Assessment in the
Workplace
Dr Gavin Johnson
Consultant Gastroenterologist UCLH
Senior Lecturer in Medical Education UCL
1
Objectives
1) Discuss the evolution of workplacebased assessment
2) Argue the pros and cons of WPBA
3) Improve the utility of WPBA
4) Evaluate the utility of WPBA
5) Appreciate the changing role of WPBA
in 2012
2
Why assess doctors?
• Public confidence
– Scepticism of profession to self-regulate (Smith 1998)
– Better measures of quality of practice (Scally 1998)
• Evidence of competence/inform progression
– Tomorrow’s doctors (GMC 1998, 2003)
• To drive learning
• To improve trainee confidence
• To rebuke legal challenges
(Van der Vleuten 2000)
(Tweed and Miola 2001)
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The Metro Front Page 2011
4
The Metro Front Page 2011
5
Assessment
– Miller 1990
DOES
SHOWS HOW
KNOWS HOW
KNOWS
6
Assessment
– Miller 1990
DOES
PERFORMANCE
SHOWS HOW
COMPETENCE
KNOWS HOW
KNOWLEDGE
KNOWS
7
Assessment
DOES
– Miller 1990
MSF, ACAT
SHOWS HOW
OSCE, miniCEX
KNOWS HOW
Best answer MCQ
KNOWS
T/F MCQ
8
WPBA – the origins
• Chart stimulated recall
– ABEM >1983
• Multisource feedback
– Business and industry >1993
• miniCEX
– Norcini >1995
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10
11
MSF
DOPS
CbD
miniCEX
12
Clinical judgement &
decision-making
Communication skills
Knowledge
Curriculum
Teaching Skills
Interpretative
Skills
Clinical skills
Team Work
Audit
Procedural Skills
13
13
Clinical judgement &
decision-making
Knowledge
KBA
mini-CEX, MSF
Curriculum
Teaching Skills
TO
Interpretative
Skills CBD
Clinical skills
Team Work
MSF
Communication skills
CBD,
ACAT
mini-CEX
Audit
AA
Procedural Skills
DOPS
14
14
✓
WPBA
✗
15
• In vivo
✓
– higher up Miller’s pyramid
• Educational Impact (facilitate feedback)
• Drive learning
• Gather evidence:
– inform decision making
– Re-sample borderline trainees
• Practical/Cheap
16
✓
Educational Impact – Cbd Comments
• “Very helpful to receive constructive feedback on outpatient
encounters + letter written to GP.”
• “Helpful to receive structured feedback on consultation in
outpatient clinic”
• “Valuable exercise covering ground not previously covered
in other assessments.”
• “Useful assessment. A useful way to document
conversations and assessments taking place on a daily
basis.”
17
✓
Educational Impact – Cbd Comments
• “Very helpful to receive constructive feedback on outpatient
encounters + letter written to GP.”
• “Helpful to receive structured feedback on consultation in
outpatient clinic”
• “Valuable exercise covering ground not previously covered
in other assessments.”
• “Useful assessment. A useful way to document
conversations and assessments taking place on a daily
basis.”
18
✓
Feedback
Kolb 1984
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•
•
•
•
✗
Time – trainee, assessor
Space – appropriate areas for discussion
Conflict - Turning supervisors into assessors
Reliability – calibrating assessors, faculty
development
• Validity – being used incorrectly/en masse
• Formative assessments summative
decisions
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✓
WPBA
✗
21
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“The profession is rightly suspicious of the use of reductive
‘tick-box’ approaches to assess the complexities of
professional behaviour, and widespread confusion exists
regarding the standards, methods and goals of individual
assessment methods…This has resulted in widespread
cynicism about WBA within the profession, which is now
increasing”
23
✓
WPBA
✗
24
Improving and Evaluating
WPBA
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Van der Vleuten (1996)
Utility = Rw × Vw × Iw × Pw
• Reliability – are the scores reproducible?
• Validity – does it measure the knowledge,
skills and
attitudes it was designed to cover?
• Educational Impact – does assessment drive
learning?
