COMMON COMPETENCES FRAMEWORK FOR DOCTORS

Transcription

1 COMMON COMPETENCES FRAMEWORK FOR DOCTORS AUGUST 2009

2 Copyright Academy of Medical Royal Colleges 2009 Designed and Typeset by Millbank Media Ltd

3 CONTENTS Foreword... Members Of The Working Group And Contributors...2. Introduction Basic Clinical Competences History taking Clinical examination Therapeutics and safe prescribing Integrated Clinical Practice and patient safety Time management and personal organisation Decision making and clinical reasoning The patient as central focus of care Prioritisation of patient safety in clinical practice Team-working and patient safety Principles of quality and safety improvement Infection control Environmental Protection and Emergency Planning Managing long-term conditions and promoting patient self care Communication Relationships with patients and communication within a consultation Breaking bad news Complaints and clinical error Communication with colleagues and cooperation Health promotion and health improvement Legal and ethical aspects of care Principles of medical ethics and confidentiality Valid consent Legal framework for practice Ethical research Standards of care and education Evidence and guidelines Audit Teaching and training Personal attitudes and behaviour Personal behaviour Management and leadership Management and NHS structure...88 Bibliography...9 Glossary & Abbreviations...94 Acknowledgements...00

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5 FOREWORD This Framework has been developed to identify the common competences that should be acquired by doctors in core and specialty training in the United Kingdom. It has been derived primarily from competences that were previously defined within the specialty training curricula and, where appropriate, the revised Foundation Programme Curriculum that have been presented by the Royal Colleges and Faculties for approval by the Postgraduate Medical Education and Training Board (PMETB). It has been supplemented by information from additional curricula and frameworks that had been developed by other bodies. The Academy of Medical Royal Colleges Specialty Training Committee (ASTC) developed this Framework to help inform the development of core and specialty curricula of the Royal Colleges and Faculties. The Framework will supplement the specialty specific competences within the specialty training curricula. It is acknowledged that only doctors who have acquired both specialty and common competences should be able to progress in training through to achieving Certification of Completion of Training (CCT). The Framework has been circulated widely for comment and refinement during its development. It will continue to be revised and kept live by the ASTC, who will review and evaluate the Framework as further competences and assessment methods are defined and refined. It is the intention to include the Medical Leadership Curriculum Framework in future revisions as well as more detailed assessment guidance. I would like to thank the significant number of individuals who have contributed to developing this framework, reflecting the importance that the Royal Colleges, Faculties, Deaneries and Service place on improving the training of doctors and the quality of patient care. Dr Mike Jones Chairman, Academy Specialty Training Committee August 2009

6 MEMBERS OF THE WORKING GROUP AND CONTRIBUTORS The framework is designed to include content and processes suitable for all registered doctors. The Common Competences Framework Working Group was set up in 2008 under the auspices of the Academy of Medical Royal Colleges Specialty Training Committee and the Chairmanship of Dr Mike Jones. It was project managed by Ms Manjula Das. The membership of the working group was: Ms Francine Alexander Joint Committee on Surgical Training Professor Michael Bannon Conference of Postgraduate Medical Deans of the United Kingdom Ms Joanne Brinklow Royal College of Pathologists Dr Andrew Brittlebank Royal College of Psychiatrists Professor Bill Burr Joint Royal Colleges of Physicians Training Board Mr David Cottrell Royal College of Ophthalmologists Dr Helen Cugnoni College of Emergency Medicine/Academy Foundation Programme Committee Mr Ian Eardley Joint Committee on Surgical Training Dr Mark Jenkins College of Emergency Medicine/ Northern Ireland Dr David Kessel Royal College of Radiologists/Academy Foundation Programme Committee Professor Shelley Heard Royal College Pathologists Dr Christine Heron Royal College of Radiologists Ms Suzie Hughes Academy of Medical Royal Colleges Patient/Lay Group Ms Celia Ingham Clark Medical Director Whittington Hospital Ms Heather Laurence CEO Chelsea and Westminster Hospital Dr Andrew Long Royal College of Paediatrics and Child Health Dr Jane Mathieson Academy of Medical Royal Colleges Trainee Doctors Group Dr Mary McGraw Royal College of Paediatrics and Child Health Dr Stephen Miles Faculty of Sport and Exercise Medicine Professor Fiona Moss Conference of Postgraduate Medical Deans of the United Kingdom /Academy Foundation Programme Committee Dr Pete Nightingale Royal College of Anaesthetists Mr Manjit Obhrai Royal College of Obstetricians and Gynaecologists/ Academy Foundation Programme Committee Dr Bill Reith Royal College of General Practitioners 2

7 Dr Andrew Tomlinson Royal College of Anaesthetists Dr Charlotte Tulinius Royal College of General Practitioners Ms Winnie Wade Royal College of Physicians London/ Academy Foundation Programme Committee Dr David Williams Faculty of Public Health Advice and comments were also sought from: Academy Foundation Programme Committee Academy Patient Lay Group Academy Trainee Doctors Group Academy of Medical Educators Committee of General Practice Education Directors Conference of Post Graduate Medical Deans General Medical Council Institute of Medical Ethics National Association for Clinical Tutors UK Postgraduate Medical Education Training Board United Kingdom Foundation Programme Office 3

