1. Navigating competence: Beyond the flat earth, competency icebergs and career doldrums David Webb NZHPA Conference September 30, 2007

2. Never ascribe to malice that which can be adequately explained by incompetence Napoleon Bonaparte,1815

3. East and South East England

4. Round Earth □He came back…..□From a patient’s point of view □Professionals’ competence is not negotiable [BRI Inquiry] □Technical competence is of key importance [Picker Institute]

5. Fuzzy concepts □Competence □Overarching capacity □Competences □Functional, the what □Competencies □Qualities, the how

6. Professional 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

7. National Occupational Standard

8. Critical accounts □Competence approaches □Reductive □Shopping lists □Job specific □Central control □Adequacy □Generic/cognitive approaches □Abstract □Subject fragments □Performance deficit □Provider autonomy □Isolated excellence

9. Competency iceberg Effective and persistent behaviour Knowledge Skills Abilities Values, attitudes and beliefs

10. Alternative departures □Novice-to-expert Dreyfus & Dreyfus 1986 □5 stage progression □From adherence to intuitive grasp □Reliable metric to identify expert? □Reflective practice Schön 1983 □Learning from experience □Necessary and sufficient? □Cause or effect?

11. Characteristics and Traits Knowledge, Skills and Abilities Competencies Performance Education and training Integration Experience Innate Developed Bundled Deployed Components of performance

12. McNamara Fallacy □First step □Measure what can easily be measured □Second step □Disregard what can’t be easily measured or give it an arbitrary quantitative value □Third step □Presume what can’t be measured easily isn’t important □Fourth step □Say what can’t be measured easily doesn’t exist

13. Does it make a difference?

14. McRobbie et al 2001 General Level Framework (GLF)

15. GLF structure

16. Performance improvement AlwaysUsuallySometimesNever Need for drug Relevant Patient Background Drug history Selection of drug Drug drug interaction Drug patient interaction Drug-disease interaction Administration of drug Calculation of appropriate dose Selection of dosing regime Selection of formulation

17. Evaluation of GLF in hospital □Controlled trial □30 control pharmacists □74 intervention pharmacists □Matched for gender, age, experience, qualifications □Observations □Baseline, month-6, month-12 □Delivery of patient care □Significant changes □25 behavioural indicators 0-month 60-month 12 Control7/2512/25 Active24/25 Antoniou et al 2005

18. (log rank p=0.0048)

19. Community pharmacy I 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 do I 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

20. Performance improvement 12 months 8 months 4 monthsBaseline 4.0 3.5 3.0 2.5 Self-assessed performance in the delivery of patient care cluster (mean + 95% CI) Non-intervention (n=31) Intervention (n=69)

21. Undergraduate & preregistration General post- registration Advanced & Consultant LevelGeneral Level Professional Development Frameworks Practice development model Higher Level Phase 2 1 Consultant Pharmacist Higher level Phase 1 Advanced Practitioner

22. Advanced/Consultant Level Framework □Development □Literature review □Expert and consensus development panels □ACLF design □34 competencies in 6 clusters □Foundation, excellence & mastery □Premise □Attainment identifies level of practice □Generalisable Meadows et al 2004

23. ClustersCompetencies Expert professional practiceExpert skills and knowledge, Patient care responsibilities, Reasoning and judgement, Professional autonomy. Building working relationshipsCommunication, Teamwork and consultation. LeadershipVision, motivation, governance, Strategy, innovation, Service development. ManagementPlanning, performance, change, Priorities, resources, standards, Risk. Education, training, development Mentorship, role model, delivery, CPD, practice linkage, policy. Research and evaluationCritical evaluation, protocol review, Evidence creation, development, Supervision, partnerships.

25. Self assessment using ACLF □Practice levels □Specialist-in-training □Experienced practitioner □Leading-edge practitioner □Evidence □To substantiate assessment □Sample (n=390) □Cancer69 □Mental health69 □Critical care36 □Primary care84 □Paediatrics53 □MI43 □Other36

26. Leading-edge respondents Expert professional practiceExpert skills and knowledge, Patient care responsibilities, Reasoning and judgement, Professional autonomy. Building working relationshipsCommunication, Teamwork and consultation. LeadershipVision, motivation, governance, Strategy, innovation, Service development. ManagementPlanning, performance, change, Priorities, resources, standards, Risk. Education, training, development Mentorship, role model, delivery, CPD, practice linkage, policy. Research and evaluationCritical evaluation, protocol review, Evidence creation, development, Supervision, partnerships. Mastery Excellence

