competence, competency and pharmaceutical care: … · competence, competency and pharmaceutical...

Competence, competency and pharmaceutical care:

The why, what and how of competence assessment


The why, what and how of competence assessment

Graham Davies,Professor of Clinical Pharmacy & Therapeutics,King’s College, London


David Webb Ian BatesDenise Farmer Duncan McRobbieLizzie Mills Sotiris AntoniouLaura Obiols Naomi Meadows Roger Fernandes

FundingNWL WDC, NSC WDD and Department of Health (scoping higher level practice)

ObjectivesObjectives

Scene setting - why is competence important?Definitions:

- competence, competences, competencies- performance

Putting competence at the heart of care - the pharmacist development strategyMeasuring competence - the General Level Competency Framework

Scene setting - why is competence important?Definitions:

- competence, competences, competencies- performance

Putting competence at the heart of care - the pharmacist development strategyMeasuring competence - the General Level Competency Framework

Bristol Inquiry into Paediatric cardiac surgery -Kennedy Report (2000)Clinical governance & professional regulationAnti–professional attitude – professions are driven by self-interest and promotion.Public involvement (‘Informed consent’, Information and Choice)

Bristol Inquiry into Paediatric cardiac surgery -Kennedy Report (2000)Clinical governance & professional regulationAnti–professional attitude – professions are driven by self-interest and promotion.Public involvement (‘Informed consent’, Information and Choice)

Why is competence so important?Why is competence so important?

Why is competence so important?Why is competence so important?

‘A patient is entitled to be cared for and by healthcare professionals with relevant and up-to-date skills and expertise.’

Kennedy Report (p14)

Attaining Competence - Problems for PharmacistsAttaining Competence - Problems for Pharmacists

The service providedLack of clear career strategy with appropriate milestonesNo agreement on higher levels of practice – within and between pharmacy disciplinesVariability in quality of practice at junior and senior levelsNo succession planning

Education and trainingInequality of workforce access to structured, accredited learning experiencesDriven by academic attainment – divorced from service need and practitioner development

The service providedLack of clear career strategy with appropriate milestonesNo agreement on higher levels of practice – within and between pharmacy disciplinesVariability in quality of practice at junior and senior levelsNo succession planning

Education and trainingInequality of workforce access to structured, accredited learning experiencesDriven by academic attainment – divorced from service need and practitioner development

Outcome……………..for staff?Outcome……………..for staff?

Poor staff morale Poor job satisfactionPoor staff retentionPoor staff recruitment

Poor staff morale Poor job satisfactionPoor staff retentionPoor staff recruitment

Outcome……………..for service?Outcome……………..for service?

Increase pressure on existing staff Fire-fighting cultureLittle opportunity for service review or improvementInadequate risk management cultureIncrease in medication error

Increase pressure on existing staff Fire-fighting cultureLittle opportunity for service review or improvementInadequate risk management cultureIncrease in medication error

Why a competency approach?Why a competency approach?

PolicyFitness-for-purpose in the post Kennedy eraCommon NHS pay spine - Agenda for Changeand the Knowledge & Skills Framework

Research EvidenceResults of Clinical Skills Assessment

PolicyFitness-for-purpose in the post Kennedy eraCommon NHS pay spine - Agenda for Changeand the Knowledge & Skills Framework

Research EvidenceResults of Clinical Skills Assessment

Testing competence of pre-registration pharmacists

Objective Structured Clinical Examination (OSCE) of pre-registration pharmacists,Workstations to test required skills,Students rotate through stations,Set time in each station,Assessed against predetermined checklist.

Design of OSCE

6 baseline stations in at start of pre-registration year

15 stations at end of pre-registration year

7 minutes per station

Students assessed using checklists by experienced practitioners

Baseline workstations

Drug history takingInformation retrieval - medical notesResponding to symptomsTherapeutic Drug MonitoringDevice counsellingMedication counsellingHealth promotion

0

10%

20%

30%

40%

50%

60%

70%

1996/97 1997/98 1998/99 2001/02

Clinical Competence(OSCE)

Graduation

One year later

60%

30%

McRobbie et al

Registration

Total Comp Not Comp

Registered 136 93 43

Not Registered

20 9 11

Why a competency approach?Why a competency approach?