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9 . INTRODUCTION The Common Competences Framework for Doctors (CCFD) is designed to be a reference document that outlines the basic and generic competences required of a doctor without being specialty specific. It has been devised by the Academy of Medical Royal Colleges Specialty Training Committee (ASTC) as a repository of information that may help inform the development of specialty training curricula and that also reflects the medical profession s attitudes and beliefs with regard to the absolute common skills that should be acquired and maintained by every doctor. The Framework supports the spiral nature of learning that underpins a trainee doctor s continual development, from the undergraduate and foundation years, through to the end of clinical specialty training and subsequently into the trainee doctor s chosen field. It specifically builds upon each area of competence that a trainee doctor will have acquired during the foundation training period. It is recognised that for many of the competences outlined there is a maturation process whereby trainee doctors become more adept and skilled as their career and experience progresses. This is reflected by increasing expertise in their chosen career pathway not only in the specialty specific competences but also in the competences defined by this document. Competences are often context specific, therefore elements of the competences within this framework will be more important for some specialties than for others. Such emphasis will be outlined in the relevant specialty curriculum. This framework however, is important for all trainee doctors. While it makes no attempt to define all the competences that a doctor working in any medical discipline must have, elements from this framework will appear in the trainee doctor s specialty training curriculum. A trainee doctor in any specialty must work to acquire the competences defined in their own specialty curriculum before the completion of training and the award of certificate of completion of training (CCT). The common competences for all trainee doctors are based on the four domains of the Framework for Appraisal and, derived from Good Medical Practice () as outlined by the General Medical Council (GMC). For each competency in this framework the related domain is given. Domain Domain 2 Domain 3 Domain 4 Knowledge, Skills and Performance Safety and Quality Communication, Partnership and Teamwork Maintaining Trust of the competences in the CCFD will be dependent on the assessment framework that has been developed for each specialty by the relevant Royal College or Faculty. Suggestions of potential assessment method tools have been given in this framework, i.e. the assessment profiles present a sampling of the potential assessments that could be used rather than addressing each competence individually, as this will be left to the discretion of the relevant specialty. It is also intended that future revisions of the CCFD include examples of best practice used by the Colleges. 5

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11 2. BASIC CLINICAL COMPETENCES The first three common competences cover the principles of history taking, clinical examination and therapeutics and safe prescribing. These are competences with which the trainee doctor should be well acquainted from foundation training. It is vital that these competences are practised to a high level by all specialty trainees who should be able to achieve competences in all the descriptors early in their specialty training career. There are four Descriptor Levels. It is anticipated that early on in their specialty training trainee doctors will achieve competences to Level 2, whereas the competences defined by the Level 3 and 4 descriptors will be acquired in the latter part of specialty training. 7

12 2. HISTORY TAKING Objectives: To elicit a relevant focused history from patients with increasingly complex issues and in increasingly challenging circumstances To record the history accurately and synthesise this with relevant clinical examination, establish a problem list based on pattern recognition including differential diagnosis(es) and formulate a management plan that takes account of likely clinical evolution. Knowledge Comprehend the importance of different elements of history Comprehend that patients do not present their history in structured fashion Know the likely causes and risk factors for conditions relevant to mode of presentation Recognise that the patient s wishes and beliefs and their history should inform examination, investigation and management ACAT,3 Skills Identifies and overcomes possible barriers to effective communication,3 Manages time and draws consultation to a close appropriately,3 Comprehends that effective history taking in non-urgent cases may require several discussions with the patient and other parties, over time Supplements history with standardised instruments or questionnaires when relevant Manages alternative and conflicting views from family, carers, friends and members of the multidisciplinary team and maintains focus Assimilates history from the information available from patient and other sources including members of the multidisciplinary team Recognises and interprets appropriately the use of non-verbal communication from patients and carers (where relevant) Focuses on relevant aspects of the patients history ACAT ACAT ACAT ACAT,3,3,3,3,3 ACAT,3 8

13 Behaviours Shows respect and behaves in accordance with Good Medical Practice 3,4 Level Descriptor Obtains records and presents accurate clinical history relevant to the clinical presentation. Elicits most important positive and negative indicators of diagnosis Includes an indication of patient s views Starts to screen out irrelevant information Able to format notes in a logical way, writes legibly, dating and signing entries Records regular follow up notes in an appropriate manner. 2 Demonstrates ability to obtain relevant focussed clinical history in the context of limited time e.g. outpatients consultation onward referral Demonstrates ability to target patient history to discriminate between likely clinical diagnoses Records information informatively Able to write a summary of the case when the patient has been seen and clerked by more junior colleagues Written notes are always comprehensive, focused and informative Able to accurately summarise the details of patient notes Demonstrates an awareness that effective history taking needs to take due account of patients beliefs and understanding. 3 Demonstrates ability to rapidly obtain relevant history in context of severely ill patients and/or in an emergency situation. Demonstrates ability to obtain history in difficult circumstances e.g. from angry or distressed patient/relatives, or where there are significant communication difficulties Demonstrates ability to keep interview focussed on most important clinical issues. Writes timely, comprehensive and informative letters to patients and to GPs. 4 Focuses questioning to establish working diagnosis and able to relate to relevant examination, investigation and management plan in most acute and common chronic conditions in almost any environment. Writes succinct notes and is able to summarise accurately in complex cases. 9

