Educational Governance in Primary Care
A self audit system to support quality in Continuing Professional Development
Executive summary
There has been a fundamental shift in primary care education away from attendance at accredited educational events towards personal development planning as the main vehicle for a practitioners continued professional development (CPD). Doctors have followed other professional groups in this regard. The 1998 Chief Medical Officer’s report on continuing professional development (CPD) in general practice recommended that each practice should compile a Practice Professional Development Plan (PPDP) incorporating each practitioner’s personal development plan (PDP).
Annual appraisal has been introduced for all doctors working in the NHS and a PDP is compiled on completion of the appraisal. Many other primary health care staff are either developing or undertaking appraisal and producing personal development plans with a similar format to that used by the medical profession.
This paper develops concepts of Educational Governance from a Quality Assurance (QA) perspective for professional learning in the NHS. The foundation stones of educational governance are based on generic attributes that can be applied to any learning or assessment activity in the primary care arena. They incorporate partnership with patients and strive to enhance patient care as core values. Educational Governance will be essential to develop the NHS to fulfil the Department of Health’s recent consultation paper “Standards for Better Health”[1] and will be a dynamic process that evolves with experience. thth
Educational governance as outlined in this paper provides basic tools to guide practitioners, teams and employers in
Quality standards for CPD for teams and individuals in Primary Care
Quality standards for Personal and Practice development plans
Quality standards for appraisal in Primary Care.
1.0 Introduction
1.1 The 1998 Chief Medical Officer’s report on continuing professional development (CPD) in general practice signalled a fundamental shift away from attendance at accredited educational events towards personal development planning as the main vehicle for general practitioners’ CPD1. The CMO had been prompted to produce a report partly by the need for change in the learning culture of the NHS and partly by the successful use of Personal Development Plans (PDPs) and portfolio learning in other professional groups. The report’s main recommendation was that each practice should compile a Practice Professional Development Plan (PPDP) incorporating each practitioner’s PDP. Oft promised guidance on the implementation of the report’s recommendations never materialised – however in many areas progress has been made not only with regard to medical practitioners but indeed all staff working in primary care.
1.2 The report’s definition of CPD has been adopted, with but minor amendment, for the whole NHS:
A process of lifelong learning for all individuals and teams which meets the needs of patients and delivers the health outcomes and healthcare priorities of the NHS and which enables professionals to expand and fulfil their potential. [2]
Compulsory annual appraisal has now been introduced for all doctors working in the NHS, with a PDP being an integral element. Appraisal and personal development planning is extending rapidly to all other NHS staff. To date there has been little work reviewing the development or operational value of practice professional development plans (PPDPs) and their use in some areas is declining.
1.3 The system of accreditation for general practitioners’ CPD, the postgraduate education allowance (PGEA), ended on 31 March 2004 with the implementation of the new GMS contract. The abolition of PGEA and the move to appraisal becoming the main vehicle for personal development planning, raises the issue of quality assurance of CPD. This is also an issue of equal importance to other primary care professionals and indeed to Primary Care Organisations (PCOs). Quality assurance of professional development has received scant attention for general practitioners, nurses, allied health professionals and administrative staff, yet the public need to be assured that professionals’ competencies are being evaluated and developed. Because the process of CPD is generic, quality assurance systems should likewise be generic for all staff and be capable of being applied equally to individual and team learning as well as at any stage in a health workers career. This is likely to have increasing relevance as demarcation between health-care performers in primary care becomes progressively more blurred, in response to workforce demographics and changes in patterns of delivery of care.
1.4 How will all practitioners (not just medical practitioners) and their appraisers assure themselves that PDPs, PPDPs and educational activity are of sufficient quality? What standards should underpin the educational governance of CPD in primary care? How do we involve professionals and the public so that quality assurance occurs to the ultimate benefit of patient care? This paper sets out to describe a system of Educational Governance comprising tools that will fulfil these objectives.
1.5 We set out draft quality standards for CPD in general practice and primary care. The standards should guide the processes of CPD and can be used as a framework for educational governance, quality assuring the provision and assessment of learning in primary care. The standards can be used to help in the planning of individual, uni-disciplinary or multidisciplinary education and appraisal. They are designed as a self-audit tool for all those engaged in PD processes to optimise proposed educational activity. Widespread use of these tools amongst practitioners, appraisers and organisers of activities should progressively heighten quality, increasing standards by participation rather than accreditation. These tools give practitioners detailed guidance which is congruent with the NHS Knowledge and Skills Framework3 and should help PCOs implement the Improving Working Lives initiatives 3,4.
