1. Maintaining competence
Dr Leena Al-Qasem

2. All countries need to ensure that the practice of medicine is ethical and competent, and thereby protect their public from poor practice.

3. Definition of competence:
To master and keep current the knowledge and skills relevant to medical practice
Competence is in part the ability in part the will to consistently select and perform relevant clinical tasks in the context of the social environment in order to resolve health problems of individuals and groups in an effective, economic, and humane manner
Competence can be defined as the ability to perform a specific task in a manner that yields desirable outcomes.

4. Competence:
When we talk of professional competence, we refer to patients' expectations that the professional they come into contact with will be up to the job
Professionals should be able to do that which they profess they can do.
From the patient's point of view, it is shocking to think that this might not be the case.
A healthcare professional's competence from the patient's point of view is not negotiable.

5. Indeed, the need for healthcare professionals to acquire and maintain appropriate levels of competence is so obvious that it would seem unnecessary to refer to it.
The patient simply expects that the healthcare professional has up-to-date knowledge and skills.

6. Competence should meet a critical minimal level.
Competence will also vary at the level of specialist expertise. Consultants working in a highly specialized field, by declaring themselves to be specialists, profess that they have a greater level of competence in the particular area than a consultant who is a generalist.

7. Level of competence: consultant Registrar Resident Intern
Medical student

8. Levels of competence: Novice Advanced beginner Competent Proficient
Expert

9. Novice: The novice has no background or experience in his or her area.
Rules and objective attributes are applied without an understanding or knowledge of the context of the situation.
Medical students are novices in medicine
One becomes a novice whenever he or she is placed in an unfamiliar area of practice.

10. Advanced beginner: The advanced beginner demonstrates marginally
acceptable performance based on experience acquired under the mentoring of a more experienced physician or a teacher.
The larger context of the situation is difficult to grasp at this stage.
There is a concern for good management of skills and time, but the need for guidance and assistance remains.

11. Competent:
Competent physicians are able to differentiate between the aspects of the current situation and those of the future and can select those aspects that are important.
The focus on good management of time skills remains, but the sense of responsibility is higher.
However, they may have an unrealistic concept of what they can actually handle

12. Proficient:
Proficient physicians are able to see the whole situation in context and can apply knowledge to clinical practice, identifying the most salient aspects and differentiating them from those that are less
important.
Actions are intuitive and skilled.
They have confidence in their own knowledge and abilities, focus less on rules and time management.

13. Expert:
The expert physician is able to focus intuitively on solutions to situations without having to explore alternatives.
This ability is based on a rich experiential background.
Focus is on meeting patient needs and concerns to the point of being an advocate for the patient and care.
The focus on self and one’s own performance is diminished.

14. Requirements: Professional competence requires:
a firm educational grounding
followed by a period of formal training to acquire the relevant knowledge and skills in the workplace
continued competence rests on a combination of:
Education
Continuous development
Confidence
Experience

15. Acquiring and maintaining professional competence involves collaboration:
Regulators
Institution
Employer
Individual

16. Individual:
Personally motivated and strive to learn, develop, and continue to do so over a life long period
Active learning
Learning through mistakes

17. Individuals: Active learning:
Individual healthcare professionals, once qualified, need to be sufficiently motivated and have sufficient incentive to maintain and develop their competence.
If the process of keeping knowledge and skills up to date is neglected, the professional's level of competence will diminish.
professionals themselves must have an honest understanding of their abilities.

18. Individuals: Learning through mistakes:
It is crucial that errors in practice, or gaps in skill or knowledge, are acknowledged as early as possible
Must be used as an opportunity for learning, rather than being suppressed or hidden out of fear of blame or sanction.

19. Employers:
The employer must provide professionals with sufficient time and opportunity to maintain existing skills, and to acquire and consolidate new skills.

20. Institution:
The work environment must support and enable the process of continuous learning
the working life of healthcare professionals should be so structured as to allow them to meet these requirements

21. Regulators: Those who set standards must ensure that:
their frameworks of professional standards are and remain appropriate to the needs of patients
professionals are, in fact, observed
wider systems for ensuring that those standards are adhered to

22. How is competence acquired:
It is gained in the healthcare professions through:
pre-service education
in-service training
work experience
Measuring competence is essential for determining the ability and readiness of health workers to provide quality services.