14 2.2 CLINICAL EXAMINATION Objectives: To perform focused, relevant and accurate clinical examination in patients with increasingly complex issues and in increasingly challenging circumstances To relate physical findings to history in order to establish diagnosis(es) and formulate a management plan. Knowledge Understand the need for a targeted and relevant clinical examination CbD, Understand the basis for clinical signs and the relevance of positive and negative physical signs Comprehend constraints to performing physical examination and strategies that may be used to overcome them Comprehend the limitations of physical examination and the need for adjunctive forms of assessment to confirm diagnosis Recognise when the offer/use of a chaperone is appropriate or required CbD, Skills Performs valid, targeted and time efficient examinations relevant to the presentation and risk factors Recognises the possibility of deliberate harm (both self harm and harm by others) in vulnerable patients and report to appropriate agencies Actively elicits important clinical findings CbD, Performs relevant examinations CbD,,2 0

15 Behaviours Shows respect and behave in accordance with Good Medical Practice Considers social, cultural and religious boundaries to clinical examination, appropriately communicates with the patient and makes alternative arrangements where necessary CbD, Mini- CEX, MSF CbD, Mini- CEX, MSF,4,4 Level Descriptor Performs basic physical examination and accurately describes and records findings Elicits most important physical signs Uses and interprets findings of basic examination appropriately to perform further relevant examination e.g. internal examination, blood pressure measurement, pulse oximetry, peak flow. 2 Performs focussed clinical examination directed to presenting complaint e.g. cardiorespiratory, abdominal pain Actively seeks and elicits relevant positive and negative signs Uses and interprets findings of extended examination appropriately e.g. electrocardiography, spirometry, ankle brachial pressure index, fundoscopy. 3 Performs and interprets relevant advanced focussed clinical examination e.g. assessment of less common joints, neurological examination Elicits subtle findings Uses and interprets findings of investigation suggested by basic examination appropriately e.g. sigmoidoscopy, FAST ultrasound, echocardiography. 4 Rapidly and accurately performs and interprets focussed clinical examination in challenging circumstances (e.g. acute medical or surgical emergency) or when managing multiple patient wishes and beliefs.

16 2.3 THERAPEUTICS AND SAFE PRESCRIBING Objective: To prescribe, review and monitor appropriate therapeutic interventions relevant to clinical practice including non-medication based therapeutic and preventative indications. Knowledge Indications, contraindications, side effects, drug interactions and dosage of commonly used drugs Recall range of adverse drug reactions to commonly used drugs, including complementary medicines Recall range of drugs requiring therapeutic drug monitoring and interpret results Outline tools to promote patient safety and prescribing, including electronic clinical record systems and other IT systems Define the effects of age, body size, organ dysfunction and concurrent illness on drug distribution and metabolism relevant to the trainee s clinical practice Understand the roles of regulatory agencies involved in drug use, monitoring and licensing e.g. National Institute for Clinical Excellence (NICE), Committee on Safety of Medicines (CSM) Medicines and Healthcare Products Regulatory Agency (MHRA) and hospital formulary committees Understand the importance of non-medication based therapeutic interventions including the legitimate role of placebos,2,2,2,2 2

17 Skills Reviews the continuing need for, effect of and adverse effects of long-term medications relevant to own clinical practice Anticipates and avoids defined drug interactions, including complementary medicines Advises patients and carers (where relevant)about important interactions and adverse drug effects Prescribe appropriately in pregnancy, and during breast feeding Makes appropriate dose adjustments following therapeutic drug monitoring, or physiological change e.g. deteriorating renal function Uses IT prescribing tools where available to improve safety Employs validated methods to improve patient concordance with prescribed medication Provides comprehensible explanations to the patient, and carers (where relevant), for the use of medicines Understands the principles of concordance in ensuring that drug regimes are followed Ensures safe systems for monitoring, review and authorisation where involved in repeat prescribing Recognises the importance of resources when prescribing, including the role of a Drug Formulary and electronic prescribing systems ACAT, Mini- CEX,2,3,2,3,3 CbD,,3 CbD, CbD,,2 3

