How do we overcome wasteful and unnecessary bureaucracy associated with poorly designed accreditation and reaccreditation courses?

#GPFUQ 194 How do we overcome wasteful and unnecessary bureaucracy associated with poorly designed accreditation and reaccreditation courses.  The challenge is to provide appropriate learning for each learner. Not too little and not too much.

GPs are often expected by third parties to have initial accreditation in a task that the GPs want or need to do, and once accredited they may be expected to reaccredit their knowledge and competence at regular intervals. Many of the standards for accreditation may not be truly fit for purpose because

1.              There is poor linkage between the GPs learning needs or gaps and the learning objectives; poor linkage between the learning objectives and the content of courses: poor linkage between the content and the outcome questions about performance or patient outcomes; and poor linkage between the outcome questions and the learning objectives.  As a result a danger is that the content of the course is either poor quality or over engineered and wasteful of the time of the learner, and/or the outcome of the course in that the learners performance is not determined so there is no feedback to the learner or the course designer on the success or failures of the course.

2.              The proliferation of poor quality accreditations and re accreditations is an expensive misuse of scarce NHS resources (eg GP time).

3.              Poorly designed accreditation and re accreditation courses contribute to the unnecessary bureaucracy that make GPs feels overwhelmed.

All GPs need to give robust feedback to accreditors that the quality of accreditation and reaccreditation processes must be improved following the best quality improvement and learning principles and processes.

Principles of Quality Improvement and Learning suggest

1. What are you trying to achieve? All learning starts with a problem. You always need to describe the problem that needs to be solved. For example with cx sampling in the National Screening programmes: Is it the quantity of samplers (ie not enough to run the programme), or the quality of samples that is a problem (ie too many poor quality samples).

2.What do you know about this problem?

When you know the problem conduct a learning needs analysis, describe the gap analysis, write learning objectives, develop the content for the course and then write the assessment of outcome questions.

The needs assessment and gap analysis may need a literature review, quality performance data review, and expert interviews. This might be either interrogating the data to see if it's a general problem (affects all areas and samplers) or a specific problem (areas and samplers who have the problem can be identified). Has anyone else has the problem and solved it already?

You should identify the needs/gaps by outcomes like knowledge, confidence, competence, performance and patient outcomes

3. What are you able to do with the available resources? You should include the costs you are passing onto others (eg the learners time, and opportunity costs associated with that). You should aim for the ‘good enough’ solution. You don’t want to over engineer the solution. For example if there is a cheap, fast, reliable way to fix the problem (eg gets Cx samplers to watch a You tube video) you should use that solution in preference to anything that is more expensive or slower.

4. How are you going to measure success? What are the success criteria? You will need to have success criteria based on outcomes that are linked through the learning objectives and process to the initial needs assessments. There must be a clear connection for the structure and process of learning between the needs assessment and the outcomes. If there are any broken or weak links they must be identified and removed or repaired

and finally

5.How and when will you review what you are doing?

Examples of questions to ask are given in Appendix A- Linkage of Learning Objectives to Outcomes levels and questions

I have used Cx sampling accreditation and re accreditation as an example to test these principles and practices – see appendix B.

Appendix A

Linking (ref Derek Dietze- Linkage of Learning Objectives to Outcomes levels and questions: A practical solution for Optimal results)

1.Linking Identified Needs/gaps to Learning Objective. Do the objectives

•      Address the identified needs/gaps?
•        Reflect and deliver on the level of desired/promised outcomes?
•        Seem achievable given the nature of the intervention?

2.Linking Learning objectives to Content. Does the content

•       Specifically address each learning objective?
•       Prepare the learner to achieve the desired outcome?

3.Linking Content to Outcomes Questions. Are the outcome questions

• answered in the content and is sufficient time spent on the areas being measured?
• Asked at  the right time/place (ie in follow up for performance and patient questions)? 

4.Linking Outcome Questions to Learning Objectives. Is each outcomes question

• specifically designed to assess achievement of a specific learning objective?
• Designed to assess the level of outcome indicated in the learning objective it is linked to?

Appendix B

Good practice guidance for cervical  sample takers

A reference guide for primary care and community settings in the NHS Cervical Screening Programme

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/469962/CSP_GPG2_uploaded_211015.pdf

SECTION FOUR

Sample taker training

The resource pack for trainers of sample takers

represents best practice and is available at

www.cancerscreening.nhs.uk

A competency framework has been developed by Skills for Heath relating to Cervical Cytology Sampling CH37 and can be found at

www.skillsforhealth.org.uk

Organisation of training

Training for sample takers should be in two parts; a theoretical course followed by a period of practical training. Practical training should take place in the practice or clinic where the trainee is based. It should be supervised bythe mentor (see Criteria for Sample Taker Mentoring below).

Trainees should keep a record of their training.

Theoretical course

A theoretical training course should cover the following the NHSCSP, its background and context equality of access to cervical screening understanding test resultsanatomy and physiology of the pelvic organs practical aspects of taking cervical samples.

Update training

Sample takers should undertake a minimum of one half day's update training every three years. E-learning update modules may be used if they fulfil both the national and local requirements. Whatever form it takes, update training must cover all of the following areas

current developments in the NHSCSP, nationally and locally

recent literature relevant to sample taking, sampling devices and women's needs

changes to local screening policies and procedures

personal learning needs

qualitative assessment of 20 recent consecutive samples produced by the sample taker.

Criteria for sample taker mentoring

Trainers

Trainers should have good teaching and communication skills, and ideally hold a relevant teaching qualification. They should undertake regular update training and maintain awareness of developments in the NHSCSP. They must be practising sample takers who are able to demonstrate continuing competence in taking samples for cervical screening with particular reference to

transformation zone sampling

sampling technique

equipment and sample preparation

audit of results, including adequacy rates

effective communication awareness of developments in the NHSCSP

Practical training

For the first practical session/s the trainee should be accompanied by the training mentor and should

identify training needs in discussion with the mentor

observe at least two samples being taken

take a minimum of five samples under supervision.

The mentor and trainee should then decide whether the student may proceed without further direct supervision. Once this is confirmed, the trainee should arrange to take and document a minimum of 20 unsupervised samples. Easy access to a trained colleague is essential throughout this period.The trainee should visit both the cytology laboratory and the colposcopy clinic, documenting the visits

in the training record book

Final assessment

Both mentor and trainee are expected to maintain regular contact and to discuss progress towards meeting identified training needs and any problems. They should meet for a final evaluation session, which should include a final clinical assessment. The trainee must have completed a minimum of 20 cytologically adequate samples before the final evaluation session. All training should be completed within a nine month period.

Maintaining competence

To help to ensure continued competence in accordance with their professional codes of conduct, sample takers should conduct continuous self evaluation. They should audit and reflect on their individual rates of inadequate tests and abnormal test results compared with the rates reported by the local laboratory.