23. Competence is defined in the context of particulars:
Knowledge
Skills
Abilities
Traits
Competence develops over time and is nurtured by reflection on experience

24. Knowledge: Knowledge involves understanding facts and procedures.
Obtain knowledge is several way:
pre-service education
in-service training
on-the-job experience
feedback from supervisors
Feedback from peers
Continuing education

25. Skills:
Skills refers to “actions (and reactions) that an individual performs in a competent way in order to achieve a goal”
Skill is the capacity to perform specific actions: a person’s skill is a function of both knowledge and the particular strategies used to apply knowledge.

26. Skills: Skills are gained through: hands-on training
using anatomic models or real patients
role plays.
One may have no skill, some skill, or complete mastery
Therefore, in teaching or testing a skill, the level of acceptable mastery must be defined based on the training level.

27. Abilities:
Abilities refers to the power or capacity to do something or act physically, mentally, legally, morally, etc.
Abilities are the attributes that a person has inherited or acquired through previous experience and brings to a new task.
Abilities are gained or developed over time and, as a result, are more stable than knowledge and skills.
Traits influence abilities

28. Traits: Traits are personality characteristics:
self-control
self-confidence
Personal and social values
Predispose a person to behave or respond in a certain way.

29. Traits: Traits influence abilities.
For example, self-efficacy is the belief that one can do a task as required; it influences whether a behavior will be initiated and sustained
Self-efficacy is determined by the confidence and/or training of a health worker.
Low self-efficacy can lead to poor compliance with clinical guidelines and other standards of care.

30. Levels of competence: Medical student Resident Senior resident
Consultant
Novice
Advanced beginner
Competent
Proficient
Expert

31. Competencies: Patient care Medical knowledge
Practice base learning and improvement
Interpersonal and communication skills
Professionalism
Systems-based practice

32. Non-technical elements of competence:
six key areas:
skills in communicating with patients and with colleagues;
education about the principles and organization of the health care system, how care is managed, and the skills required for management
the development of teamwork
shared learning across professional boundaries
clinical audit and reflective practice
leadership

33. Broader concept of competence:
Clearly, healthcare professionals must be technically competent to do the task they profess to do, but technical competence is no longer sufficient
there are a number of non-technical, non-clinical skills of doctors which are crucially important to the care of patients.

34. Communication skills:
The focus here is attitudes
the frame of mind which the professional brings to the job
The pre-eminent attitude must be that the Health care system is a service for the public
The needs of the patients must be the driving concern.
This calls for a recognition of the need to establish and maintain good communication with patients and with fellow professionals

35. Communication skills:
It calls for a commitment to respect patients, and to be honest and open towards them
honesty includes the obligation of professionals to be honest with themselves about their abilities
An attitude of public service also calls for the ability to convey uncertainty without fearing that it will appear weak
It calls for retaining and conveying a sense of open- mindedness in the dialogue which is the patient's journey

36. Communication skills:
Perhaps most important of all, it calls for a sense of:
shared humanity
sympathy
Understanding
an ability to engage with the patient on an emotional level
an ability to listen
an ability to assess how much patients wish to know about their condition and treatment
an ability to convey information with clarity and sympathy

37. Communication skills:
Caring is not just `what nurses do'. It is what all healthcare professionals should do.

38. Management:
many individuals may take up specifically managerial roles at different points in their careers
aware of what management of healthcare processes and organizations entails, the type of decisions which those specifically designated as managers must make and the skills which management requires.
This should include an understanding of the management of resources, and an awareness of the choices to be made in organizing and delivering services for people with widely different needs and in greatly different circumstances.

39. The development of team work:
Healthcare professionals in hospitals have always worked in teams of one sort or another.
Teamwork has to be flexible, involving varying groups of professionals from a variety of disciplines and from a variety of specialties and organizations, all working together.
This will be so, as much in hospitals as in community and primary healthcare.

