e-Appraisal: A Guide for Primary Care

e-Appraisal A guide for primary care Paul Robinson and Louise Simpson Foreword by Professor Sir Liam Donaldson Chief Medical Officer

Radcliffe Medical Press

Radcliffe Medical Press Ltd 18 Marcham Road Abingdon Oxon OX14 1AA United Kingdom www.radcliffe-oxford.com The Radcliffe Medical Press electronic catalogue and online ordering facility. Direct sales to anywhere in the world.

© 2003 Paul Robinson and Louise Simpson All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the copyright owner. British Library Cataloguing-in Publication Data A catalogue record for this book is available from the British Library. ISBN 1 85775 961 3

Typeset by Acorn Bookwork, Salisbury, Wiltshire Printed and bound by TJ International Ltd, Padstow, Cornwall

Contents Foreword Preface About the authors Acknowledgements List of abbreviations

vi viii ix x xi

1 About e-appraisal Who is this book for? How to use this book

1 2 2

2 Introduction to e-appraisal Informatics and appraisal in primary care What do people think about appraisal? What is informatics and what can we find in it to support appraisal? Why you still don't need to worry about the stuff in the grey box of wires The role of individual and organisational learning Self-managed learning Appraisal and clinical governance Some final thoughts

3 3 4

6 7 8 9 10

3 What and where is appraisal? Appraisal in the spectrum Experience in and of appraisal Dimensions of appraisal Situating GP appraisal

13 13 14 15 18

4 Appraisal and the educational framework A beginner's guide to appraisal

23 23

5

iv • Contents

So why aren't we doing it already? An educational framework for appraisal How e-appraisal helps define learning needs

24 25 27

5 The art of appraisal I Appraisal offers a structured and sequenced process Appraisal offers the opportunity to reflect Appraisal offers someone to talk to The Johari window Roles in appraisal Roles in the appraisal meeting Roles after the appraisal How e-appraisal helps

29 29 30 31 31 32 33 34 34

6 The art of appraisal II The art of appraisal Bringing two worlds together Personal learning and development plans (PDPs) More on the Johari window Confidentiality, openness and trust Confidentiality in e-appraisal The appraisal meeting Communication in the appraisal meeting e-Appraisal and the appraisal meeting Preparing for the e-appraisal meeting How to reflect

37 37 38 39 41 42 43 44 44 47 48 49

7 Reporting and demonstrating - reflecting and showing It depends how you look at it... Shop windows The NHS Appraisal Toolkit: developing the appraisal statement The advantages of a dynamic electronic appraisal record (EAR) The NHS Appraisal Toolkit: the appraisal questionnaire Using information and the appraisal statement in the appraisal meeting Signing off after the appraisal Using the personal learning and development plan throughout the year Some final thoughts

51 51 52 53 54 55

8 GP appraisal and the practice team by John Bibby Development plans, the individual and the practice Out with the old ...

56 57 57 58 61 62 62

Contents • v

Nurse education leading the way ... and the administrative team? Practice planning PCTs and practice planning in partnership External influences Organisational development facilitation Practice professional development planning A look at appraisal and revalidation The role of computers Some final thoughts ...

63 63 63 65 65 65 66 69 70 73

9 Focus on informatics for e-appraisal Why and how informatics has a role in appraisal Training and personal development Using the GP clinical system The world wide web Accessing the NHS Appraisal Toolkit Patient surveys and consumer health informatics The value of the e-community

75 75 76 76 77 78 79 79

10 Training and resources Primary care informatics training Web-based resources Some useful addresses Further reading and resources Additional reading Lessons from industry

81 81 83 84 85 92 94

Index

99

Foreword Appraisal is a positive and developmental process for individual clinicians, aimed at supporting good patient care and high standards of clinical practice in the NHS. It forms an important building block in the strategy to ensure high clinical standards that doctors, and all people working in the NHS, can be proud of. It is a part of clinical governance; to work well it has to be something that every doctor takes part in, which is why it will be a condition of contract in the future. It is a process to give GPs feedback on their past performance, to chart their continuing progress and to identify development needs. It is a forward-looking process, essential in identifying the developmental and educational needs of individuals. The primary aim of appraisal is to help GPs consolidate and improve on good performance, aiming towards excellence. In doing so, it will identify areas where further development may be necessary or useful. The prospect of appraisal is new to many clinicians and it is important that they are comfortable with the concepts and have the access and knowledge to use resources that support appraisal as a formative, reflective and useful part of both the quality and personal development agenda. Informatics tools are available to facilitate the appraisal process itself, but also the ongoing reflection and development activity before and after the appraisal meeting. By reflecting in the context of day-to-day work in general practice, much of the preparation for appraisal can be a by-product of existing activity. Thus, the appraisal process will not of itself result in the generation of significant amounts of new evidence or information, rather it will capture the information that already exists. I welcome the work that SCHIN have done on the development of the electronic NHS Appraisal Toolkit. To me, the Toolkit demonstrates how appraisal for general practitioners is important for the individual as well

Foreword • vii

as for the wider quality context. It also demonstrates the value of an ongoing reflection in the context of day-to-day practice and general practice. This book, a guide for primary care, covers the underpinning principles to appraisal, and also demonstrates how clinicians, both appraisers and appraisees, can exploit their informatics resources to enjoy excellence in appraisal - a benefit to the quality and the personal development agendas. Appraisal is an opportunity for general practitioners to reflect on their work and to consider how their effectiveness might be improved. It is also a sign of commitment to professional and personal development within primary care. The Toolkit will mean that an informatics resource will be available to support both the individual and the organisation in developing appraisal. Professor Sir Liam Donaldson Chief Medical Officer October 2002

Preface This book is about appraisal and the role that today's information technology can play in making appraisal more effective and easier for both the appraiser and the appraised. The idea for the book grew from our previous book, e-Clinical Governance: a guide for primary care (Radcliffe Medical Press, 2002) and our work on the NHS Appraisal Toolkit. The links between appraisal and clinical governance are considered in detail in the book. Clinical governance is about co-ordinating the planning, management and delivery of healthcare and appraisal is the cornerstone that involves the practitioner in this process. The NHS Appraisal Toolkit is a web-based electronic resource that provides background guidance for appraisees and appraisers and a comprehensive appraisal record for the practitioner. It has been developed for GP Principals, for whom the first round of appraisal will be completed by April 2003. The focus of the book is therefore appraisal of general practitioners in the UK, and we have drawn on the NHS Appraisal Toolkit as an instance of the application of information technology to appraisal. In Chapters 9 and 10, in particular, we show how a wide range of electronic resources can be used in appraisal and in Chapter 8 John Bibby shows how appraisal of individual practitioners relates to work in teams. We feel that this approach, although it builds on specific contexts in the domain of primary healthcare in the United Kingdom, is applicable to appraisal in many other contexts and within other parts of the health services, and beyond. Paul Robinson Louise Simpson October 2002

About the authors Paul Robinson is a GP in Scarborough and GP educational consultant to the Sowerby Centre for Health Informatics at Newcastle (SCHIN). Paul is a key member of the NHS Appraisal Toolkit project team, drawing on his expertise as a VTS course organiser, lecturer and educationalist. Paul is author and co-editor of e-Clinical Governance: a guide for primary care (Radcliffe Medical Press, 2002). Louise Simpson leads the SCHIN education and communications team, developing and implementing initiatives for primary care including the NHS Appraisal Toolkit. She has worked in health informatics since 1992, with experience as a GP computer facilitator in Nottinghamshire and with EMIS National User Group. Louise is author and co-editor of e-Clinical Governance: a guide for primary care (Radcliffe Medical Press, 2002) and she successfully achieved an MBA with a thesis entitled Organisational Learning in General Practice. Caroline Rickard and Laura Bond are contributing authors from SCHIN and provided many of the web links and resource lists for this guide. John Bibby is a GP in Shipley, near Bradford, and a GP tutor in Yorkshire. He has worked extensively in GP education, clinical governance, appraisal and revalidation. He is the author of Chapter 8 GP appraisal and the practice team.

Acknowledgements The authors would like to thank Dr Philip Leech, Claire Whittington, Josie Godfrey and Mike Sowerby from the Department of Health for their vision and support. Thanks also to Professor Ian Purves and all the team at the Sowerby Centre for Health Informatics at Newcastle (SCHIN) at the University of Newcastle upon Tyne, particularly Dmytro Andriychenko, Laura Bond, Sally Fraser, Beth Wood, Terry Brown, Mark Gibson, Caroline Rickard and Rob Wilson for their contributions to the NHS Appraisal Toolkit project. A special thank you to Lucy Hatt and Sian Rae from Nigel Wright Consultancy Ltd in Newcastle upon Tyne for their expertise in the human resource (HR) management domain. Finally, thank you to the team at Radcliffe Medical Press, especially Paula Moran and Jamie Etherington.