18 Behaviours Minimises the number of medications taken by a patient to a level compatible with best care Appreciates the role of non-medical prescribers Remains open to advice from other healthcare professionals on medication issues Ensures prescribing information is shared promptly and accurately between a patient s healthcare providers, including between primary and secondary care,3,3 ACAT, CbD,3 Participates in adverse drug event reporting mechanisms, CbD Remains up to date with therapeutic alerts, and responds appropriately ACAT, CbD Level Descriptor Understands the importance of patient compliance with prescribed medication Outlines the adverse effects of commonly prescribed medicines Uses reference works to ensure accurate and precise prescribing Takes advice on the most appropriate medicine in all but the most common situations Makes sure an accurate record of prescribed medication is transmitted promptly to relevant others involved in a patients care Knows indications for commonly used drugs that require monitoring to avoid adverse effects. 2 Modifies patients prescriptions to ensure that the most appropriate medicines are used for any specific condition Maximises patient compliance by minimising the number of medicines required that is compatible with optimal patient care Maximises patient compliance by providing full explanations of the need for the medicines prescribed. 3 Is aware of the precise indications, dosages, adverse effects and modes of administration of the drugs used commonly within their specialty Uses databases and other reference works to ensure knowledge of new therapies and adverse effects is up to date Knows how to report adverse effects and take part in the Committee on Safety Medicines regulatory mechanism Is aware of the regulatory bodies relevant to prescribed medicines both locally and nationally Ensures that resources are used in the most effective way for patient benefit. 4

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21 3. INTEGRATED CLINICAL PRACTICE AND PATIENT SAFETY This part of the generic competences relate to direct clinical practice; the importance of patient needs at the centre of care and promotion of patient safety, team-working and high quality infection control. Furthermore, the prevalence of long-term conditions in patient presentations means that specific competences have been defined and these are mandated in the management of this group of patients. Many of these competences will have been acquired during the Foundation programme and core training but as part of the maturation process these competences will become more finely honed and all trainees should be able to demonstrate the competences as described by the highest level descriptors by the time of their CCT. 7

22 3. TIME MANAGEMENT AND PERSONAL ORGANISATION Objective: To prioritise and organise clinical and clerical duties in order to optimise patient care and makes appropriate clinical and clerical decisions in order to optimise the effectiveness of the clinical team resource. Knowledge Understand that effective organisation is key to time management ACAT, CbD Understand that some tasks are more urgent and/or more important than others Understand the need to prioritise work according to urgency and importance ACAT, CbD ACAT, CbD Understand that some tasks may have to wait or be delegated to others ACAT, CbD Understand the roles, competences and capabilities of other professionals and support workers ACAT, CbD Outline techniques for improving time management ACAT, CbD Understand the importance of prompt investigation, diagnosis and treatment in disease and illness management,2 Skills Maintains focus on individual patient needs whilst balancing multiple competing pressures Identifies clinical and clerical tasks requiring attention or that are predicted to arise Estimates the time required for essential tasks and plan accordingly Groups together tasks when this will be the most effective way of working Recognises the most urgent/important tasks and ensure that they managed expediently Regularly reviews and reprioritises personal and team workload Organises and manages workload effectively and flexibly Makes appropriate use of other healthcare professionals and support workers ACAT, CbD Mini- CEX Mini- CEX,2 8

23 Behaviours Works flexibly and deals with tasks effectively and efficiently Recognises when self or others are falling behind and takes steps to rectify the situation MSF MSF Communicates changes in priority to others ACAT, MSF Remains calm in stressful or high pressure situations and adopts a timely, rational approach 3 3 ACAT, MSF Appropriately recognises and handles uncertainty within the consultation ACAT, MSF Level Descriptor Comprehends the need to identify work and compiles a list of tasks Works systematically through tasks and attempts to prioritise Discusses the relative importance of tasks with more senior colleagues Understands importance of completing tasks and checks progress with more senior members of the multidisciplinary team Understands importance of communicating progress with other team members Able to say when finding workload too much Always consults more senior member of team when unsure. 2 Organises work appropriately and is able to prioritise Works with and guides more junior colleagues and takes work from them if they are overloaded Discusses work on a daily basis with more senior member of team Completes work within an acceptable amount of time. 3 Organises own daily work efficiently and effectively and supervises work of others Acts professionally and works within reasonable timescales Manages to balance competing tasks Recognises the most important tasks and responds appropriately Anticipates when priorities should be changed Starting to lead and direct the clinical team effectively Supports others who are falling behind Requires minimal organisational supervision. 4 Automatically prioritises, reprioritises and manages workload in most effectively and efficiently Communicates and delegates rapidly and clearly Responsible for organising the clinical team Manages, supervises or guides the work of more than one team e.g. out-patient and ward team Calming leadership in stressful situations. 9

24 3.2 DECISION MAKING AND CLINICAL REASONING Objectives: To develop the ability to formulate a diagnostic and therapeutic plan for a patient according to the clinical information available To develop the ability to prioritise the diagnostic and therapeutic plan To be able to communicate a diagnostic and therapeutic plan appropriately. Knowledge Define the steps of diagnostic reasoning Conceptualise clinical problem in a clinical and social context Understand the psychological component of disease and illness presentation Recognise how to use expert advice, clinical guidelines and algorithm Recognise and appropriately respond to sources of information accessed by patients Define the concepts of the natural history of disease and assessment of risk Outline methods and associated problems of quantifying risk e.g. cohort studies Outline the concepts and drawbacks of quantitative assessment of risk or benefit e.g. numbers needed to treat,2 ACAT, CbD Describe commonly used statistical methodology ACAT, CbD Know how relative and absolute risks are derived and the meaning of the terms: predictive value, sensitivity and specificity, in relation to diagnostic tests CbD, 20