• Practicality/Cost – is assessment feasible an
acceptable?
w = ‘weighting’ depending on context
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Validity
•To improve:
– Match objectives and to
assessments
– Pilot
– Collaborate in the
development of the
assessment
•To measure:
– Question trainees and
assessors
– Correlation between
similar performance traits
within assessment
– Correlation between
different assessments
measuring similar traits
e.g. CbD and ACAT
– Do scores improve over
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time?
Reliability
To improve:
•Train assessors
•Use grounded
descriptions of
performance
•Increased number of
assessments
•Increase number of
assessors
To measure:
• Gather a large number of
assessments
– Generalisability theory
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Ask a stupid question, you’ll get a
stupid answer: Construct
alignment improves the
performance of WPBA
J Crossley, GJ Johnson, JR Booth, WB
Wade
Medical Education 2011
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ACAT ratings CMT 2008-9 - Overall Clinical
Judgement
Well below expectations
0.0%
Below expectations
0.0%
Borderline
0.1%
n=13,977
Meets Expectations
18.8%
Above expectations
55.0%
Well above expectations
26.0%
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Hypothesis
‘WPBA reliability improves when the
assessor’s rating uses anchor statements
based on clear descriptors of
performance, rather than on a scale based
on what was expected by the assessor’
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Methods (1)
• RCP Nationwide electronic portfolio
• WPBA form had both old and new scales
• Data extracted and anonymised
• ‘Real world assessments’
• All years of higher speciality training
• Generalisability theory used to calculate
reliability for both old and new rating
scales
32
Methods (2) : ACAT Anchor Statements
Below level expected during
Foundation Programme
Trainee required frequent supervision to
assist in almost all clinical management
plans and/or time management
Performed at the level expected Trainee required supervision to assist in
some clinical management plans and/or time
at completion of Foundation
Programme / early Core Training management
Performed at the level expected
on completion of Core Training /
early Higher Training
Supervision and assistance needed for
complex cases, competent to run the acute
care period with senior support
Performed at the level expected
during Higher Training
Very little supervising consultant input
needed, competent to run the acute care
period with occasional senior support
Performed at the level expected Able to practise independently and provide
for completion of Higher Training senior supervision for the acute care period
Results (1)
• mini-CEX, n = 3185
• CbD, n = 4513
• ACAT, n = 3235
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Results (2) : mini-CEX
Number of CbDs
3
6
9
12
R co-efficient – old rating
0.55 0.71 0.78 0.83
R co-efficient – new rating
0.77 0.87 0.91 0.93
Results (3) : CbD
Number of CbDs
3
6
9
12
R co-efficient – old rating
0.48 0.65 0.73 0.78
R co-efficient – new rating
0.73 0.84 0.89 0.92
Results (4) : ACAT
Number of CbDs
3
6
9
12
R co-efficient – old rating
0.21 0.35 0.44 0.52
R co-efficient – new rating
0.36 0.53 0.63 0.70
Conclusion from Study
• The reliability of WPBA improves
significantly when the ratig for Overall
Performance is based on the stage of
training (with descriptive anchor
statements) rather than a scale based on
‘what was expected’ by assessor
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Feasibility
•To improve:
•To measure:
 length of
– Question trainees and
assessments
assessors
• Questionnaires
 number of
• Focus groups
required assessments
• Interviews
– Embed in working day
– Assessment form data
– Facilitate process
• handheld
• Duration
• Satisfaction
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Educational Impact
•To improve:
– Faculty development
– Find time!
– Encourage free text
boxes to be completed
(reflective practice)
– Discuss at appraisal
•To measure:
– Question trainees and
assessors
– Evaluate quality of free
text entries
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Challenges 2012
• Too many WPBA
• Ratings removed
• Only ‘anchor statements’
• Difficult to use to inform progression
• Legal challenges
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Where do we go?
• Clarity – purpose and benefits
• Train the assessors
• Use formatively only – ? reliability irrelevant
• Educational Supervision
• Progression needs to be the opinion of an
‘expert’ and evidence based
• ARCP decision need to stand up to legal
scrutiny
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Conclusions
• Boom…to bust?
• There are established benefits
– Educational Impact
• Consensus needed on how summative
decisions are reached
– But this must be evidence based
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Assessment in the Workplace Dr Gavin Johnson