List of abbreviations ACAS BAMM BMA CME CPD DH EAR FTE GMC GMS GP HA HIP HIMP HR HRM IPR IRS MIQUEST NHS NSF PBDP PCG PCIP PCO PCT PDP PGEA

Advisory, Conciliation and Arbitration Service British Association of Medical Managers British Medical Association Continuing Medical Education Continuing Professional Development Department of Health Electronic Appraisal Record Full-time Equivalent General Medical Council General Medical Services General (Medical) Practitioner Health Authority Health Informatics Programme Health Improvement and Modernisation Programme Human Resources Human Resource Management Individual Performance Review Industrial Relations Services Morbidity Information QUery Export SynTax National Health Service National Service Framework Practice (Business) Development Plan Primary Care Group Primary Care Investment Plan Primary Care Organisation Primary Care Trust Personal Development Plan Post Graduate Education Allowance

xii • List of abbreviations

PPDP PMS RAID RCGP ScHARR SCHIN VTS

Professional Practice Development Plan Personal Medical Services Review, Agree, Implement and Demonstrate Royal College of General Practitioners School of Health and Related Research Sowerby Centre for Health Informatics at Newcastle Vocational Training Scheme

From Louise To Rob and James, with love. From Paul To David, who was the first doctor to interest me in education. To Brian, who was the first to appraise me.

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1

About e-appraisal There is a kind of character in thy life That to th'observer doth thy history Fully unfold.

(William Shakespeare, Measure for Measure, Act I Scene I 27-29) There is no such thing as time Only this very minute And I'm in it. (Joyce Grenfell, Time) Appraisal and health informatics - both big topics on the primary care agenda. Both require investment in terms of time and resources and both may mean new ways of thinking or working for some. So how can one support the other? How can the day-to-day information activities of patient care and general practice enable this thing called appraisal? In other words, how can we make what we already have and already do work for us to build a picture that supports a reflective and developmental process, without reinventing the wheel or investing in new expensive gadgetry? This book will guide you through the principles of appraisal and also demonstrate how clinicians, both appraisers and appraisees, can exploit their informatics resources to enjoy excellence in appraisal - a benefit to the quality and the personal development agendas. It aims to show how the electronic resources on your desktop can be used to support you as you plan, prepare and reflect. The guiding principles here are formative, developmental and reflective. Appraisal is not a once-a-year mad dash to the finishing line, but a new name for something lots of us already do - that is to think about

2 • e-Appraisal

where we are, where we want to be and how we might get there. Informatics can provide the colour palette and the canvas so you can stand back and see something like a 'true' picture.

Who is this book for? Appraisal is for and about everyone working in the primary care team. This guide has been written with and for GP appraisees, appraisers and those people that inform and support the informatics, educational and personal development processes in primary care. You may be a GP about to appraise or be appraised, or the information specialist in your team. You may be a primary care trust person and you may have a role in advising, guiding or providing information, evidence, personal development, education or all of these! This guide focuses on introducing some of the concepts generic to appraisal, but applies them specifically to GP appraisal in primary care. Because we take a formative, whole team approach, this is relevant to everyone in the team. Objectives set nationally and locally are bound to inform the development process for individual GPs and those special interests developed by GPs will necessarily have an impact on the team within the general practice unit. Whatever your role in primary care or in appraisal, information and informatics can help - this guide is for you.

How to use this book This book has been written as an easy to use, dip in and out guide. The book can be read from cover to cover, or you may choose to pick out one section and use that bit first. As well as being a guide to support individuals' knowledge development about both informatics and clinical governance in primary care, it can also be used as a teaching resource, either as background reading or you may use the 'bullet point' sections to prompt small group work.

2

Introduction to e-appraisal Key points covered in this chapter » How appraisal can be supported by informatics * Why informatics is important to appraisals * Learning not to worry about what's inside the grey box of ,, wires* The role of individual and organisational:learning Self-managed learning Appraisal and clinical governance

Informatics and appraisal in primary care Appraisal is being introduced across the NHS, with many clinicians in primary care approaching appraisal for the first time, either as appraiser or appraisee. The prospect of appraisal may be daunting to many and it is important that access is available to resources that support appraisal as a formative, reflective and useful part of both the quality and personal development agenda. Informatics tools are available to facilitate not only the appraisal process itself, but also the ongoing reflection and development activity before and after the appraisal meeting.

4 • e-Appraisal

Computers appear as commonly on a GP's desk as a stethoscope or prescription pad these days. Over 95% of GP practices have computer systems and most use them for accessing electronic patient notes, prescribing and clinical guidance, prompts or decision-support.1

What do people think about appraisal? At a meeting of primary care team members in Warwick in September 2001 (the EMIS National User Group annual conference, www.emisnug. org.uk), the 350-strong audience - with access to feedback keypads were asked about their attitudes to and experiences of appraisal. At the start of the talk, the presenters posed a number of questions. Of the mixed professional audience, 86% knew what appraisal was, 57.5% had been appraised and 73% said they felt confident or very confident about being appraised. After a presentation of an on-line resource designed to enable and assist appraisal (the NHS Appraisal Toolkit, www.appraisals.nhs.uk), 94.4% stated that they knew what appraisal was, 76% felt confident or very confident about being appraised, 52% said they would use the eAppraisal Toolkit and 43% wanted more information.

Figure 2.1

Levels of confidence in appraisal.

The audience were more likely to be technically 'savvy' and, as members of a user group for one of the clinical computer supplier systems,

Introduction to e-appraisal • 5

possibly more open to using electronic resources and informatics in general. However, the impact of a software tool as it might be applied to a generic programme like appraisal must be considered. Computers are not just data hungry boxes balancing precariously on the edge of a desk, but potentially a rich source of information and guidance, as well as a tool for collating and producing relevant reports, for personal development and educational insight. This is the story of part of that journey appraisal is the map and e-appraisal an efficient means of travelling.

What is informatics and what can we find in it to support appraisal? Health informatics is more than just 'computers in general practice'. The information explosion has seen the clinical computer system become a common part of the GP consulting room. As we have seen, about 95% of GPs have already invested in clinical computer systems, but the level of use of those systems varies enormously. Providing practitioners with a connection to the Internet and to the NHS Net, and encouraging their use, is a core policy tenet. It offers clinician (and patient) access to millions of pages of information, knowledge and evidence. A few key informatics areas emerge as useful in the process of implementing appraisal in primary care: Box 2.1

World wide web

• Finding out what appraisal is. • Sharing and investigating best (and worst) practice. • What does the NHS say about appraisal? • Stealing ideas and avoiding reinventing the wheel. • Information about education and training programmes.

E-mail and e-lists

• • • •

GP clinical computer systems

• Searches and audit facilities. • Reports on clinical activity (what actually happened versus what do I think happened).

Developing a community of appraisers/appraisees. Sharing what worked and what didn't. Sharing and investigating best practice. Discussing and exploring personal experience.

6 • e-Appraisal

• •

Reports on management information. Repository for day-to-day clinical and administrative information for later use. • Clinical knowledge bases for reflection and personal development (for example, PRODIGY or Best Evidence). Web-based appraisal portals

• Year-round electronic appraisal records for collating relevant data privately and confidentially to avoid last minute panic in preparing for the appraisal information. • Finding out what appraisal is. • Sharing and investigating best (and worst) practice. • What does the NHS say about appraisal? • Stealing ideas and avoiding reinventing the wheel.

This is a brief summary of some of the electronic tools that can support appraisal, and later chapters will explore these in more detail in the context of GP appraisal. The Johari window model is a useful one for showing the importance of feedback and reflection, and Chapter 5 investigates this in more detail. As well as the electronic tool bag, the importance of feedback from colleagues and patients is also crucial in helping us identify our strengths and development needs and helping us focus our appraisal on personal and continuing professional development. Let's remember that appraisal should be a positive experience, helping us move forward professionally and personally and there should be no surprises. Utilising our electronic tool bag in the process of preparation and reflection not only helps us avoid overlooking the 'good news' stories of our appraisal period, but also helps us with planning.

Why you still don't need to worry about the stuff in the grey box of wires Informatics is about enabling personal and professional development as well as using information to support and enable patient care. Let's establish two important principles. Firstly, the 'technology', for most clinicians, is irrelevant. The old allegory is that you do not need to know how a car functions to drive safely from your base to your destination but you do need to know about putting the

Introduction to e-appraisal • 7

right fuel in and which pedals to press. It's the same with computers programming languages are irrelevant for most of us, but using the right fuel (quality data) and navigating the pedals (the menus and functions of your software) will help you reach your destination a lot more smoothly. The second principle is that computers are very good at doing routine jobs quickly and efficiently. For most people this means searching. For most practices, the days of pulling hundreds of sets of Lloyd George notes to run an audit are over. However, most paper-frugal practices think carefully about what their information requirements are likely to be and agree together what data will be captured on the practice system from patient encounters. Informatics is as much about teamwork and 'organisational learning' as any other element of general practice. It is also worth thinking about the other benefits that the computer can bring to the practice, the clinician and the patient. 'Searches and audits' are one type of information retrieval that clinical software can do quickly and efficiently. There is more. And you should find most, if not all, within existing GP clinical computer software.