PolicyFitness-for-purpose in the post Kennedy eraCommon NHS pay spine - Agenda for Change and the Knowledge & Skills Framework

Research EvidenceResults of Clinical Skills AssessmentThe General Level Competency Framework

Accelerated and sustained performance(Antoniou et al. Pharmacy Education 2005)defines and makes explicit development needsachieves dynamic between workforce flexibility and competence

PolicyFitness-for-purpose in the post Kennedy eraCommon NHS pay spine - Agenda for Change and the Knowledge & Skills Framework

Research EvidenceResults of Clinical Skills AssessmentThe General Level Competency Framework

Accelerated and sustained performance(Antoniou et al. Pharmacy Education 2005)defines and makes explicit development needsachieves dynamic between workforce flexibility and competence

Competence approaches have their critics…..………Competence approaches have their critics…..………

Critical accountCritical accountCompetence approaches

ReductiveShopping listsJob specificCentral controlAdequacy

Competence approaches

ReductiveShopping listsJob specificCentral controlAdequacy

The problem with competency frameworks………….The problem with competency frameworks………….

Robust developmentValidity and Reliability

Duplication of effort –“Not invented here syndrome”Lack of testing and use of evidence – “Do they do what it says on the tin?”Lack of integration – silo mentality

Robust developmentValidity and Reliability

Duplication of effort –“Not invented here syndrome”Lack of testing and use of evidence – “Do they do what it says on the tin?”Lack of integration – silo mentality

Alternative departuresAlternative departures

Novice-to-expertDreyfus & Dreyfus 1986

5 stage progressionFrom adherence to intuitive graspReliable metric to identify expert?

Novice-to-expertDreyfus & Dreyfus 1986

5 stage progressionFrom adherence to intuitive graspReliable metric to identify expert?

Reflective practiceSchön 1983

Learning from experienceNecessary and sufficient?Cause or effect?

Reflective practiceSchön 1983

Learning from experienceNecessary and sufficient?Cause or effect?

Competency icebergCompetency iceberg

Effective and persistent behaviour

Knowledge

Skills

Abilities

Values, attitudes and beliefs

Competency…a complex constructCompetency…a complex construct

Skills

Behaviours

Knowledge

Valuesattitudes

Competency

Skills

Behaviours

Knowledge

Valuesattitudes

Competency

Skills

Behaviours

Knowledge

Valuesattitudes

Competency

Skills

Behaviours

Knowledge

Valuesattitudes

Competency

In search of the holy grailIn search of the holy grail

…………….assessing performance…………….assessing performance

Characteristics and Traits

Knowledge, Skills and Abilities

Competencies

Performance

Education and training

Integration

Experience

Innate

Developed

Bundled

Deployed

Competence and performanceCompetence and performance

Fuzzy conceptsFuzzy concepts

CompetenceOverarching capacity

CompetencesFunctional, the what

CompetenciesQualities, the how

CompetenceOverarching capacity

CompetencesFunctional, the what

CompetenciesQualities, the how

Professional competenceProfessional 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

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

Pharmacist Development StrategyPharmacist Development Strategy

……don’t consider competence in isolation……don’t consider competence in isolation

Key Ingredients of a StrategyKey Ingredients of a StrategyDescribe the key areas of practice & their associated outputs or competencies,Tool to measure competence of 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?

Describe the key areas of practice & their associated outputs or competencies,Tool to measure competence of 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?

Higher Level Development Phase

Practice development strategy

General Level Development

PhaseUndergraduate & Pre-registration Phases

General Level Practitioner

Advanced Practitioner

Higher Level Development Phase 2

1Consultant Practitioner

General Level Framework

Higher Level Framework: Advanced & Consultant

The General Level FrameworkThe General Level Framework

Design and EvaluationDesign and Evaluation

Framework StructureFramework StructureCompetency models

OutcomeEducationalPersonal

General Level FrameworkHybridDerived by recognised process

Agenda for Change - NHS common pay spine.Adopts a generic evaluation framework (the Knowledge and Skills Framework {KSF}) – with gateways GLF consistent with requirements of KSFGLF enables KSF – provides evidence of care made.

Competency modelsOutcomeEducationalPersonal

General Level FrameworkHybridDerived by recognised process

Agenda for Change - NHS common pay spine.Adopts a generic evaluation framework (the Knowledge and Skills Framework {KSF}) – with gateways GLF consistent with requirements of KSFGLF enables KSF – provides evidence of care made.

Structure of the GLFStructure of the GLF

Competency Framework: General Level

PERSONAL PROBLEM MANAGEMENT

DELIVERYOF

PATIENTCARE

Organisation, Team working,Communication,Professionalism

Drug use

process

Gathers informationKnow ledge

Analyses InformationProvides information

Follows up and reflects

PunctualityInitiative

Confidentiality

Drug history takingInteraction identification

Patient counselling

Assesses informationAccurate providesRelevant, Timely

McRobbie, Webb, Bates, Davies, Wright 2001

GLF structureGLF structure

Selection of formulation and conc

Selection of dosing regime

Calculation of appropriate dose

Administration of drug

Drug-disease interaction

Drug patient interaction

Drug drug interaction

Selection of drug

Drug history

Relevant Patient Background

Need for drug

NEVERSOMETIMESUSUALLYALWAYSCompetencies

Intervention: (a) standard settingIntervention: (a) standard setting








Selection of drug

Drug history


Need for drug


(b) performance measurement(b) performance measurement








Selection of drug

Drug history


Need for drug


(c) performance improvement(c) performance improvement

Month-12 findingsBPC 2004

Month-12 findingsBPC 2004

RecruitmentRecruitmentEducational research

Difficulty with controlled study designs3-part recruitment

Election for intervention groupElection for non-intervention groupNo preference

Final allocationIntervention group: 13 NHS trustsNon-intervention group: 9 NHS trusts