40. Shared learning:
One enormously beneficial result of this approach would be to engender mutual understanding and respect among those starting out on the road to becoming healthcare professionals.
It would help to address the damaging inter-tribal rivalries
What matters is that those caring for patients with a particular condition or illness learn and develop their skills together to provide the best possible care for their patients.

41. Leadership:

42. Competence is an ongoing process:
Initial development
Maintenance of knowledge and skills
Remediation and redevelopment

43. Maintaining professional competence:
in practice, the vast majority of consultants are constantly developing their skills and knowledge
the patient's wellbeing should not depend solely on the individual doctor's motivation.
It is not enough to argue that the hospital doctors can be left to recognize their own needs and limitations.
Furthermore, it is very often those who do not feel the need to submit themselves to further development and training, who, in the absence of some formal system, may pose the greatest threat.

44. Continuing professional development:
Also known as CPD
CPD must be part of a process of lifelong learning for all healthcare professionals.
Its primary purpose is to help professionals to care for patients.
A secondary purpose, but one which must not be ignored, is to help professionals to be fulfilled in their work.

45. CPD
CPD is not just a case of attending courses and conferences, albeit that these have their place.
There should equally be a strong element of professional development within the workplace, since this is where skills and competence are put to the test.

46. Appraisal: Appraisal is a common feature in most large organizations.
The annual appraisal of all healthcare professionals should be the norm.
Annual appraisals are an essential part of an overall strategy aimed at maintaining competence and thereby securing safe care and improving the quality of care in hospitals.

47. Appraisal: Appraisal should focus on: past performance
the maintenance and development of skills as they touch on competence
on job fulfillment

48. Revalidation:
Revalidation is the regular demonstration by all practicing doctors that they remain up to date and fit to practice medicine
Is about the achievement and continuous improvement of doctors who are on the register
is concerned with ensuring that the appropriate levels of skill necessary for continued competence have been and are maintained.
a mechanism whereby healthcare professionals are required regularly (for example every 3 or 5 years) to demonstrate that they remain fit to practice.
It involves the submission of evidence to external assessors of continuing competence.

49. Revalidation:
In the case of the system proposed for doctors, it is linked to registration
if they cannot demonstrate evidence of continuing competence, their registration, and thus their right to practice as doctors, may be called into question and, ultimately, may be withdrawn.

50. Revalidation:
Revalidation of healthcare professionals marks a significant break with the past
Until very recently it was regarded as a sufficient assurance of competence that young, newly qualified healthcare professionals had passed the relevant examinations, and had received guidance and support from more senior colleagues.
Thereafter, throughout the whole of their working life, there were no mechanisms, whether within or outside the professions, whether from employers or bodies concerned with registration and discipline, to assess and check a professional's competence.

51. Revalidation:
Of course, most professionals developed and improved their competence through experience.
many have seen it as part of their professional duty to undertake continuing professional development.

52. For some, however, competence did not grow with experience.
Others did not pay much attention to continuing professional development.
And others tried their best but their competence diminished with time.

53. Revalidation:
Revalidation is the regular demonstration by all practicing doctors that they remain up to date and fit to practice medicine. It is one method of attempting to assess performance, leading to the provision of a license to practice

54. A senior resident asks a medical student to put in an arterial line
A senior resident asks a medical student to put in an arterial line. The student has never seen or performed this procedure before. The resident explains the technique, then tells the student to proceed and leaves.
Case 1:

55. Acquiring and developing new skills to an appropriate level of competence
how is a healthcare professional to acquire competence in a new clinical activity so as to enhance skills while at the same time safeguarding the interests of patients?
applies to any circumstance in which the healthcare professional proposes to carry out a clinical procedure with which he is unfamiliar and which, by its nature, exposes the patient to a risk of significant harm.

56. Acquiring new skills: Three guiding principles may offer a way
Supervision
Openness
honesty with patients

57. Supervision
If a procedure has already been carried out in the institution, it is essential, that the professional carrying out the procedure for the first time should be:
suitably trained
directly supervised by colleagues who have the necessary competence and proficiency, until the relevant degree of expertise has been acquired
the patient is not exposed to a risk greater than the norm.