The role of individual and organisational learning When there is a balance between culture, technology, communication, infrastructure and organisational structure, then organisational learning occurs.2 Andrew Forrest, in Fifty Ways Towards a Learning Organisation3 writes that it is not enough for individuals to 'indulge in plenty of learning activities, and for the organisation to provide expensive structures such as intranets or learning resource centres. The two must support each other'. Similar criticisms have been made of the adult learning model - picking the topics we are most interested in might not give us the developmental pathway we, our patients, or our organisations, need. Information and informatics, and the findings of searches and audits using our clinical computer systems, can help throw light on our needs rather than our wants. Peter Senge's classic definition of the learning organisation is: An organisation which is continually expanding its capacity to create its own future. In the context of the NHS, this might raise a smile as we wonder how we can transform ourselves under the weight of paperwork, seven-and-a-half minute consultations and increasing demands and initiatives. Appraisal

8 • e-Appraisal

should give us the opportunity to reflect and enable change, driven from the 'bottom up', as our own development plans attune to our needs, as our feedback informs the primary care organisations and our objectives concord with those of our colleagues and our context. Knowledge management can be part of the information management story, but is more closely aligned with some of the principles of organisational learning in that it recognises that information is not knowledge (or wisdom!) until it is applied and communicated. There is nothing like first-hand experience for learning something, but the management of knowledge can help us share lessons and experiences where appropriate. We don't need to put our own hand in the fire to know that it hurts! Informatics and the use of information are part of the knowledge management story, and integral to appraisal. There may always be a problem with, and a reluctance about, sharing knowledge. It might leave us vulnerable, open up discussions that cause dissonance and move us out of our comfort zone. These feelings are common in any innovative activity, or with the introduction of change, and it is because of this that it is all the more important that the information we use as a spotlight in the personal and professional scope of appraisal and reflection is reliable, trustworthy and relevant. That is not to say you need to understand the complexities of the computer system, but you do need to have faith in and trust the findings from your Internet search or clinical system audit. Forrest describes the core competencies for organisations on page 34 of Fifty Ways Towards a Learning Organisation.3 • • • • • •

team working people management communication leadership problem solving planning and organisation.

These facets and assets are not a million miles away from the sort of items that an appraisal might look at. Some are clinically bound, but most help position us in our organisation and within the objectives of our working unit, whether that's a GP practice, a primary care trust or the wider NHS.

Self-managed learning Primary care has an advantage in that the opportunities for educational, personal and professional development are abundant. The problems lie in

Introduction to e-appraisal • 9

finding the time to access the learning, innovating our practice after the learning experience and choosing something that reflects our learning needs rather than our wants, when our needs often lie outside our comfort zone. A balance needs to be struck if the investment in training is to reap any reward in turn of our personal satisfaction and our ongoing organisational need. Knowing what and how to learn is crucial. It is also likely to be an important part of the appraisal process, both in terms of identifying needs prior to or at the appraisal meeting, or in terms of applying the findings and output of the appraisal. You may choose not to disclose something in your appraisal meeting, and local arrangements will dictate the extent to which training budgets are allocated, but with a view of your strengths and development needs within the context of the 'bigger picture', you will be better placed to exploit the opportunities that appraisal presents.

Appraisal and clinical governance I do not make mistakes. I make predictions which turn out to be wrong.

(Murray Walker) There is an issue of expectation here, and expectations need to be managed as you embark on the process of preparing for appraisal. Expectations might be implicit or explicit, and the expectations we overlay on ourselves may be different from those of our patients, colleagues, staff or organisations. Some standards are explicit - national service frameworks, for example. Some are implicit - patient satisfaction might be another example. Clinical governance is one way of drawing out the quality standards, and therefore expectations, for a number of clinical, administrative and management activities. To summarise the complex concept of clinical governance: • improving patient care • implementing evidence-based medicine into every day patient care • clinical audit and reflection on individual and team work • ensuring patient safety and the management of risk • life long learning and personal development • getting the culture right - through leadership, teamwork and communication. The evidence and information you collect for clinical governance, and the informatics activities behind clinical governance, are mutually supportive

10 • e-Appraisal

of appraisal, and it is up to you to choose how much you use or disclose. The year-round approach of clinical governance and the reflection it encourages is fundamental to appraisal and duplication of work can be avoided by thinking about what you have 'done for clinical governance' and how this fits in with your appraisal. Here are some starting questions that you may be able to address by yourself or within the context of your general practice unit. • • • • • • • • • •

Is the data you enter into your clinical computer system of sufficient quality, quantity, reliability, timeliness and accessibility? Can your data be retrieved easily from your clinical computer system? What other sources of clinical and management knowledge do I access? How up-to-date am I? Do you collect data on the themes, topics and areas that you want to cover for your appraisal? Do you know which audits have been run? What changed as a result? What sources of clinical evidence do I have and/or use? How has my decision-making and knowledge assimilation changed in the period under reflection? What do I do differently now to how I did it a year ago? What are my GP practice objectives? How is their implementation measured? What is in place in my every day practice to help me manage risk? How and what information do I share with my patients? How do I check and qualify communication? What other internal and external reflection tools do I use? Does my practice participate in a MIQUEST or HIP/NSF programme?

Some final thoughts If appraisal is about preparation, reflection, showcasing and innovation, then informatics can play a crucial role in helping each of these stages in the appraisal process. Information provides the colour palette from which the appraisal picture can be drawn, providing the data, whether from a GP clinical computer system or the Internet, is reliable, timely and accurate. Use the questions here, and the themes from later in this guide to start a dialogue with your informatics colleagues, and as a review for your own informatics activity, to ensure the investment in the technical network truly maximises the benefits to support the introduction and implementation of appraisal for you.

Introduction to e-appraisal • 11

References 1 2

3

SCHIN (1966) Computerisation in General Practice. Sowerby Centre for Health Informatics at Newcastle. Stonehouse G and Pemberton J (1999) Learning and knowledge management in the intelligent organisation. Participation and Empowerment. 7(5): 131–44. Forrest A (1999) Fifty Ways Towards a Learning Organisation. The Industrial Society, London.

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3

What and where is appraisal? Key points covered in this chapter

* How appraisal fits in the spectrum of performance,' review and mentoring * The dimensions of appraisal * The link with education and training

Appraisal in the spectrum 'Appraisal' is a word in common usage. The 1992 edition of The Collins English Dictionary defines appraisal as an assessment or estimation of the worth, value or quality of a person or thing. The verb 'appraise' is defined as to assess the worth, value or quality; to make a valuation. More recently, the current edition of The Oxford English Dictionary defines appraisal as a formal evaluation of the performance of an individual over a particular period and some medical educators1 have used the following definition, a process which describes current performance in terms of past activity and future plans, based on personal review and informed feedback. These different definitions show how perceptions of appraisal are altering, and suggest a trend away from appraisal as measurement or assessment.

14 • e-Appraisal

Many people have experience of appraisal at work. Here, appraisal is an organisational process in which there is a dialogue between the individual and an appraiser, often a representative of 'management'. In primary care, the concept of a 'management representative' or line manager is not as clear as in operational or industrial organisations. Jelley and van Zwanenberg describe a process of peer appraisal, between 'doctors of equal status', who may work in the same practice.2 We have made an assumption with this guide that a GP peer is usually likely to be the appraiser, although local arrangements may well define the shape of the experience of the appraiser. It is likely that the majority of GPs will be appraised by trained GPs who are from a different practice (external peer appraisal). For the purposes of this chapter, in positioning appraisal as a formative, educational and developmental process, we will refer to that organisational representative appointed to lead appraisal as an appraiser.

Experience in and of appraisal During the appraisal the individual's past and future work and activities are considered. Through experience we each develop our own idea of what appraisal is for, how it works and how it should work. The difficulty is that there are many definitions of these terms, probably as many different definitions as there are organisations and employers and perhaps as many definitions as there are people who have been appraised. When there are so many different versions of what something means, it is natural to think that 'my definition' is the right one and that everyone else's is wrong, or at least not as good. We hope to take a more pluralist view of appraisal. Because appraisal means so many different things to different people, we need to define carefully what we mean by appraisal. We have to be able to situate our version of the process among all the other possible versions. We have to do this so that we can communicate our ideas to other people, we have to do this before we can be clear, ourselves, about what we are doing and why. Having said that, the principles of e-appraisal that we have worked with can be applied more broadly - to nurses, primary care administrative staff, secondary care and even other domains. In exploring all the different possibilities of what 'appraisal' means, we will look at all the different 'appearances' that appraisal can have. This will allow you to situate your own view of appraisal in the broader context. The way that we will do it is to use our specific case (the

What and where is appraisal? • 15

appraisal of GPs in the UK) as an example, which you can generalise or transfer to your own context.