25 Skills Interprets clinical features and their reliability and relevance to clinical scenarios, including the recognition of the breadth of presentation of common disorders Incorporates an understanding of the psychological and social elements of clinical scenarios into decision making through a robust process of clinical reasoning Interprets history and clinical signs Generates hypothesis within context of clinical likelihood Tests, refines and verifies hypotheses Develops problem lists and action plans Comprehends the need to determine the best value and most effective treatment both for the individual patient and for a patient cohort Recognises critical illness and responds with due urgency Generates plausible hypothesis(es) following patient assessment Constructs concise and applicable problem lists using available information Applies quantitative data of risks and benefits of therapeutic intervention to an individual patient Mini- CEX Mini- CEX Searches and comprehends medical literature to guide reasoning AA, CbD 2

26 Behaviours Recognises the difficulties in predicting occurrence of future events Willing to discuss intelligibly with a patient the notion and difficulties of prediction of future events, and the benefit/risk balance of therapeutic intervention Willing to adapt and adjust approaches according to the beliefs and preferences of the patient and/or carers (where relevant) Willing to facilitate patient choice Willing to search for evidence to support clinical decision making Demonstrates ability to identify one s own biases and inconsistencies in clinical reasoning 3 3 3,3 22

27 Level Descriptor In a straightforward clinical case: Develops a provisional diagnosis and a differential diagnosis on the basis of the clinical evidence Institutes an appropriate investigative plan Institutes an appropriate therapeutic plan Seeks appropriate support from others Takes account of the patients wishes and records them accurately and succinctly. 2 In a difficult clinical case: Develops a provisional diagnosis and a differential diagnosis on the basis of the clinical evidence Institutes an appropriate investigative plan Institutes an appropriate therapeutic plan Seeks appropriate support from others Takes account of the patients wishes and records them accurately and succinctly. 3 In a complex, non-emergency case: Develops a provisional diagnosis and a differential diagnosis on the basis of the clinical evidence Institutes an appropriate investigative plan Institutes an appropriate therapeutic plan Seeks appropriate support from others Takes account of the patients wishes and records them accurately and succinctly. 4 In a complex, emergency case: Develops a provisional diagnosis and a differential diagnosis on the basis of the clinical evidence Institutes an appropriate investigative plan Institutes an appropriate therapeutic plan Seeks appropriate support from others Takes account of the patients wishes and records them accurately and succinctly. 23

28 3.3 THE PATIENT AS CENTRAL FOCUS OF CARE Objective: Prioritise the patient s wishes encompassing their beliefs, concerns expectations and needs. Knowledge Outline health needs of particular populations e.g. ethnic minorities and recognise the impact of healthcare beliefs, culture and ethnicity in presentations of physical and psychological conditions ACAT, CbD Skills Gives adequate time for patients and carers (where relevant) to express their beliefs ideas, concerns and expectations Encourages the healthcare team to respect the philosophy of patient focussed care Develops a self-management plan with the patient Supports patients and carers(where relevant) to comply with selfmanagement plans Encourages patients to voice their preferences and personal choices about their care ACAT, Mini- CEX, MSF, Patient Survey ACAT, Mini- CEX, Patient Survey,3,4 3,

29 Behaviours Supports patient self-management Responds to questions honestly and seeks advice if unable to answer Recognises the duty of the healthcare professional to act as patient advocate Constructs an appropriate management-plan in conjunction with the patient, carers (where relevant) and other members of the clinical team and communicates this effectively to the patient and carers (where relevant) Applies the relevance of the risk of a future event to an individual patient Uses risk calculators appropriately Considers the risks and benefits of screening investigations, Patient Survey, MSF, Patient Survey 3 3 3,4 3 25

30 Level Descriptor Responds honestly and promptly to patient questions but knows when to refer for senior help Comprehends the need for disparate approaches to individual patients Always respectful to patients Introduces self clearly to patients and indicates own place in team Always checks that patients are comfortable and willing to be seen. Asks about and explains all elements of examination before undertaking straightforward procedures e.g. taking a pulse Always warns patients of any procedure and is aware of the notion of implicit consent Only undertakes consent for a procedure that he/she is competent to do Always seeks senior help when does not know answer to patients queries Always asks patients if there is anything else they need to know or ask. 2 Recognises more complex situations of communication, accommodates disparate needs and develops strategies to cope Sensitive to patients cultural values and beliefs Able to explain diagnoses and clinical procedures in ways that enable patients understand and make decisions about their own healthcare. 3/4 Deals rapidly with more complex situations, promotes patients self care and ensures all opportunities are outlined Able to discuss complex questions and uncertainties with patients to enable them to make decisions about difficult aspects of their health e.g. to opt for no treatment or to make end of life decisions. 26

