1. The Milton Keynes Traffic Light System How to get round Milton Keynes avoiding the roundabouts A structured mechanism for identifying trainees in difficulty

2. The RDM-p Model Tim Norfolk – Quality in Primary Care 2009 17 (1), pp37-49 Unifying theory of clinical practice Links Relationship, Diagnostics, Management and Professionalism Overarching model, provides a framework that can incorporates criteria and competencies across the range of assessments of a GP's work

3. RDMp Relationships descriptor R=relationshipsNegativepositive Holistic Consulting skills Communicating Working with colleagues Lacks warmth in voice/manner uses too many closed questions Unable to adapt language Unclear when communicating Gives little support confrontational (+p) Authoritarian (+p) Good non verbal behaviour Uses open questions Adjusts questioning Expresses ideas clearly Encourages contribution Delegates appropriately Non-judgemental Adapted from Tim Norfolk; Quality in Primary Care 2009

4. RDMp Diagnostics descriptor D=Diagnosticsnegativepositive Data gathering Data interpretation Making diagnoses Making decisions Clinical Management Managing complexity Can’t find a way of resolving the problem (D+M) Makes immediate assumptions Dogmatic Overlooks important information Options too limited Positive when dealing with problems Thinks around issues Open to new ideas Shows interest and understanding Identifies key points Aware of options Adapted from Tim Norfolk, Quality in Primary Care 2009

5. RDMp Management descriptor M= managementnegativepositive Community orientation Practice Management IMT Maintaining performance Learning and teaching Unsystematic Fails to apply lessons Disorganised Doesn't keep up to date Poor prioritisation Misses reasonable deadlines Doesn't think ahead Doesn't cope well with unexpected Becomes agitated Sound systematic judgement Admits to and learns from mistakes Organised Regularly updates job related skills Prioritises effectively Coordinates activity Thinks ahead Delivers on time Stays calm under pressure adapted from Tim Norfolk, Quality in primary care 2009

6. RDMp professionalism descriptor P= professionalismnegativepositive Ethics Fitness to practice Defensive (M+P) Critical Shows favouritism Narrow perspective Fails to take responsibility for poor actions Treat issues as problems Disrespectful to colleagues, staff or patients Finds it difficult to seek help when appropriate Receptive Gives constructive feedback and support Collaborates Sees bigger picture Takes responsibility appropriately Recognises limitations Shows respect Seeks help when necessary Adapted from Tim Norfolk, Quality in primary care 2009

7. Using the Traffic Light System Look at descriptors for RDMp domains Apply the grading in each domain using your knowledge of the trainee, experience and evidence e.g. eportfolio, feedback Decide whether the trainee demonstrates insight with reflective ability with + or - Categorise Green/ Amber/ Red

8. Grading (Milton Keynes) 1 = clearly failing 2 = concerns 3 = expected stage 4 = above expectation for stage 5 = ready for independent practice Add in insight/lack insight (+/-)

9. Amar Rughani’s Insight Table Performa nce Insight Reflect What do you think?? Good Ideal 5+ GoodPoor Unconsciously competent doctors may not adapt to changing situations as they don't understand why they are (currently) competent. They may also engage in risky practices through lack of insight regarding the connection between action and effects. PoorGood Consciously incompetent doctors might be difficult because they have low motivation to improve. The causes of low motivation, such as stress need to be looked for. Poor Unconsciously incompetent doctors may be the most difficult to remediate because despite regular exposure to deficiencies in performance, they may lack the capacity to change 1- Insight/ Reflection

10. ROMp - Defines the Performance Concern, records the behavioural evidence and looks for themes RelationshipDiagnostics ManagementProfessionalism With patientsAssessing patients and their needs Managing patientsRespect for people With staffAssessing oneselfManaging oneself: Performance, health, well being Respect for protocol With other colleagues inside/outside practice Assessing staff and colleagues Managing staff and colleagues Being aware of and carrying out contractual responsibilities Decision making in practice related activities Managing practice related activities

11. Traffic Light System for MKVTS- Tables colourconcerneportfolioESPD/AD Greennone Sufficient number and quality of entries. Progression in PDP and skills log Satisfactory coverage curriculum Satisfactory completion Assessments Continue regular review eportfolio Continue 6/12ly reviews RDMp3+ in all areas Monitor eportfolio

12. Traffic light system for MKVTS colourconcernePortfolioESPD/AD AmberSome Consistently poor quality/ number of entries Poor PDP Poor coverage of curriculum Inadequate number of mandatory assessments RDMp2 in any one area One area may be (-) for insight PD interviews trainee + ES

13. Traffic light system for MKVTS colourconcernePortfolioESPD/AD RedSignificant Failure to engage ePortfolio Unsatisfactory progress signalled by ES or CS RDMp1/2 in more than one area poor insight (-) in multiple domains Interview with PD/AD with ES with a view to referral to ARCP

14. Looking for the Cause of Performance Problems - often several contributing factors Past Factors Current Factors - External Current Factors -Internal interacting with the individual acting within the individual Personal historyWork environmentAttitudes Upbringing/cultureRelationshipsPersonality : Traits/Attributes Primary relationshipsResourcesHealth& Capacity- Physical/mental Other significantWorkload experiences/influencesSystems etc Professional historyNon-work environmentThese all have an effect on: Style of med educationHome & Social lifeSkills and Knowledge Medical experienceRelationships Resources Responsibilities Non Medical Professional History