Dimensions of appraisal Part of the uncertainty about what is meant by 'appraisal' is that there are several concepts and terms that overlap. Each term has different overtones and undertones, some clarity is required. The range incorporates: mentoring appraisal monitoring assessment performance management. In illuminating the differences and the similarities, let's consider the following dimensions. Who is driving the process? Who is listening to whom? Who provides evidence? Who 'does' the appraisal? Performance development or performance assessment? What are the links to pay? What are the links to education and training? How does appraisal fit in with mentoring?

Who is driving the process? Appraisal is usually, though not always, driven by 'management'. This normally is the employer, which means that, whether the appraisal is voluntary or compulsory and whether or not there is an overt link to pay and promotion, the individual who is appraised is likely to think that their job is on the line. Voluntary, peer-led appraisal has been described in general practice, but it is not clear how widespread this is.2 The process may be completely formalised so that every appraisal in the organisation is identical. On the other hand, the person being appraised may be able to choose the topics for discussion, who does the appraisal, what is recorded and what, if

16 • e-Appraisal

anything, is passed on to a third party or to management. Equally, the appraiser may be given discretion in the way s/he runs the process.

Who is listening to whom? The question here is whether the purpose of the appraisal is for the appraiser (and therefore the organisation) to find out about the individual, and so influence his or her behaviour, or is the organisation listening for ways to improve itself?

Who provides evidence? Does the appraisee prepare and gather evidence about their performance? Does the appraiser present performance data that has been collected? Are colleagues, clients, suppliers and patients invited to comment or provide evidence (360 degree)? If so does the appraiser or the appraisee invite them?

Who 'does' the appraisal? Traditionally, line managers or human resource (HR) personnel lead appraisal. This is particularly likely in hierarchical organisations. Professionals, such as GPs, may think that appraisal by a peer is more appropriate. Is the appraiser someone from within the individual's team or partnership (internal appraisal) or an outsider (external appraisal)?

Performance development or performance assessment? This is perhaps the key dimension, and it is highlighted in the ScHARR report.3 It reflects the philosophical purpose of appraisal. Performance development implies that the purpose of appraisal is to enable the individual to develop themselves and their role in the organisation. In educational terms, this is a formative approach: • • •

what are your learning needs in relation to your work? how can the organisation help you to meet them? how can the organisation change to help you do your job more effectively?

The other end of the scale is the idea of performance assessment, now embodied in 'performance management'. This is more of a summative approach:

What and where is appraisal? • 17

• have you met these targets? • Are you doing what you should be doing? Formative, developmental, appraisal implies open questions: 'how do you think you are doing?', 'tell me about your opportunities for learning'. Performance assessment implies closed questions: 'are you meeting your targets?' (yes or no). The ScHARR report describes a general trend in appraisal away from performance assessment towards performance development. The report cites evidence for this, but other professional groups may disagree. Teachers in England and Wales, for instance, have worked with developmental appraisal for the last nine years or so, and are now being introduced to performance management. Among practitioners in the health service, there is the view that while the official language around appraisal may be developmental, the 'hidden agenda' is performance management.

What are the links to pay? Does appraisal inform promotion and pay prospects (formally or informally)?

What are the links to education and training? Does appraisal lead to opportunities to take part in education and training? Are these opportunities adequate, are they well resourced and funded?

How does appraisal fit in with mentoring? The first use of the word 'mentor' is reputed to be in Homer's Odyssey. Very briefly, a mentor, in this context, refers to a trusted, experienced other. The role is to help with strategic decision-making in the person's journey through life or career. It is specifically not to give advice, it is more a way of facilitating decision-making. The focus is entirely on the individual's development. Unlike appraisal, mentoring is not situated within a context such as work, it is much broader than that. Mentors can be peers, but often they are older, senior and more experienced. The key point is that the individual seeks out the mentor, and sets the pace and the tone of the process. Mentoring shares many of the features of non-directive counselling and formal supervision (as used by psychotherapists). Counselling and supervision are focused on emotional aspects and the relationship is often therapeutic. In Figure 3.1, they would be further to the top and left, beyond

18 • e-Appraisal

Figure 3.1 How appraisal, mentoring and performance management fit together.

mentoring but overlapping with it. It is crucial for appraisers and appraisees to appreciate that all these different terms overlap and that it is possible for an appraisal relationship to drift towards mentoring and possibly counselling. If that should happen, it should be explicitly acknowledged. Generally speaking, if a need for mentoring or counselling comes to light it is better for that role to be taken on by someone else, either that or find another appraiser. We do not think that a mentor or a counsellor can be an effective appraiser. Our reason for saying this is that individual and organisational considerations have to be given equal weight in appraisal and a mentor or counsellor is so focused on the individual that it is extremely difficult to balance this with organisation's needs.

Situating GP appraisal Who is driving the process? It is a stated aim of the Department of Health that all GPs should undergo an annual developmental appraisal, and this is now part of the

What and where is appraisal? • 19

GMS and PMS Terms of Service. Overall responsibility for appraisal will rest with the Chief Executive of the primary care trust. Although Personal Medical Services (PMS) contracts and the rising numbers of non-principals and part-timers are beginning to alter the status quo, it is still true that the clear majority of GPs are self-employed and working in partnerships. This means that GP appraisal, although driven by 'management' is not driven by the employer. As we will discuss later, appraisal in the GP context cannot be considered on its own. Clinical governance, revalidation and target setting (in both PMS and General Medical Services contracts) are also part of the picture. Of course, all of these are being driven by the Department of Health nationally and the primary care organisations (PCOs) locally.

Who is listening to whom? GP appraisal is intended to be a dialogue. As well as finding out what GPs need to improve their practice, one purpose of appraisal is to feed back (aggregated and anonymous feedback in some circumstances) to 'management' about what resources are required to achieve this. The processes for this need to be explicit to the appraisee and appraiser in order to maintain trust.

Who provides evidence? The emphasis in GP appraisal is on evidence provided by the appraisee as part of a reflective process. Some information, such as prescribing data or immunisation targets, is already being collected by the PCOs, and this evidence should also be available in the appraisal meeting.

Who 'does' the appraisal? This is at present unclear. In some localities, senior GPs, often with an educational and GP training backgrounds, are coming forward as appraisers. In other areas, the emphasis is more on peer appraisal. Finally, there is the suggestion that the appraiser does not need to be a GP at all. In some ways the skills and training of the appraiser are more important than their professional background. The Department of Health guidance on GP appraisal specifies that the appraiser should be a GP from the same area, though not necessarily from the same PCT. Many practitioners are concerned that their appraiser should understand their particular type of practice, since different contexts of primary care (e.g. small inner city practices) have particular sets of problems and needs. Clearly the availability of appraisers is a key

20 • e-Appraisal

issue for the process as a whole, as is the acceptability of individual appraisers to the practitioner concerned. It may well be that current guidance on who 'does' GP appraisal will be reviewed in the light of experience.

Performance development or performance assessment? The ScHARR report and policy statements from the Department of Health clearly state that the purpose of GP appraisal is performance development. The appraisal discussion should not be seen as the vehicle for dealing with performance problems. Stewart and Stewart (1983) indicate that it is rare for an organisation to have a well thought out policy on poor performers and even rarer to find one which trains managers to deal with them. In that context, the temptation to use appraisal for identifying and dealing with poor performance, in the absence of other acknowledged processes, is understandable. But the 'best practice' message is that performance problems should be coped with as they arise within the framework of a separate, explicit approach. Storing up serious problems for appraisal is obviously very risky for the organisation. It also diminishes the value of appraisal by casting it as a faultfinding, troubleshooting process and surrounding it with an aura of threat.

Source: Martin D et al.3 The important point here is that appraisal is being introduced along with revalidation, clinical governance and contractual issues. The question of whether a practitioner is meeting minimum standards of performance (summative assessment) belongs in the revalidation process and is also a contractual matter. Clinical governance consists of a series of processes by which quality of care can be monitored and improved. The aim of appraisal is to provide a structured process by which an individual practitioner's learning needs can be defined, and plans can be made to meet those needs.

Appraisal is there to help all practitioners to raise their standards and develop themselves as professionals. It is clearly at the performance development end of the spectrum.

Links to pay In appraisal for GPs in the NHS the emphasis is on the formative aspects. Appraisal is concerned with helping practitioners to achieve their poten-

What and where is appraisal? • 21

tial. Links between pay and performance are mediated through the contracting process, whether that be the current General Medical Services (GMS) and Personal Medical Services (PMS) contracts or the 'new contract' that is due to be introduced in 2003/2004. Undergoing the appraisal process is now a contractual requirement for GPs. In this sense it is linked to pay, since failure to be appraised will be a breach of contract. There is, however, no link between rates of pay and the immediate outcome of the appraisal.