1.6 The following illustration summarises the process and the desired outcome:
2.0 Quality Standards for CPD in Primary Care
2.1 Much work has already been undertaken looking at maxims that might guide the quality management of CPD activity. One of the easiest to understand are the APPLE principles. These principles can be applied to any individual or team and at any stage in a person’s career. They can be used to set the agenda for team based as well as personal development. There are five aspects of the process of CPD that should be addressed to ensure quality (APPLE) [3].
Assessment of educational need
Prioritising needs
Planning learning activity
Learning activity –using appropriate methods
Evaluation of learning, including follow up and dissemination
2.2 Patients, carers and users are at the core of APPLE. All healthcare workers can identify learning needs from our patients, as well as actively learning from our patients at an individual level (the use of Patients Unmet Needs © and Doctors Educational Needs- PUNS & DENS - © is an established example). The role of patients or their representatives may vary depending on the form and content of the developmental activity. Patient involvement for example in clinical consultations, in user surveys, or in delivering learning events all have a vital but differing role in enhancing the quality of CPD.
2.3 The following paragraphs describe quality criteria for each element of APPLE as they apply to individuals, teams, employers and educational providers. The criteria are sufficiently broad to be applied to any educational process, and can be used by any participant in that process. Thus they are equally suited to:
An individual considering their personal leaning plan
- An appraiser assessing a personal learning plan
- A PCT reviewing a practice professional learning plan
- A provider of an educational meeting
- Clinical Governance lead thinking through a PCO’s system of appraisal
- An external assessor considering the culture of learning in a PCO
Assessment of educational needs
Personal : The individual can show how the learning needs were defined and their relevance to practice or personal development to improve patient care in their work environment. Usually needs will have been derived objectively from reflection on current provision compared with professional and NHS standards.
Team: Personal learning needs and service development needs are integrated in the practice or unit plan to improve service provision.
Employer: Recognises the professional standards of staff and supports their learning development as individuals and teams via appraisal systems, good Human Resource practice and educational provision where relevant. Is open to audit and external review
Provider: Can demonstrate educational experience and local input in formulating the learning activity from subjective and objectively determined learning needs. Can show the learning activity is relevant, necessary and is best practice to potentially improve care and or service provision
Prioritising needs
Personal: Can demonstrate that areas involving patient safety are prioritised and that objective methods such as appraisal are used to produce the learning plan
Team: Can demonstrate that a consideration of the needs and performance of the local service against national standards has resulted in the priorities laid down in the Practice Professional Development Plan
Employer: Can demonstrate that learning needs are captured and have been prioritised by considering formal schemes such as PPDPs, appraisal scheme outputs and a comparison of service provision against national standards
Provider: Can define the relevance of the topic to health professionals being targeted and patients and to the primary care community
Planning the Learning Activity
Personal: Can demonstrate the reasons for the type of learning activity chosen, and ensure there are SMART (Specific, Measurable, Achievable, Relevant and Time-tabled) objectives which will allow an appropriate evaluation
Team/Employer: Can demonstrate the reasons for the type of learning activity and whether the activity is uni- or multidisciplinary. The activity should be planned to incorporate reflection and appropriate evaluation, and have clear and SMART objectives
Provider: The provider should involve learners in planning the activity and should ensure the activity chosen is relevant to the learner’s context. SMART objectives should be agreed and time set aside for reflection and evaluation. Evaluation should be fit for purpose
The Learning Activity
Personal/Team/Employer/Provider: A suitable range of teaching modalities and participants should be used, appropriate to the context, learning outcomes and past experience of the learners. The participants should be encouraged to write reflections of their learning arising from the activity
Evaluation of learning
Personal: The learner should be able to demonstrate learning which meets their needs and the needs of the population and practice, both for themselves and for formal systems such as appraisal. The evaluation should consider actual learning and aid reflection on the care delivered by the individual or team.
Team: The learning, evaluation and reflection should be transmissible to all team members involved in improving care. Agreement about service changes should include the programme for reassessing the area of work in the future
Employer: Evaluations and the results of formal systems for managing learning should include reflection on service design and resources for service delivery, including both staff and capital projects. Available evidence from differing sources should be collated and disseminated as appropriate. Ideally the process of CPD in the organisation should be reviewed by an external assessor annually.
Provider: Evaluations should allow reflection on teaching technique and the success or otherwise of the activity in meeting the defined need(s). Such evaluations should be available for independent review.
2.4 The practical application of the APPLE process has been illustrated using the following matrix. This has been adapted to apply to primary health care workers:
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APPLE
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Criteria
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Additional guidance
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Applicable at personal, team and organisation levels
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Individual
Personal
Learning
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Healthcare team
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Course provider
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Employer
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Assessment of educational needs
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Is there evidence of need, rather than just want?
Have objective measures been used, where appropriate?