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32 3.4 THE PATIENT AS CENTRAL FOCUS OF CARE Objectives: To understand that patient safety depends on: the effective and efficient organisation of care healthcare professionals working well together safe systems, not just individual competency and safe practice To ensure that all staff are aware of risks and work together to minimise risk To ensure actions always promote patient safety. Knowledge Outline the features of a safe working environment Outline the hazards of clinical equipment in common use ACAT, CbD Recall side effects and contraindications of prescribed medications Recall principles of risk assessment and management CbD Recall the components of safe working practice in the personal, clinical and organisational settings ACAT, CbD Outline human factors theory and understand its impact on safety CbD Understand root cause analysis CbD Understand significant event analysis CbD Outline local procedures and protocols for optimal practice e.g. GI bleed protocol, safe prescribing Understand the investigation of significant events, serious untoward incidents and near misses Skills Recognises limits of own professional competence and only practices within these Recognises when a patient is not responding to treatment, reassess the situation, and encourages others to do so Ensures the correct and safe use of clinical equipment, ensuring that faulty equipment is reported appropriately Improves patients and colleagues understanding of the side effects and contraindications of therapeutic intervention Sensitively counsels a colleague following a significant untoward event, or near incident, to encourage improvement in the practice of individuals and the unit Recognises and responds to the manifestations of a patient s deterioration or lack of improvement (symptoms, signs, observations, and laboratory results) and supports other members of the team to act similarly 3 ACAT, CbD 3, MSF 28

33 Behaviours Maintains a high level of safety awareness and consciousness at all times Encourages feedback from all members of the team on safety issues Reports serious untoward incidents and near misses and co-operates with the investigation of the same Shows willing to take action when concerns are raised about performance of members of the healthcare team, and act appropriately when these concerns are voiced to you by others Continues to be aware of own limitations, and operates within them competently, MSF, MSF, MSF

34 Level Descriptor Respects and follows ward protocols and guidelines Takes direction from the nursing staff as well as medical team on matters related to patient safety Discusses risks of treatments with patients and is able to help patients make decisions about their treatment Always ensures the safe use of equipment Follows guidelines unless there is a clear reason for doing otherwise Acts promptly when a patient s condition deteriorates Always escalates concerns promptly. 2 Demonstrates ability to lead team discussion on risk assessment and risk management and to work with the team to make organisational changes that will reduce risk and improve safety Understands the relationship between good team-working and patient safety Able to work with and when appropriate lead the whole clinical team Promotes patient safety to more junior colleagues Comprehends untoward or significant events and always reports these Leads discussions of causes of clinical incidents with staff and enables them to reflect on the causes Able to undertake a root cause analysis. 3 Demonstrates awareness of human factors Able to assess the risks across the system of care and to work with colleagues from different department or sectors to ensure safety across the health care system Involves the whole clinical team in discussions about patient safety Shows support for junior colleagues who are involved in untoward events. 4 Fastidious about following safety protocols and ensures that junior colleagues to do the same. Able to explain the rationale for protocols Demonstrates ability to lead an investigation of a serious untoward incident or near miss and synthesise an analysis of the issues and plan for resolution or adaptation. 30

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36 3.5 TEAM-WORKING AND PATIENT SAFETY Objectives: To work well in a variety of different teams and team settings for example the ward team, the laboratory team, the infection control team, the theatre team and to contribute to discussion on the team s role in patient safety To display the leadership skills necessary to lead teams so that they are more effective and better able to deliver safer care. Knowledge Outline the components of effective collaboration and team-working ACAT, Cbd Describe the roles and responsibilities of members of the healthcare team Understand the role of Notification of diseases within the UK and identify the principle notifiable diseases for UK and international purposes Outline factors adversely affecting doctor and team performance, and methods to rectify these ACAT, Cbd CbD Skills Provides good continuity of care Accurately attribute note-keeping including appropriate use of electronic clinical record systems Prepares patient lists with clarification of problems and ongoing care plan, MSF Gives detailed hand over between shifts and areas of care DOPS,3,4,3,2 Demonstrates leadership and management in the following areas: education and training of junior colleagues and other members of the healthcare team deteriorating performance of colleagues e.g. stress, fatigue high quality care effective handover of care between shifts and teams Leads and participates in multidisciplinary team meetings Provides appropriate supervision to less experienced colleagues MSF,2,