What are the links to education and training? Appraisal of this sort is all about links to education and training. The first stage of this is to consider the individual's learning needs in the context of their work in the health service, nationally and locally. Once the learning needs are defined and refined in the appraisal meeting, they need to be met and the learning that has taken place is reflected on as part of the next definition of learning needs. This is a continuous, helical process that we shall refer to throughout this book.

How does appraisal fit in with mentoring? As we discussed earlier, the territories of appraisal and mentoring may overlap. It is best to keep the process separate. An outcome of appraisal may be the realisation that an individual practitioner may benefit from either mentoring or counselling. This mentoring should be provided separately from the appraisal. Many deaneries coordinate mentoring services for GPs through the network of GP tutors. Counselling services are available locally and through professional bodies nationally.

References 1 2 3

Grant J, Chambers E and Jackson G (1999) The Good CPD Guide. Joint Centre for Education in Medicine, London. Jelley D and van Zwanenberg T (2000) Peer appraisal in general practice: a descriptive study in the Northern Deanery. Educ Gen Pract. 11(3): 281–8. Martin D, Harrison P and Josebury H et al. (2001) Appraisal for GPs. School of Health and Related Research, University of Sheffield (www.doh.gov.uk/ gpappraisal).

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4 Appraisal and the educational framework Key points covered in this chapter • A beginner's guide to appraisal - what it is and what it is not •

So why aren't we doing It al ready ?

• An educational framework for appraisal • .Describing and defining learning needs • Making learning effective The aim of appraisal is to provide a structured process by which an individual practitioner's learning needs can be defined, and plans can be made to meet those needs.

A beginner's guide to appraisal In the last chapter, we gave you some ways of defining appraisal. We went on to describe GP appraisal and show how appraisal, as a formative and developmental process, fits in with other initiatives that are intended to improve quality in the health service.

24 • e-Appraisal

Appraisal provides the individual with the opportunity to make sense of their work and to plan ways of learning how to be more effective. Revalidation and contracts represent the checks on performance. Clinical governance supports practitioners and teams in the task of providing the best possible care for their patients. All of this is very worthy, but it is a bit abstract. Where do I start? If it's so good and so obvious, why aren't we doing it already?

So why aren't we doing it already? We'll take the second question first. General practice in the UK developed as a cottage industry. When the NHS was introduced in 1948, nearly all GPs worked as single-handed practitioners or in small partnerships; they nearly all worked from their own homes, they had little or no help with clerical or reception tasks, and they retained their self-employed status. Antibiotics had recently been introduced and transformed the management of infectious diseases, but most other aspects of investigation and treatment were primitive and limited by today's standards. The doctor-patient relationship was the crucial therapeutic tool, with trust and the placebo effect its most important components. In the last 50 years or so much has changed. There has been enormous development of medical technology; GPs mostly work in groups of four or more partners, in purpose-built premises. Primary care is seen as a multi-professional, team-based activity. Successive re-organisations have moved GPs closer to a managed service and the autonomy and authority of 'the professional' has been increasingly questioned by society. Much of this change is external to the key aspects of general practice. The GP remains, in his or her own eyes at least, in charge of patient care, remains self-employed and usually owns the premises s/he works from. Consultations take place behind closed doors. Trust, the placebo effect and the doctor-patient relationship remain paramount. Whether it is because of cost, lack of availability, waiting lists or lack of knowledge, the implementation of new medical technology remains patchy. External threats, such as the rising number of complaints, tend to encourage GPs to be defensive rather than open. The transfer of work from secondary care and increased public awareness of health issues make GPs busier. So, it is perhaps not surprising that GPs have not widely taken up appraisal. Appraisal depends on having time to think and time to reflect. It requires openness and a willingness to discuss your work (your devel-

Appraisal and the educational framework • 25

opment needs as well as your strengths) with someone else. It also requires a willingness to change and adapt. GPs as dominant professionals with a dependant clientele work in an environment that encourages the status quo rather than change, as well as being overloaded and put on the defensive by a blame culture. There is a way to go. So, where to start?

An educational framework for appraisal Our approach to appraisal is based on an educational framework so we will start with 'learning needs'.

Learning needs A lot has been written about adult learning, and the works of Brookfield and Knowles are often quoted.1,2 Adult learning theory says that learning is most effective when the learner perceives that the topic is relevant and interesting. Frequently this is taken to be the same as learner-centred education (as opposed to teacher-centred). This learner-centred view is taken to be the learner deciding what to do and when to do it. It is about 'felt needs' or 'wants'. In our view this is explicitly not an adult approach to learning. Our definition of adult learning uses the word 'adult' in the same way as it is used in transactional analysis. Here transactions between individuals are characterised according to roles of 'parent', 'adult' and 'child'. Education in schools and medical schools is often organised as teachercentred, that is, the teacher decides on what is taught, how it is taught and when. As a transaction this is 'parent-child'. The opposite approach, letting the learner do what s/he wants without regard to external influences, is also childlike: it's the equivalent of letting an eight-year-old loose in a toy shop. If you look at educational planning and delivery as an 'adult-adult' transaction, it implies that the learner is taking a share of the responsibility for the decisions about the learning and is acknowledging that other people also have a role in this. In the case of education for practitioners there are five groups who have a stake in the what, how and when of any work related learning that takes place: 1 learner 2 colleagues

26 • e-Appraisal

3 client 4 teacher 5 institution.

Making learning effective For any learning to be effective, both the learner and the teacher have to value what is being done and have some ownership of the process. In the special instance of work-related learning the other groups need to be taken into account too. Professional development is about learning how to work more effectively, and about keeping up to date. The practitioner's clients and colleagues have an interest in what the practitioner gets out of professional development and have their own views of what the practitioner's needs are. This is what is meant by service-led education, and it is a key component of clinical governance. Finally, the educational institution has an interest in the quality of the learning that takes place in its name, particularly if there is some form of certification or award for the learning.

Defining learning needs: how appraisal helps The aim of appraisal is to provide a structured process by which an individual practitioner's learning needs can be defined, and plans can be made to meet those needs.

The different stakeholders in practitioner education all have a different vision of what the practitioner's learning needs are. The key task for appraisal is to bring these different visions together. The outcome of this is an agreed programme of learning - the personal learning and development plan (PDF). The PDP is of no use if the practitioner does not sign up to it. S/he will not learn if s/he does not see the relevance of the learning. This is why a formative approach is essential for this type of appraisal. If the practitioner is told what to do, and does not see the relevance, then effective learning will not take place and there will be no personal development. At the same time it is very difficult for the practitioner, working in isolation, to place their work and aspirations in a broader context. In a busy environment, such as primary care, day-to-day things demand so much attention that there is no time to stop and reflect on what is happening. This is a source of frustration to practitioners, because they want to do the best for their clients. The problem is one of opportunity (constrained by heavy workload) rather than motivation.

Appraisal and the educational framework • 27

There are five key ways in which appraisal can help in defining learning needs. 1 By enabling a structured and sequenced process for the practitioner to follow. 2 By providing the opportunity to stop and think and to reflect on one's work. 3 By offering the opportunity to take advantage of the specific skills that the appraiser brings to the process. 4 It helps to have someone else to talk to. 5 The appraisal meeting acts as a deadline, which encourages the practitioner to get on with the task rather than put it off.

Defining learning needs: how e-appraisal helps We have described the definition of learning needs as the bringing together of a number of different strands - the priorities of the different stakeholders along with the immediate and more considered reflection on the part of the practitioner. One way in which information technology can help is by making information from diverse sources available on your desktop when you want it. Instead of paper documents, such as National Service Frameworks, Health Improvement Plans, Practice Development Plans, Personal Learning Plans, being difficult to find in the bottom of a drawer or the back of a filing cabinet, they can be available on-line at the click of a mouse. The other way that information technology helps is through the electronic appraisal record (EAR). We will describe this more fully in the next chapter. The EAR helps by allowing the practitioner to record aspects of his or her practice all in the same place, such as audit meetings, significant events analysis, prescribing data and his/her reflections on this data. In addition, because the electronic record is available throughout the year, prompts and issues that crop up can be recorded at the time and on a medium that allows easy retrieval.

How e-appraisal helps define learning needs • •

By bringing the views of different stakeholders together in one place. By letting the practitioner record data, and his/her thoughts about it in the same place. • By being available year round, it encourages the recording of ideas and needs when they arise.

28 • e-Appraisal

References 1 2

Brookfield SD (1986) Understanding and Facilitating Adult Learning. Open University Press, Milton Keynes. Knowles MS (1985) Andragogy in Action. Jossey Bass, San Francisco.