Do the needs reflect the context of the individual’s / group’s work?
Do the needs have the potential to improve patient care?
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This should be from reflection on practice using, e.g. PUNS & DENS © or audit, 360° feedback
Needs reflect the individuals agenda and the needs of patients and the service
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Personal learning needs and service development needs are integrated in the practice or unit plan to improve service provision to the benefit of patients and the service
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Seeks to involve learner in formulating the learning objectives, and uses recognised and agreed evidence
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Information about local needs, esp. that arising from appraisal, PPDPs and comparison of service provision against national standards is formally considered
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Prioritising needs
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Where the needs have implications for patient safety, have these been prioritised?
Where relevant, have needs from the umbrella organisation (e.g. practice/ PCT/ NHS) been prioritised?
Have needs identified through formal means such as appraisal/clinical governance been addressed?
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Patient safety is of paramount importance but the needs of the practice and PCO should also be considered
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Patient safety is of paramount importance but the needs of the PCO and national agendas should also be considered
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Patient safety is of paramount importance but the activity should be based on participants needs derived directly and from local NHS structures
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Patient safety is of paramount importance but the regional and national agenda should also be considered
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Planning the Learning Activity
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Are the learning objectives SMART?
Are the proposed learning activities informed by a Primary Care perspective and fit for purpose?
Is time allowed
for reflection and evaluation?
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An individual and their appraiser should consider the context, resources and position of the individual in deriving a plan
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The plan should include measurable endpoints and be realistic in the practice and PCO context, with timescales and arrangements for review
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The provider should involve learners in planning the activity. The activity chosen should be relevant for the workplace context and involve a primary care resource where appropriate.
Conflicts of interest and activities promoted by commercial organisations should be avoided
Evaluation should be fit for purpose
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The employer should have HR policies which encourage learning activities, which are relevant, specific, timely and produce measurable outcomes
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The Learning Activity
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Is there a description of the type and purpose of the learning activity?
Where beneficial to learning, are a suitable range of activities and participants used?
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Has the individual thought about the most effective activity to achieve the learning objectives?
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The activity may include specific and general sections, for example the implementation of a new practice service and its monitoring by SEA and clinical audit
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The provider must not be engaged in or rewarded for supporting external commercial gain
The teaching modalities and participants should be appropriate to the context, learning objectives, preferred learning styles and past experience of the learners.
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The employer should understand and encourage differing learning activities and promote inter-professional or uni-proessional fora where appropriate
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Evaluation of learning
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Is there evidence of learning?
Has the process of learning been evaluated?
Where relevant, has learning been disseminated to the appropriate parties?
Where relevant, has learning been applied to improve patient care?
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Evidence should be available to show reflection allowing understanding and application of learning to practice, ideally resulting in evidence of change if necessary
Implications for future learning should be clear from the evaluation
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Agreement about service changes should include the programme for reassessing the area of work in the future, e.g. audits, appraisals, competency based assessments
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Evaluations should allow reflection on teaching technique and the success or otherwise of the activity in meeting the defined need.
Such evaluations should be available for independent review
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Evaluation should include reflection on service design and resources for service delivery, including both staff and capital projects.
The outcomes should be disseminated as appropriate.
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2.5 The matrix includes examples of different activities involving learning. The key to quality in educational activities is to ask the appropriate questions, derived from the matrix, during the planning, execution and evaluation of the learning activity. The following two examples show more comprehensively how important components of different activities are translated from the matrix:
Appraisal (may apply to individuals, teams or organisations)
- Was the appraiser selected using agreed criteria derived from national guidance and given relevant training using skills and attitudes consistent with their work experience?
- Did the initial training prioritise the appraiser’s tasks to focus on formative development enhancing patient services?
- Does the appraiser gather evidence with the appraisee and develop a learning plan appropriate to that individual and the needs of the practice and service?
- Is the appraisal itself and the system evaluated appropriately?
- Do broad and relevant outcomes inform the employing organisations policies?
- Is the individual enabled to reflect on the outcomes of the learning plan, informing the next audit cycle?
Educational Events (may apply to individuals, teams or organisations)
- Does the facilitator have some educational experience or qualification?
- Does at least one primary care worker take part in planning the event, accepting responsibility for the quality of the educational content? Does the learning activity involve all team members involved in the topic in the workplace?
- Will the provider undertake pre-activity evaluation to determine the expected learning needs and therefore the objective of the activity?
- Will the provider set outcomes which can demonstrate the achievement of the objectives?
- Will appropriate teaching/learning modalities be chosen to achieve the outcomes?
- Will the facilitator make an attempt to provide different teaching styles so that as many learning styles as possible can be accommodated?
- Will the programme include time for or means of reflection on the activity for the learner?