Educational researchDifficulty with controlled study designs

3-part recruitmentElection for intervention groupElection for non-intervention groupNo preference

Final allocationIntervention group: 13 NHS trustsNon-intervention group: 9 NHS trusts

Intervention Group n= 74 NHS Trusts = 13

Junior grade pharmacists

All use competency framework, supervised and assessed by clinical managers

Non-intervention Group n= 30 NHS Trusts = 9

Junior grade pharmacists

All undertake orthodox training supervised by clinical managersAssessment made using framework by independent assessor (no feedback)

Design

DemographicsDemographics

2626weeks (median)41.7542.9weeks (mean)

Time with trust 1 (1.35)0 Diploma completed24 (32.4)11 (36.7)Certificate completed

Academia9 (12.2)2 (6.7)Split39 (52.7)17 (56.7)Hospital26 (35.14)11 (36.7)Community

Place of Pre-reg8473Gender (% F)26.87 (+/- 4.17)27.2 (+/- 5.02)Mean age (yrs) +/- stdIntervention (n=74)Non-intervention (n=30)

One Minus Survival Functions

TSURVIVE

14121086420-2

One

Min

us C

um S

urvi

val

.7

.6

.5

.4

.3

.2

.1

0.0

-.1

group

active

active-censored

control

control-censored

(log rank, p=0.0048)

Adapting the General Level Competency Framework for Primary Care and Community Pharmacy

Adapting the General Level Competency Framework for Primary Care and Community Pharmacy

General Level Framework 2nd EditionGeneral Level Framework 2nd Edition

Testing the 2nd Edition General Level Competency Framework in Primary Care and Community Pharmacy

Testing the 2nd Edition General Level Competency Framework in Primary Care and Community Pharmacy

Evaluation

AimsTo evaluate the framework as a measurable mechanism to support the continuing professional development of pharmacists

To validate self assessment as a measure of competence

To explore the use of facilitators to support pharmacists using the framework.

Performance improvementPerformance improvement

12 months8 months4 monthsBaseline

4.0

3.5

3.0

2.5Self-

asse

ssed

per

form

ance

in th

e d

eliv

ery

ofpa

tient

car

ecl

uste

r (m

ean

+ 95

% C

I) Non-intervention (n=31)Intervention (n=69)

Community pharmacyCommunity pharmacyI 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 doI 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

Competency Framework: General LevelCompetency Framework: General Level

Describes the competencies• Patient care• Problem solving• Personal• Management & organisation

Sector independent• Evidence supporting it’s use in

the acute and community sectors

Valid, evaluated tool• No disagreement on content• Sensitive to change• Improves and sustains

performance

Describes the competencies• Patient care• Problem solving• Personal• Management & organisation

Sector independent• Evidence supporting it’s use in

the acute and community sectors

Valid, evaluated tool• No disagreement on content• Sensitive to change• Improves and sustains

performance

Benefits to clinical pharmacy service

‘These grids, allow me to give structured feedback and target the response to agree an action plan’‘The framework is now an integral part of my training armoury. A development programme for each junior pharmacist has been drawn up based on their competency assessment’

Benefits to clinical pharmacy service

‘These grids, allow me to give structured feedback and target the response to agree an action plan’‘The framework is now an integral part of my training armoury. A development programme for each junior pharmacist has been drawn up based on their competency assessment’

ImplementationImplementation

East and South East EnglandSouth West of EnglandParts of North of England

Piloting in Ireland and Wales

Adapted and adopted in Queensland, Australia

Discussions with Spain

East and South East EnglandSouth West of EnglandParts of North of England

Piloting in Ireland and Wales

Adapted and adopted in Queensland, Australia

Discussions with Spain

Competence, like truth, beauty and contact lenses, is in the eye of the beholder

Laurence J Peter

Competence, like truth, beauty and contact lenses, is in the eye of the beholder

Laurence J Peter

Copy of slides and 2nd Edition of GLF available on: www.codeg.orgCopy of slides and 2nd Edition of GLF available on: www.codeg.org


The why, what and how to competence assessment


The why, what and how to competence assessment



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competence, competency and pharmaceutical care: … · competence, competency and pharmaceutical...

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