5 The art of appraisal I Key points covered In this chapter What appraisal offers The Johari window revisited •

Roles in appraisal - the appraiser and the appraisee

* The appraisal meeting After the appraisal How e-appraisal helps Appraisal offers a number of opportunities and benefits to the clinician, including: • • •

a structured and sequenced process the opportunity to reflect someone to talk to (the appraiser).

Appraisal offers a structured and sequenced process The basic sequence of appraisal is summarised in Box 5.1.

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Box 5.1 Process of appraisal 1 2 3 4 5

Preparation. Appraisal meeting. Learning and development plan. Learning and development. Preparation.

This is a helical process, the learning and development that follow one appraisal meeting inform the preparation for the next round of appraisal. The appraisal meeting is where the joint definition of learning needs is agreed and plans are made for future learning and development. Essential to the appraisal meeting is the preparation done by the practitioner: the key components of this preparation are shown in Box 5.2.

Box 5.2 Process of appraisal: preparation 1 2 3 4 5

Consider contexts and priorities. Reflect on own practice. Use tools to assess own practice. Reflect on assessment findings. Prepare written statement to appraiser.

Appraisal offers the opportunity to reflect The essence of preparation is to reflect on your own practice in the light of broader contexts. In primary care in the NHS there is a hierarchy of contexts. These are: •

national policy, expressed in National Service Frameworks, White Papers and documents from the Chief Medical Officer • health authority and primary care organisation policies and documents, health improvement plans, care pathways etc. • practice development plans, protocols and targets • personal development, as summarised in the previous personal learning and development plan It is possible to reflect on the previous year's work from memory and experience as a purely mental exercise, but it is often easier to work from

The art of appraisal I • 31

a written source. This may simply be an account of what you have done over the last year, and that is usually the best place to start. Often when you come to write this down you are surprised by how much has happened. Often, too, you will compare what you have done with the various broader contexts and priorities and this may lead you to look at some simple ways of assessing what you have done. For instance, you may be reminded of a practice prescribing policy to use shorter courses of antibiotics for urinary tract infections and do a simple audit on your GP clinical computer system to check on how well you have kept to this.

Appraisal offers someone to talk to Even with the best of intentions the pressures of daily work are often such that stopping to think and reflect are never at the top of your list of priorities. You know that it is important, but you really do have to get on with today's work. One of the main benefits of having someone come in to do your appraisal is that it forces you to give the process of reflection some priority and it dignifies it with some importance. Another benefit of having someone to talk to is to do with story telling. Presenting a narrative to someone else alters the way that you see the story yourself, it is a way of learning. We will talk about this more in Chapter 6. Finally, the appraiser is able to give you feedback in the appraisal. Giving and receiving feedback is a crucial part of teaching and learning. The Johari Window is a model that neatly summarises this in relation to learning needs (see Figure 5.1).

The Johari window The Johari window is a very useful model for thinking about all this, and it particularly relates to self-awareness. The working area is called the 'arena'. To the right of this is the person's blind spot - here there are things that s/he does not know about her/himself but others can see these. Below the arena in the diagram is an area called facade - here the person knows things that s/he is not prepared to share. In relation to learning needs, the blind spot contains needs that you are unaware of. You may not know about a particular set of resources, or you may not know how they could be used by someone like you. In the facade area are needs that you acknowledge to yourself, but find it difficult to acknowledge to other people.

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Figures 5.1/5.2 The Johari window. One aim of appraisal is to increase the area of the arena section. The blind spot is reduced by feedback, the arena is reduced through disclosure and these processes of feedback and disclosure are inter-related through trust. If someone gives you honest feedback that rings true, then you will trust them a bit more, and so will be prepared to disclose things to them. This then makes it easier for them to give you appropriate feedback and so on. It is clear from this that the relationship between the practitioner and the appraiser who is sharing the information is very important. With the Johari window: • • • • •

the aim is to increase the size of the arena the blind spot is reduced by feedback facade is reduced by disclosure feedback and disclosure work together and are interdependent both feedback and disclosure depend on trust.

Roles in appraisal So far in this chapter we have worked from the premise that the purpose of appraisal is to provide a structured process by which an individual practitioner's learning needs can be defined, and plans can be made to meet those needs. We have explained how a formal process can help ensure that practitioners are able to take the time to stop and reflect on their work, and how the presence of a 'trusted other' can enhance the process. We will now take a more detailed look at the role of the appraiser and the appraisee.

Openness Using appraisal to define learning needs will only be effective if the process is an open one. This depends on trust and trust takes time to

The art of appraisal I • 33

develop. Trust can be nurtured by the way that appraisal is structured, for instance by making the information flows transparent and by making the rules of confidentiality between appraiser and appraisee explicit. Trust is also influenced by the culture of the organisation more generally, in particular by the attitude to mistakes - is there a blame culture (blaming individuals for errors) or a systems view (how can we prevent this from happening again?)? The appraiser has a key role in developing trust and openness. This depends largely on the way that feedback is given in the appraisal meeting. For the practitioner who is being appraised the task here is to be open and frank about your strengths and weaknesses. It is unrealistic to expect full disclosure when appraisal is first introduced. Trust takes time to develop and, as we mentioned in Chapter 3, there are many reasons why GPs may not find it easy to talk openly about their work. Not least of these is the point that GP consultations take place behind closed doors. GPs are used to working with patients on their own, they are not used to discussing their work with outsiders.

Preparation There is a truism in education that assessment drives the curriculum. Similarly, with appraisal, the documentation drives the process. The forms given to the appraiser to assist in the preparation of the appraisal statement (which is the documentation submitted to the appraiser before the meeting) will influence the way that the practitioner does the preparation. This influence is in terms of both the aspects of practice that are looked at and also the spirit in which this is done. In the first cycle of appraisal the appraiser's role is restricted, although the practitioner may be grateful for the offer of help and support with tackling the documentation. However, the way that the appraiser responds to the preparatory work done by the practitioner will have significant bearing on what happens in future cycles of appraisal. For the appraisee the task is to provide as much information as they feel comfortable to share.

Roles in the appraisal meeting In the appraisal meeting the practitioner's work, hopes and concerns are presented in the form of documentation and discussed verbally. What starts as a subjective account is translated into a plan for learning and development and this plan will fit in with the broader requirements of the organisation and service.

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The appraiser's role in the meeting is in part facilitative, encouraging the appraisee to talk openly about his or her work. The second aspect of the appraiser's role is to give feedback. The manner in which the feedback is given should encourage trust and openness. The content of the feedback should assist the translation of the practitioner's story into a coherent set of learning objectives. Finally, the appraiser's task is to help the practitioner plan the learning that will help him/her to meet those objectives. The planned learning should be appropriate to the individual's needs and preferred learning styles. The appraisal meeting may be stressful for the appraisee. However confident one is of one's own worth it is still daunting to have your work scrutinised by someone else. The appraisee's task in the meeting is to participate and contribute, and be open to suggestions.

Roles after the appraisal The appraisal meeting is unlikely to produce a polished finished version of the personal learning and development plan (PDP) for the next year. The meeting is busy and both parties need some time to chew over what has happened. There also needs to be some checking that both appraiser and appraisee have the same understanding of what was agreed in the meeting. The standard way for this to be done is for the appraiser to prepare a summary of the meeting and then give the appraisee the opportunity to amend and then approve the summary. In a reciprocal way, the appraisee produces a personal learning and development plan and then passes that to the appraiser for approval. When these two documents are signed off by both parties the formal part of that year's appraisal is completed. The practitioner's job now is to act out the development plan, record the learning activities that evolve from it, and weave this into the preparation for the next year's appraisal. The helix turns on itself.

How e-appraisal helps An Electronic Appraisal Record (EAR), such as that in the NHS Appraisal Toolkit (www.appraisals.nhs.uk) assists and facilitates appraisal at every stage. It is readily available throughout the year and its memory means that items need only be recorded once; it brings information of different sources and of different types together in one place, where it is all readily

The art of appraisal I • 35

accessible. More specifically it helps in each of the stages of appraisal that we have just outlined.

Preparation • • • • •

Offers guidance and background information. Structures the process for the practitioner. Allows the practitioner to record things as they happen. Brings different types of information together. Automatically generates the appraisal statement in the format prescribed by the organisation.

The appraisal meeting • •

Is a reference, which can provide information during the interview. Can be used to generate a profile of the practitioner's needs, this can be used to inform the decisions about learning needs and the appropriate ways to meet them. • If appropriate software is used, decision support can be provided here.

36 • e-Appraisal

After the appraisal •

The appraiser's summary and the fair draft of the PDP can be generated electronically, and viewed by both appraiser and appraisee on the system. • The practitioner can record their learning activities, and amend the PDP as the year unfolds. • The system can aggregate the learning needs of practitioners in a particular area, and this information be used to help providers of education and training to plan courses.