58. Supervision:
If the procedure is one which has not previously been performed, the professional carrying it out must have obtained appropriate training in a place where expertise in the procedure is established.
He must further ensure that, initially, he is supervised within his own institution by someone who has the necessary expertise

59. Openness: Patients are entitled to know:
what experience the professional has
how experimental or innovative a procedure is
this may be the first occasion on which the professional has carried out the procedure.
This knowledge is essential if patients' consent to treatment is to be valid.

60. Competency verification methods:
Takes on many forms:
Self-assessment
Observation
Post-test

61. Similarly, more sophisticated techniques are now available to assess a doctor’s competence, often in a simulated clinical environment. There is now increasing evidence that a doctor lacking the requisite knowledge, skills, and competence is unlikely to perform satisfactorily in clinical practice. The converse, however, may not be true. Many doctors whose clinical care is found to be below accepted standards are both competent and have adequate knowledge and skills. In day- to-day practice, however, they do not, for whatever reason, deliver care to acceptable standards.

62. Strategies for Improving Provider Competence
Lecture programs and conferences:
Disseminate information about new innovations among health workers and other staff.
Cover information on the current scope of practice or changes in the art and science, based upon scientific information learned from current medical research.
Continuing education (CE) courses:
An effective way of keeping health workers abreast of new innovations in their field of specialization.
In some countries, health workers must earn a minimum number of CE units every year as part of re-certification.

63. Strategies for Improving Provider Competence
Refresher programs:
Enable health workers to review the original training program in a condensed number of hours
Do not help in expanding the cognitive or psychomotor ability above the entry level.
Self-education:
Can improve knowledge in specific areas.
This method can be useful for acquiring new knowledge or skills with immediate application to a task.
Self-education may involve manuals or computer-based training

64. Strategies for Improving Provider Competence
Case reviews:
Rely on patient-care reports, audio/video tapes of services, and laboratory and other diagnostic reports.
Provide an opportunity for discussion, usually led by a mentor or preceptor
Appear to be more effective than other didactic methods in improving knowledge or skills.
Grand rounds:
Provide a unique learning opportunity for novices.
Novices are exposed to the wider continuum of patient care they can interact with other members of the healthcare team and experience a higher level of cognition about patient conditions and recovery than would normally occur outside the hospital setting.

65. Strategies for Improving Provider Competence
Sentinel-event review:
Involves a review of an unexpected occurrence (mortality or morbidity)
provides an opportunity to conduct a root cause analysis.
Results should form the basis of a plan to reduce risk.
The plan must be monitored to evaluate its effectiveness relative to the root cause.
Mentoring:
Provided by more experienced health professionals
A good strategy for improving skills of novices and new-entry health professionals.

66. Why assess competence:
Health care reform
Organizational performance
Liability and ethics
Risk management
Certification and recertification of providers
Planning for new services
Measuring training outcomes
Selection of new staff
Individual performance improvement
Supervision

67. Competence vs. performance
Competence is different from performance
Performance is something that people actually do
It can be observed
It is what the organization hires one to do, and do well
Knowing and showing how to act does not necessarily guarantee that the doctor will act in that way in every practice

68. Factors affecting performance:
Tiredness
Poor facilities
Burnout
Domestic problems
ill health
Arrogance
Contempt for patients or colleagues

69. Characteristic of competent physician:
Critical approach to own work
Willingness to engage in audit
Commitment to independent learning
Honest
Self-awareness
Empathy
Respect
Confidentiality
Patient autonomy
Time
Resources

70. عن عائشة رضي الله عنها أن رسول اله صلى الله عليه وسلم قال: ” إن الله يحب إذا عمل أحدكم عملا أن يتقنه“ رواه الطبراني

71. Summary: Competence is a process It can be learned
Many factors feed into it:
Personal
Employer
Institutional
Regulator

72. Summary: It is acquired through Levels of competence
pre-service education
in-service training
work experience
Levels of competence
Non-technical components of competence
There is a requirement to gain and maintain competence
Needs to be assessed

73. Summary: Different methods of assessment
Different ways of maintaining competence

74. Questions?