- Will the organisers ensure a relevant evaluation is carried out by the learners?
- Are any assessments recognised professional processes? If an assessment is devised, is it based on established educational theory with advice sought from the accreditor?
3.0 Conclusion
3.1 This paper describes guidance that can be used to quality assure different aspects of professional development in primary care, through use of a self audit tool. It has attempted to generalise principles in such a way that the application of quality assurance can be extended to the whole range of PHCT activity. The language has been kept simple and tools have been provided for easy application of quality assurance. These tools are in the form of a series of questions which can be applied to educational activities.
3.2 This approach will lay down the basis of a universal standard for processes and systems supporting continuing development in primary care. They will create universality of expectation – both of internal and externally driven developmental activity. The principles in this document seek to tie together different processes and emphasise the continuum of these, rather than the disconnection that is often perceived at present.
3.3 Further advice on PD and QA can be obtained from a number of sources. Professional Associations and Colleges have a vital role in setting and encouraging standards for PD. Your deanery office for your locality is a source of expert advice. The Postgraduate Medical and Dental Deaneries or Workforce Development Confederation personnel will usually interact with the primary care organisation either directly, in the case of GP appraisal support, or indirectly in terms of facilitating learning activities. This will usually be in conjunction with local appraisers and educational leads. Other support structures are emerging – particularly practice nursing support networks and practice manager support networks.
3.4 Maximal benefit will be gained by using the same language and culture of quality professional development across the whole of the UK. Expert sources of advice and help can be sought in Scotland via regional offices of NHS Education for Scotland, In Wales through the University of Wales Department of Postgraduate Education for General Practice and in Northern Ireland through the Northern Ireland Council for Postgraduate Medicine and Dentistry.
4.0 References
[1] Standards for Better Health: Health Care Standards for Services under the NHS. Department of Health, London, February 2004
2 Department of Health (1998) A Review of Continuing Professional Development in General Practice. Department of Health, London
3 The NHS Knowledge and Skills Framework (NHS KSF) and Development Review Guidance. Department of Health, March 2003
4 Improving Working Lives – National Audit Instrument. Department of Health, October 2003
5 Sylvester S (2001) Continuing professional development. In: J Harrison and T van Zwanenberg (eds) The New GP: changing roles and the modern NHS. Radcliffe Medical Press, Oxford.
5.0 Appendices
1 APPLE Self Assessment Tool
Record of Educational Event conforming to APPLE criteria
Organiser:
Address
Email
Telephone
Organisers job
PCO
Title of activity
Date and time
Venue
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APPLE
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Assessment of educational needs
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Describe how need was identified; describe the individual and team context; describe individual and team needs, how these link to service and the response of the provider in seeking to address these needs
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Prioritising needs
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Describe the relative priority for this activity; describe how the activity will ensure patient safety; describe how the activity is balanced against individual, team / locality, and national need
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Planning the Learning Activity
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Describe how SMART has been incorporated; describe content of the activity and the balance between individual and organisational development; describe involvement of learners; specify the level of any support or sponsorship; specify evaluation
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The Learning Activity
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Describe the activity, the educational methods to be used and why this was decided; state who is involved; specify the level of financial gain of any contributors
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Evaluation of learning
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Specify arrangements for reflection, evaluation, collation and dissemination; state what tool will be used to do this
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2 Evaluation tool
EVALUATION OF LEARNING ACTIVITY
Title of event:
Reasons for Attendance
Please identify your MAIN reasons for attending the above event (tick all relevant boxes):
To learn more about my favourite topic(s) o
To remedy deficiencies in my knowledge/skills o
I believed it would help me to improve patient care o
To update knowledge/skills o
To learn new knowledge/skills o
To meet with colleagues o
To meet with external peers o
To meet with non-medical colleagues o
To gain accreditation o
Topic(s) appeared interesting o
Reputation of organiser(s)/speaker(s) o
Other reasons (please specify)
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What change(s), if any, do you intend to make at an individual/team/PCO level as a result of attending the above activity?
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3. TITLE OF ACTIVITY: ..........................................................................................................
PLEASE INDICATE THE FORMAT(S) OF THE ACTIVITY:
Lecture-based o Small Group Work/Discussion o Practical-Skills Based o
Please tick appropriate boxes:
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The activity (was)
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Strongly
Agree
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Agree
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Neutral
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Disagree
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Strongly Disagree
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Not Applicable
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Well presented
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Interesting
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Allowed sufficient time for audience participation
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Relevant to primary care
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Well organised
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Appropriately led
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Enjoyable
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Challenging
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Met my educational NEEDS in this area
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Offered sufficient hands-on experience
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Reinforced
my existing knowledge/skills
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