37 Behaviours Encourages an open environment to foster and explore concerns and issues about the functioning and safety of team- working Recognises limits of own professional competence and only practices within these Recognises and respects the request for a second opinion Recognises the importance of induction for new members of a team Recognises the importance of prompt and accurate information sharing with Primary Care team following hospital discharge MSF MSF MSF MSF, MSF Level Descriptor Works well within the multidisciplinary team and understands when assistance is required from the relevant team member Demonstrates awareness of own contribution to patient safety within a team and is able to outline the roles of other team members Keeps records up to date, legible and relevant to the safe progress of the patient. Hands over care in a precise, timely and effective manner. 2 Demonstrates ability to discuss problems within a team to senior colleagues Provides an analysis and plan for change Demonstrates ability to work with the virtual team to develop the ability to work well in a variety of different teams (e.g. the ward team and the infection control team) and to contribute to discussion on the team s role in patient safety Developing team leadership skills to deliver more effective and safer care. 3 Leads multidisciplinary team meetings and encourages contribution from all team members Comprehends the need for optimal team dynamics and promotes conflict resolution Demonstrates ability to convey to patients after a handover of care that although there is a different team, the care is continuous. 4 Leads multidisciplinary team meetings allowing all voices to be heard and considered; fostering an atmosphere of collaboration Comprehends situations in which others are better equipped to lead or where delegation is appropriate Demonstrates ability to work with the virtual team Ensures that team functioning is maintained at all times Promotes rapid conflict resolution. 33

38 3.6 PRINCIPLES OF QUALITY AND SAFETY IMPROVEMENT Objective: To recognise the desirability of monitoring performance, learning from mistakes and adopting a no blame culture in order to ensure high standards of care and optimise patient safety. Knowledge Understand the elements of clinical governance CbD, MSF Define local and national significant event reporting systems relevant to specialty Outline local health and safety protocols e.g. fire, manual handling etc CbD Understand risk associated with the trainee doctors s clinical specialty work including biohazards and mechanisms to reduce risk Outline the use of patient early warning systems to detect clinical deterioration where relevant to the trainee doctor s clinical specialty Keep abreast of national patient safety initiatives including NPSA, NCEPOD reports, NICE guidelines etc CbD Skills Adopts strategies to reduce risk e.g. safe surgery checklist ACAT, CbD,2 Recognises that governance safeguards high standards of care and facilitates the development of improved clinical services Recognises the importance of evidence-based practice in relation to clinical effectiveness Reflects regularly on own standards of medical practice in accordance with GMC guidance on licensing and revalidation CbD,2 CbD AA,2,3,4 34

39 Behaviours Shows willing to participate in safety improvement strategies e.g. critical incident reporting CbD, MSF 3 Reflects on own professional practice in order to achieve insight CbD, MSF 3 Demonstrates personal commitment to improve own performance in the light of feedback and assessment Contributes to quality improvement processes e.g.: Audit of personal and departmental/directorate/practice performance Errors/discrepancy meetings Critical incident and near miss reporting Unit morbidity and mortality meetings Local and national databases Maintains a portfolio of information and evidence, drawn from own clinical practice CbD, MSF 3 AA, CbD 2 CbD 2 Engages with an open no blame culture CbD, MSF 3 Responds positively to outcomes of audit and quality improvement CbD, MSF,3 Co-operates with changes necessary to improve service, quality and safety CbD, MSF,2 Level Descriptor Understands that clinical governance is the over-arching framework that unites a range of quality improvement activities; safeguarding high standards of care and facilitating the development of improved clinical services Maintains personal portfolio. 2 Able to define key elements of clinical governance e.g. understands the links between organisational function and processes and the care of individuals Engages in audit and understands the link between audit and quality and safety improvement. 3 Demonstrates personal and service performance Designs audit protocols and completes audit cycle through understanding the relevant changes needed to improve care Able to support the implementation of change. 35

40 3.7 INFECTION CONTROL Objective: To manage and control infection in patients. Including controlling the risk of cross-infection, appropriately managing infection in individual patients, and working appropriately within the wider community to manage the risk posed by communicable diseases. Knowledge Understand the principles of infection control as defined by the GMC Understand the principles of preventing infection in high risk groups (e.g. managing antibiotic use to reduce Clostridium difficile infection) including understanding the local antibiotic prescribing policy Understand the role of Notification of diseases within the UK and identify the principle notifiable diseases for UK and international purposes Understand the role of the Health Protection Agency and Consultants in Health Protection (previously Consultants in Communicable Disease Control CCDC) Understand the role of the local authority in relation to infection control, OSATS CbD, ACAT Skills Recognises the potential for infection within patients being cared for Counsels patients on matters of infection risk, transmission and control Recognises potential for cross-infection in clinical settings MSF, MSF, Patient Survey,, MSF,2 2,3,2 Practices aseptic technique whenever relevant DOPS 36

41 Behaviours Actively engages in local infection control procedures ACAT, CbD Actively engages in local infection control monitoring and reporting processes ACAT, CbD,2 Complies with bare below the elbows dress code ACAT, CbD Complies with and encourages others to comply with use of hand decontamination before and after every patient contact Prescribes antibiotics according to local antibiotic guidelines. Works with microbiological services where this is not possible Encourages all staff, patients and relatives to observe infection control principles Recognises the risk of personal ill-health to patients and colleagues in addition to its effect on performance ACAT, CbD ACAT, CbD MSF MSF,3 37

