Quality: assurance or standards? - Kuwait Institute for Medical ...

BULLETIN OF THE KUWAIT INSTITUTE FOR MEDICAL SPECIALIZATION 2003;2:1-4ReportDiscussion of the issues of quality and safetyin clinical practice go far beyond the definitionsof terms such as ‘competence’ and‘performance’. Certainly an understanding ofthe distinction between these terms in amedical education context is important, butfar more important are “the implications ofthe distinctions between the two areas for thepurpose of assessing doctors in practice”. 3 Thedistinction between competence and performancehas particular relevance for identifyingmethods of assessment. Those methods whichcan measure what a practitioner actually doesin professional practice when dealing with theproblems of patients (i.e. the clinical performance)may be quite different from the methodsneeded to assess what doctors are capableof doing in controlled representations of professionalpractice as possible predictors of futurepractice (i.e. clinical competence). As isclearly true at all levels of professional learning,amongst other variables the context ofpractice, including the nature of professionalteams and systems, impacts dramatically onthe outcomes and quality of patient care. 4Any investigation into the assessment ofclinical performance in practice settingsshows very readily that clinical performanceis an extremely varied and idiosyncratic construct,and therefore although a vast array ofperformance components and tasks may beidentifiable 5 , the matching of appropriate assessmentmethods 4-6 is a complex and difficultprocess. Practitioners, employers and consumerswill obviously need to accept thatsome form of performance assessment is actuallynecessary as a personal and professionalresponsibility 7 no matter what range of contextsand systems are involved. 4 To achievethis, assessment approaches will need to beseen as being fair and defensible 8-10 andclearly relevant to the defined purposes of assessmentand the nature of the clinical performance.Such is the complexity and hugerange of potential combinations of factors involvedthat any single approach to assessmentor single method of assessment wouldbe extremely limited in its application. Whatis necessary is an understanding of principlesand guidelines that allow for their applicationin any well-defined setting.Further, acceptance of any model of learningand practice that builds upon and furtheradvances the notion of CME/CPD will requirean understanding of distinctions between formativeand summative assessment approaches.11 Gathering information and providingfeedback that is largely qualitativeand designed to assist in the improvement ofan individual practitioner’s performance is avastly different activity from gathering ratingsor largely quantitative informationwhich demonstrates characteristics of practicewhich are then used for judgmental orlegislated summative purposes. Any approachthat is designed to provide comparativedata against other practices, standardsor requirements will also require individualpractitioners to accept the need to have a realisticinsight into their own performance 12and accept the need for remediation wheneverindicated. A conflict will arise wheneverthe purposes or intentions of an approach,and thus the outcomes, are used for differingpurposes. A basic starting position requiresthe clear and accepted definition of the purposesof assessment, and the intended use ofthe outcomes or judgments made as a resultof the assessment.An approach recommended for considerationis one that links “performance and assessmentto ensure that ongoing learning andcontinuing competence are, in reality, connected”.11 It needs the practitioner to be ableto identify and accept those aspects of clinicalpractice that are not only adequate and acceptableto himself or herself but also in linewith acceptable professional standards. Assessment,as an educational process, allows aclinician opportunity to compare characteristicsof actual practice with some ideal or desiredpractice, whether defined by the individual,by the profession or by some externalregistration or accreditation authority. Assessmentalso validates good practice whenthere is consistency between what the individualdoes and what is expected of him orher. Any perceived discrepancy between performanceand requirements should initiatefurther consideration and reflection.As clinicians are involved in such a vastrange and variety of tasks and components,assessment through any single approach isunlikely to be able to reflect an overall levelof performance. Typically, the notion of case2Quality: assurance or standards? ● Neil Paget