6

The art of appraisal II Key points covered in this chapter The art of appraisal » Bringing worlds and: stories.,together

••

The personal learning and development plan (POP) Confidentiality and openness ••» The appraisalmeeting • '

;

» Communication in the appraisal meeting ' How to reflect and methods of reflection * Utilising information and the appraisal statement in the appraisal meeting

The art of appraisal In the last three chapters, we have described appraisal as a structured process by which an individual practitioner's learning needs can be defined and plans can be made to meet those needs. In Chapter 4, we looked at learning needs and the different stakeholders in a practitioner's education and development. The purpose of appraisal is to bring these different aspects of the individual's learning needs together, put them

38 • e-Appraisal

into a coherent learning plan, and then review the learning and development that takes place. The way that appraisal can do this is summarised in Boxes 6.1 and 6.2. Box 6.1 Process of appraisal 1 2 3 4 5

Preparation. Appraisal meeting. Learning and development plan. Learning and development. Preparation.

Box 6.2 Process of appraisal: preparation 1 2 3 4 5

Consider contexts and priorities. Reflect on own practice. Use tools to assess own practice. Reflect on assessment findings. Prepare written statement to appraiser.

Bringing two worlds together Presented in this sequential way, appraisal looks like a mechanical process or a production line. That is too much of a simplification. Another way to describe appraisal is as the bringing together of two different worlds. On the one hand there is the world of the clinician, who is dealing with scores of different problems every day. Each problem is important and individual and demanding of attention, the practitioner is trying to do the best for each client. There is little time to think about more general policies or protocols. On the other hand are different versions of the organisational world - the practice, the health authority or PCG/T, the NHS - all representing colleagues, clients and the institution. The practitioner's story, grounded in day-to-day detail, has to be reconciled with the organisational stories of plans and policies, consistency and quality. Bringing these stories together, making the narratives intertwine, requires art as well as a production line. This chapter is about the art of appraisal and how it features in all of the different aspects of the appraisal process.

The art of appraisal II • 39

Personal learning and development plans (PDPs) The personal learning and development plan is the key output of the appraisal process. Years ago, a professional qualification such as the MB BS (Bachelor of Medicine, Bachelor of Surgery) marked the end of formal learning for many practitioners. The exams were appropriately called 'finals'. As recently as 1989 it was possible to become a principal in general practice with no further qualification, completion of the pre-registration year was the only other requirement for independent practice. The introduction of mandatory vocational training, summative assessment, and now revalidation, constitute a formal recognition of a broader truth. This is that healthcare professionals (including doctors) are embarked on a process of lifelong learning. This is necessary to help the practitioner cope with external change. Change is constant in the professional knowledge base, as new discoveries add to and supplant the knowledge of previous generations. Change is also taking place in society, culture and attitudes to medicine as well as the context of work represented by re-organisations of the service. Lifelong learning is also necessary to help the practitioner cope with internal change. As the practitioner gathers experience s/he changes: the 50-year-old GP is not the same person as the 30-year-old who began in practice. Personal learning and development plans are a medium term statement of learning objectives and ways to address them. They reflect the fact that learning objectives change through the practitioner's career. They are based on the learning needs that emerge from the appraisal, and so constitute an agreed output of the appraisal that has to be signed off by the appraiser and appraisee. We are working on the assumption that appraisal is an annual process. Learning needs will evolve over the year, and the personal learning and development plan will need modifying as the year goes on. New learning needs and development objectives will emerge throughout the period. So the development plan should be a dynamic document, and reflect changing needs on the part of the individual practitioner as well as changing needs and priorities on the part of the service. Finally, the amended personal learning and development plan will feed into the next appraisal at the end of the year.

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Table 6.1 A personal development plan template What development needs have /?

How will l address them?

Date by which l plan to achieve the development goal

Outcome

Completed

Explain the need.

Explain how you will take action, and what resources you will need?

The date agreed with your appraiser for achieving the development goal.

How will your practice change as a result of the development activity?

Agreement from your appraiser that the development need has been met.

1

2

3

4 etc.

The art of appraisal II • 41

The personal development plan in the NHS Appraisal Toolkit. Personal development plans are: • • • • •

a medium term snapshot of development needs and learning plans that change over a working life the agreed output of the appraisal dynamic: amended and reviewed throughout the year dynamic: reflecting changes in the individual and in the service a starting point: the amended version feeds into next year's appraisal.

Within a practice, individual personal learning and development plans may be collated and contribute to the practice development plan. This is a two-way process, the individual and the practice plans having influence on each other. The input of locums, for instance, into a practice plan may be limited, but theirs is a voice that should be heard.

More on the Johari window We introduced the Johari window in the last chapter and showed how feedback and disclosure are related to each other and how both work

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Figure 6.1 The Johari window together to increase the size of the arena, that is the range of topics that is 'in the open'. It is trust between the appraiser and the appraisee that allows this to happen; defensive attitudes prevent it, or inhibit it. One essential component of this trust is the relationship between the appraiser and the practitioner and we will focus on that in the next section. The other essential component relates to confidentiality, how much of the appraisal discussion is private between the appraiser and practitioner and how much is shared with colleagues and management?

Confidentiality, openness and trust If the learning and development plan that emerges from an appraisal is going to be meaningful and useful, it has to reflect the concerns and ambitions of the practitioner. The practitioner is required to discuss strengths and weaknesses. This means disclosing things that are normally private. This is not always easy to do, and the appraiser has a key role in facilitating an open discussion. The rules about what information remains private to the appraiser and appraisee may vary in different systems of appraisal and depend on the context. We discussed the possible scope of appraisal in Chapter 3. In a context of performance assessment, in an organisation where performance targets are openly discussed, it may be that large parts of the appraisal discussion would be expected to be shared through the organisation. In a formative context, where more personal hopes and fears are part of the discussion, the extent to which the conversation is shared may be more limited. The crucial thing is that both appraiser and appraisee are clear about the extent of the privacy that surrounds the appraisal. There has to be

The art of appraisal II • 43

transparency about what information goes where. Plainly this is mainly to do with the culture of the organisation in question. As we have discussed earlier, the NHS has historically adopted a blame culture, although one of the key aims of clinical governance is to change this towards a systems-based approach. GPs are used to working on their own, and appraisal of doctors in the NHS is intended to be formative and developmental, with revalidation, clinical governance and contracts being in place to monitor delivery.

Confidentiality in e-appraisal People are concerned about the security of information that is held electronically. Concerns relate to the storage of information on databases, which can be hacked into, and electronic transfers of information, which can be intercepted. Neither paper systems nor electronic systems can be made 100% secure, and it is perhaps familiarity that makes people feel more confident about paper systems, although this confidence is probably unfounded. In a paper-based appraisal, the appraisee will send his/her preparatory documentation to the appraiser by post, probably to another office and probably opened by a secretary and passed on to the appraiser. After the appraisal the appraiser's summary may well be typed up by a secretary, posted to the appraisee's office and opened and left in an in-tray. Appraiser and appraisee's copies of the documentation may then be stored in filing drawers. In the paper-based world, there are a lot of opportunities for casual sharing of the information in the documents. In the electronic world the concerns are more with deliberate attempts by unauthorised outsiders to get hold of the information in the records. Steps can be taken to make the electronic system secure. •

Secure servers to house the databases of appraisal records. This refers to physical access (locked room in a secure building) and electronic access (firewall and passwords). • Secure transfer of data between computers, using encryption. • Password protection of data on the user's computer, and good practice on the part of the user. By good practice, we mean locking the computer every time the user leaves the desk, keeping passwords private and other good-housekeeping measures. • Design of the system so that it is clear to the user just who has access to different documents and files on the system.

44 • e-Appraisal

However good these security measures are, they depend on people being careful about what they do. The transfer of documents between appraiser and appraisee in an electronic system is more private than in a paperbased system, but there is still a particular responsibility on the appraiser. Whichever route documents take to the appraiser's desk, they will still be filed in places where other people may be able to look. Whatever the history of the documents, some of their content will be in the appraiser's head and s/he has to be careful not to disclose information unwittingly.

The appraisal meeting The appraisal meeting is the centrepiece of appraisal. It is the forum in which information prepared by the appraisee is discussed, perhaps along with performance data, by the appraiser and practitioner. The main output from the appraisal meeting is the personal learning and development plan. The result of the appraisee's preparation may be a well-structured learning plan, but it may just as well be a less tidy mixture of aspiration and dissatisfaction. In either case the appraisee's initial offering is going to be subjective and personal. The shared task of the appraisal meeting is to translate this into a plan that serves the needs of the individual and of the service and the organisations. In addition to the facilitation of this shared task the appraiser also has the responsibility of keeping the process on track, making sure that the practitioner's subjective account is considered in light of the appropriate contexts and that there is movement towards a realistic set of learning objectives. At the end of the session the appraiser needs to check out that the personal learning and development plan that is generated really does represent what the appraisee means. This part of the appraisal relies on general communication skills. Many GPs will be familiar with the application of communication skills theory to the consultation.