42 Level Descriptor Always follows local infection control protocols. Including washing hands before and after seeing all patients Able to explain infection control protocols to trainee doctors, patients and their carers (where relevant). Always defers to the nursing team about matters of ward management. Aware of infections of concern including MRSA and C difficile Aware of the risks of nosocomial infections Understands the links between antibiotic prescription and the development of noscomial infections Always discusses antibiotic use with a more senior colleague Understands need for aseptic technique Demonstrates ability to perform basic hand hygiene. 2 Demonstrates ability to perform simple clinical procedures utilising effective aseptic technique Manages simple common infections in patients using first-line treatments Communicates effectively to the patient the need for treatment and any messages to prevent re-infection or spread Liaises with diagnostic departments in relation to appropriate investigations and tests Knowledge of which diseases should be noted and undertake notification promptly. 3 Demonstrates an ability to perform complex clinical procedures whilst maintaining aseptic technique throughout Identifies potential for infection amongst high risk patients obtaining appropriate investigations and considering the use of second line therapies Communicates effectively to patients and their carers (where relevant) with regard to the infection, the need for treatment and any associated risks of therapy Works effectively with diagnostic departments in relation to identifying appropriate investigations and monitoring therapy Works in collaboration with external agencies in relation to reporting common notifiable diseases, for any appropriate investigation or management. 4 Demonstrates an ability to perform most complex clinical procedures whilst maintaining full aseptic precautions, including those procedures which require multiple staff in order to perform the procedure satisfactorily Identifies the possibility of unusual and uncommon infections and the potential for atypical presentation of more frequent infections. Manages these cases effectively with potential use of tertiary treatments being undertaken in collaboration with infection control specialists Works in collaboration with diagnostic departments to investigate and manage the most complex types of infection including those potentially requiring isolation facilities Works in collaboration with external agencies to manage the potential for infection control within the wider community including communicating effectively with the general public and liaising with regional and national bodies where appropriate. 38

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44 3.8 ENVIRONMENTAL PROTECTION AND EMERGENCY PLANNING Objectives: To understand the relationship of the physical environment to health To be able to identify situations where environmental exposure may be the cause of ill health To relate to emergency planning arrangements both in and around environmental matters and other issues in clinical practice. Knowledge Understand in outline the mechanisms by which environmental chemicals have an impact on human health Understand in outline the mechanisms by which adverse chemical exposure can be mitigated e.g. decontamination, specific antidotes Know the potential sources of information and guidance to manage a case of chemical etc exposure, including local, regional and national sources Understand the principles of emergency planning. Know in outline the emergency plan for the healthcare organisation currently working for and specifically know duties and responsibilities within the plan CbD ACAT, CbD ACAT, ACAT, CbD ACAT, CbD Skills Recognises the potential for chemical or other hazardous environmental exposure in relation to an individual patient Manages patients in an appropriate manner according to guidance Recognises the importance of evidence-based practice in relation to clinical effectiveness ACAT, CbD,2,2 ACAT, CbD,3 40

45 Behaviours Actively engages in emergency planning arrangements including exercises in accordance with Trust plans Openly considers the possibility of chemical or environmental exposure in clinical work MSF MSF 2,3,2 Level Descriptor Always follows local protocols in relation to obtaining advice and guidance regarding the management of a patient Effectively undertakes any specific procedures required by these protocols Effectively undertakes duties within the Trust emergency plan. 2 Appropriately considers the possibility of chemical exposure in relation to a patient s presenting condition or response to therapy Actively discusses such issues with other members of the team including potential management options. 3 Actively seeks advice and guidance from appropriate sources in consideration of atypical presentations. 4 Works with Trust s emergency planning arrangements to consider issues that will affect the clinical department, how the department will support the rest of the Trust in responding to major emergencies and identifying any resources the department might require to make that response as effective as possible. 4

46 3.9 MANAGING LONG-TERM CONDITIONS AND PROMOTING PATIENT SELF CARE Objective: Work with patients and use their expertise to manage their condition collaboratively and in partnership, with mutual benefit Knowledge Describe the natural history of diseases and illnesses that run a chronic course Define the role of rehabilitation services and the multidisciplinary team to facilitate long-term care Outline the concept of quality of life and how this can be measured whilst understanding the limitations of such measures for individual patients CbD Outline the concept of patient self care and the role of the expert patient CbD, Understand and be able to compare and contrast the medical and social models of disability CbD Know about the key provisions of disability discrimination legislation CbD,4 Understand the relationship between local health, educational and social service provision, including the voluntary sector CbD Skills Develops and agrees a management plan with the patient and carers (where relevant),ensuring awareness of alternatives to maximise self care within patients care pathway Develops and sustains supportive relationships with patients and carers (where relevant) with whom care will be prolonged and potentially life long Provides relevant evidenced based information and where appropriate, effective patient education, with support of the multidisciplinary team,3 CbD,,4,3,4 Provides relevant and evidence based information in an appropriate medium to enable sufficient choice, when possible CbD, Patient Survey,3 42