27. Experienced practitioner respondents Expert professional practiceExpert skills and knowledge, Patient care responsibilities, Reasoning and judgement, Professional autonomy. Building working relationshipsCommunication, Teamwork and consultation. LeadershipVision, motivation, governance, Strategy, innovation, Service development. ManagementPlanning, performance, change, Priorities, resources, standards, Risk. Education, training, development Mentorship, role model, delivery, CPD, practice linkage, policy. Research and evaluationCritical evaluation, protocol review, Evidence creation, development, Supervision, partnerships. Excellence Foundation

28. Competency profiles

29. Consultant pharmacist posts □Aims □Ensure highest level of expertise is available to those patients who need it □Strengthen professional leadership □Retain experienced pharmacists in practice □Responsibilities □Expert practice □Research, evaluation and service development □Education, mentoring and overview of practice □Professional leadership

30. Practice beyond initial registration □Annotation to the professional register □Supplementary and independent prescribers □1,241 SPs □142 IPs □Regulation of advanced practice? □Risk perspectives? □Systems for recognition of expertise □Approval of consultant pharmacist posts □Accreditation of pharmacists with special interests

31. Training infrastructure Pharmacist development model Undergraduate & preregistration General post- registration Higher Level Phase 2 1 Consultant Pharmacist Higher level Phase 1 Advanced Practitioner Pharmacist Registered band 6 Pharmacist Specialist band 7 Pharmacist Advanced band 8a/b Consultant Pharmacist band 8b/d ACLFGLF PG enabling programmesGeneral DiplomaMasters Adv PracticeResearch Degree College system

32. Training infrastructure Pharmacist development model Undergraduate & preregistration General post- registration Higher Level Phase 2 1 Consultant Pharmacist Higher level Phase 1 Advanced Practitioner Pharmacist Registered band 6 Pharmacist Specialist band 7 Pharmacist Advanced band 8a/b Consultant Pharmacist band 8d/d ACLFGLF PG enabling programmesGeneral DiplomaMasters Adv PracticeResearch Degree College/faculty system

33. Characteristics and Traits Knowledge, Skills and Abilities Competencies Performance Education and training Integration Experience Knows Shows Does OSCE, simulation Mini-CEX, mini-PAT, CbD MCQ, MEQ Assessment Strategies Performance assessment after Miller 1990

34. Training infrastructure Pharmacist development model Undergraduate & preregistration General post- registration Higher Level Phase 2 1 Consultant Pharmacist Higher level Phase 1 Advanced Practitioner Pharmacist Registered band 6 Pharmacist Specialist band 7 Pharmacist Advanced band 8a/b Consultant Pharmacist band 8d/d ACLFGLF PG enabling programmesGeneral DiplomaMasters Adv PracticeResearch Degree College system

35. Curriculum design

36. Land ahoy □Professional coherence □Higher level practice in community pharmacy □Careers in research, teaching and management □Higher level practice □Consistent and equitable recognition □Clarity for, and safety of, the public □Infrastructure □To bridge education and service provision □General professional development for all?

37. Graham DaviesIan Bates Denise Farmer Duncan McRobbie Lizzie MillsSotiris Antoniou Laura ObiolsNaomi Meadows Roger Fernandes With thanks to DH Steering Group, GHP, UKCPA, CPP and E&SE England Specialist Pharmacy Services. Members of Specialist/Practice Interest Groups and CPP Faculties Funding NWL WDC, NSC WDD and Department of Health (scoping higher level practice )

38. Bibliography Antoniou S, Webb DG, McRobbie D et al. A controlled study of the general level framework: results of the South of England competency study. Pharmacy Education 2005: 5 : 201-7 Dreyfus HL, Dreyfus SE. Mind over Machine. Oxford: Blackwell, 1986 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002; 287 : 226- 235 McRobbie D, Webb DG, Bates I, et al. Assessment of clinical competence: designing a competence grid for junior pharmacists. Pharmacy Education 2001; 1 : 67-76 Meadows N, Webb DG, McRobbie D et al. Developing and validating a competency framework for advanced pharmacy practice. Pharm J 2004; 273 : 789-792 Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990; 65 (suppl): S63-S67 Schön DA. The Reflective Practitioner: how professionals think in action. London: Temple Smith, 1983 Downloads: www.codeg.org www.postgraduatepharmacy.org