analysis of medical underperformance: the SKIPE model (skills, knowl-edge, internal, past and external factors).
In the SKIPE model (Figure 3), skills and knowledge form the bedrock of competence, but their application can be affected by internal factors such as attitudes, personality and health, or external factors such as the work or non-work environment.
Improvement implies that we assess our strengths and weaknesses in a systematic way. These models enable us to consider our strengths and weaknesses more broadly and thus to build on our strengths and address our weaknesses.
Appraisal and revalidation
Currently, the main focus for doctors thinking strat-egically about their own learning needs is through periodic, formalised appraisal. Appraisal is a process for constructive dialogue in which the health profes-sional being appraised has a formal structured oppor-tunity to reflect on his or her work and to consider how his or her effectiveness might be improved. It is an opportunity to give feedback on past performance, to chart continuing progress and to identify future de-velopment needs. The primary aim of appraisal is to help health professionals consolidate and improve on good performance. In doing so, it helps to identify areas where further development may be necessary or useful. It can help to identify problems of performance at an early stage; and also to recognise factors which may have led to poor performance, such as ill health (Box 1).
Appraisal underpins continuing professional devel-opment (CPD) and provides doctors and nurses with an opportunity to demonstrate the evidence required for revalidation. While appraisal is formative, revalid-ation is a summative process. Revalidation involves a judgement as to whether a doctor is fit to practise and
should remain on the medical register. The revalid-ation process informs the General Medical Council’s (GMC) decision on whether to renew an individual’s registration and this currently occurs every five years. The Nursing and Midwifery Council (NMC) is currently consulting on the corresponding processes for nurses.
How appraisal works
Appraisal is personal; its purpose is to support indi-vidual development. The process should be develop-mental, rigorously conducted and well informed. That means adequate preparation time, both by appraiser and appraisee. Its prime focus is on how patient care can be improved.
The content of medical appraisal was originally based on the core domains set out in the GMC’s ‘Good Medical Practice’ document together with consideration of the doctor’s contribution to meeting local patient needs (Box 2).
Being appraised – the process
Appraisees need to consider their priorities, reflect on practice over the previous year, choose appropriate tools/portfolios to help this review, and prepare a submission for the appraiser. At interview, progress is charted beginning with a review of last year’s personal development plan (PDP). Personal learning needs are identified and an outline learning plan is generated. The appraiser should provide feedback that is honest, sensitive and encouraging.
Prompts to reflection include reviews of significant event logs, audits, complaints, case reviews, prescrib-ing or other activity data. More personalised insights into the way you practice can stem from multi-disciplinary peer review (multisource or ‘360 degree’ feedback). Health professionals are strongly encouraged to measure their patients’ satisfaction using validated questionnaires.
The key points of the discussion and outcome must be fully documented. Appraiser and appraisee must
complete and sign the appraisal summary statement and send a copy, in confidence, to the relevant respon-sible officer. Electronic portfolios greatly facilitate this process. All records must be held on a secure basis compliant with the requirements of the Data Protec-tion Act. If it becomes apparent, during the appraisal process, that there is a potentially serious performance issue which requires further action, the appraiser must refer the matter immediately to the senior appraiser/ responsible officer. This may culminate in referral to other sources of support.
Improving individual performance
In previous articles, we have described how perform-ance can be improved at organisational or multi-organisational levels using quality improvement and change management techniques and skills.[7–12] Quality improvement projects can also be effectively used to improve individual performance and can be used as part of the appraisal process (Box 3).
The models described above enable us to assess individual practice, identify and address problems, and improve individual practice through the use of quality improvement techniques, which can provide evidence for appraisal and revalidation. An example of a quality improvement project is shown in Box 4.
In this series of articles, we have attempted to provide readers with an introduction and primer to the science of quality improvement and implementation. We have included articles on quality improvement tools and techniques, the foundations of which are im-provement frameworks and models, which led to a discussion of processes, their measurement, managing change through leadership, spreading improvement using the features of healthcare systems, and eval-uating improvement initiatives.
Finally, we have examined evidence-based health-care, addressing gaps in translation of evidence into practice and, in this article, how to apply improve-ment science to personal improvement.
Quality improvement, safety and implementation science are rapidly becoming essential knowledge for healthcare staff in medicine, nursing and allied health professions. We hope this series of articles has pro-vided an introduction and whetted your appetite to learn more.
Commissioned; not externally peer reviewed.
We would like to thank Tim Norfolk for his comments and use of the RDM-p and SKIPE figures.