Communication in the appraisal meeting The following guide to communication in the appraisal covers similar ground.

The exchange An appropriate exchange during an appraisal discussion may go something like this:

The art of appraisal II • 45

Appraiser

Practitioner

Giving general information Seeking general information Clarify Seeking general feelings Clarify Giving support/feelings Seeking effects Clarify Seeking proposals

Giving general information Clarify Giving general feelings Clarify Giving general information Clarify Giving proposals

Building Clarify Summarise

Giving proposals Clarify

It is clear from this table that this is a dialogue, and both parties do their share of listening, information giving and clarifying. The skills identified below are needed by both.

Giving information Information giving is more likely to be successful if the speaker and listener are on the same wavelength, if the information is broken down into manageable chunks, and if the speaker checks from time to time that s/he has been understood. 'Listen before you tell' is a good general rule. There are two types of information giving that have a specific purpose: Support/feelings. This is usually encouraging or congratulatory statements or recognition of feelings. For example, 'Good! That's challenging, but still realistic', or 7 understand you were particularly concerned about ...'. Empathic statements are often helpful in this context: 7 can see that you are concerned about...'. Building. Any statement that slightly modifies or adds to any idea or suggestion made. Be accepting, rather than dogmatic - individuals will be more motivated to execute a plan of action if it has been their idea. For

46 • e-Appraisal

example, 'That's a useful suggestion, and you could also use it in next year's development plan.'

Clarifying information Make sure that you understand what was said and reassure the speaker that you were listening. Here are two ways to do this: Paraphrasing. Restate what was said using different words, so you can confirm your own understanding and the speaker can correct any misunderstandings. Summarising. At key points in the discussion it is important to summarise the areas covered in a brief form. This aids understanding and also gives structure to the discussion.

Seeking information Active listening.

• Encourage people to talk by not talking yourself. • Make listening noises like, 'mmm .. ', 'yes • • •' and 'go on ...' . • Use positive body language like sitting forward, nodding and making eye contact. • Listen to what they say by eliminating distractions. • Attending to what they're NOT saying (body language, tone etc.). • Not thinking about what you're going to say next instead. • Show that you've heard what they've said. Types of question. Open questions start with Who? Where? Why? What? How? They cannot be answered with a 'Yes' or 'No'. Reflective questions encourage further detail or clarification without being overtly direct. They can also be used to express doubt about something that has been said, without directly disagreeing with it. The advantage of this type of question is that it does not risk conflict. For example: Person A: 'Everyone was very pleased with the outcome of that piece of work I did.' Person B: 'Everyone was pleased?'

Direct questions require specific factual responses. For example, 'What specific steps did you take that contributed to the outcome of this project?'

The art of appraisal II • 47

Purpose Some questions have a specific purpose, which is communicated by the form of the question: General information. General questions requesting factual data. For example, 'How do you think you've done against your objectives?' Feelings. Where a value judgement is sought. For example, 'How do you feel you performed in that aspect of your job?' Effects. Where information is sought about the consequences of some action. For example, 'What happens when referral letters you send contain errors or come in late?' Proposals. Where a commitment to action is sought. For example, 'So should we meet in three months time to discuss progress on this?'

The watch outs Bias or prejudice. Make judgements based on the facts, and only evaluate on performance. The halo effect. Letting a recent event positively bias your assessment of a group of events. This can also work with recent negative events. Assumptions. Avoid assumptions based on impressions and memory, rather than factual data. Confusing external factors influencing performance with internal factors. This can happen either to the advantage or disadvantage of the practitioner. Insufficient information or misunderstanding. This can refer to both the appraisal purpose or process, and relates to insufficient information from the e-appraisal sources that informatics can support. Being influenced too much. Over-emphasis on one's own past experience. Taking a microscope to some areas while ignoring others. It is important to take a balanced and overall appreciation and this is an aspect of need appraisal. Avoiding the issue. Constructive criticism is as important as positive feedback. Evasion behaviour can be circumvented by the use of e-reports, searches, audits and reflection on clinical decision-making processes as a focus and prompt for discussion.

e-Appraisal and the appraisal meeting In the appraisal meeting both parties will refer to the appraisal statement, which is the documentation that is prepared by the appraisee and

48 • e-Appraisal

submitted to the appraiser before the meeting. This material can be available in the meeting either on-screen or as paper printouts. One advantage of having the document on-screen during the meeting is that the appraisee can navigate through it and show the appraiser what s/he is referring to. Also, in a system like the NHS Appraisal Toolkit there may well be more information on the electronic appraisal record than has been printed out in the appraisal statement. If the mood of the appraisal is supportive, the practitioner may feel confident to share more information. In addition to this, there are tools that can be specifically designed to be used during the meeting. One example of this is the appraisal checklist. In the NHS Appraisal Toolkit this is a confidence rating scale, which reflects the seven domains of the CMC's document, Good Medical Practice. The appraiser may get the sense in the meeting that one area of the checklist may be particularly relevant to the appraisee. Filling in the checklist during the meeting is then a useful way of profiling the practitioner's needs in that context. The profile that is generated by using the checklist can then be used as a guide not only in defining learning needs, but also in deciding on what is the most appropriate way for that individual to meet them. Decision support software could be used in the course of the meeting to help formulate this part of the learning plan. This is precisely analogous to the use of decision support software such as PRODIGY in the medical interview. Be careful to avoid shifting the contents of your in tray into the appraisal meeting. An electronic appraisal record can help focus the meeting, and carefully prepared results of computer-based audits, searches and reports can be illuminating - demonstrating your appraisal related activity and providing a focus for discussion and reflection.

Preparing for the e-appraisal meeting It is in the preparation phase that the electronic appraisal record (EAR) comes into its own. Paper-based appraisal systems rely on the sending out of forms to the appraisee no more than a week or two before the appraisal meeting. This stimulates a flurry of activity leading up to the meeting. Once the summary of the meeting from the appraiser has been sent everything goes quiet again. It may be 11 months before appraisal is thought of again. An EAR is available throughout the year. We think that the best way to structure the EAR is so that it contains space for the appraisee to record

The art of appraisal II • 49

his or her reflections on things that happen (how this problem could be avoided, how that good idea could be put to use more often, how this activity could be better resourced) as well as a straightforward account of what has happened and the raw data (such as prescribing figures) that describe activity. The advantage of this is that it means that events or ideas can be recorded in the EAR when they happen. A web-based EAR, such as the NHS Appraisal Toolkit, is only one mouse click away for someone with a computer on his or her desk, such as a GP with an NHSnet connection.

How to reflect Methods of reflection Different people prefer different methods of reflection. Some people will jot down notes while others may write more formally. Some people will talk things over with colleagues or with their partner, while others may sit and think, or go for a walk. The key thing about reflection is that it involves thinking about a task when you are not actively engaged in it. Sitting quietly, talking, writing or walking are just different ways of promoting this. Different methods will suit different people at different times. The best way to encourage reflection when you are talking to someone is to give them as much chance to talk as possible. This involves the use of the active listening skills that we outlined earlier in this chapter and, importantly, it entails the use of open questions. For this reason, parts of the appraisal documentation that invite reflection should also use open questions. In appraisal, the aim is to frame the reflection in broader priorities and contexts.

How an electronic appraisal record can help with reflection The electronic appraisal record can help with reflection in the following ways. • • • •

Availability/easy access means that it can be used when needed. Using open questions that invite reflective answers. Framing these questions in broader contexts. Linking the open questions to other parts of the EAR that carry factual accounts of what has happened, or performance data.

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In the NHS Appraisal Toolkit (see www.appraisals.nhs.uk) the appraisal questionnaire forms the backbone of the preparation for the appraisal meeting. The questionnaire invites reflection by the methods listed above. The formal part of the preparation for the appraisal is completion of the appraisal questionnaire. For some the process of completing this questionnaire will stimulate all the reflection required, others would need to use other methods of reflection before they fill in the questionnaire, or they may need to break off part way through. Some prompts to reflection are provided in the Toolkit. • • • • • • •

Lists of local and national priorities. Appraisal questionnaire. The checklist. Review of critical incidents diaries/ significant events logs. Review of audits. Review of practice report or practice professional development plan. Review of the practice as an organisation and working relationships with colleagues. • Review of the personal learning and development plan, log of learning needs, log of completed learning. • Review of feedback from patients. • Review of prescribing data, referral data and other aspects of practice performance. • Review of teaching, management and research activity.

7

Reporting and demonstrating reflecting and showing Key points covered in this chapter * Developing the appraisal statement •

Using information and the appraisal statement in the appraisal meeting

» Signing off after the appraisal •

Using the personal learning and development plan through the year

* Setting objectives, measuring success, regular reviews

It depends how you look at i t . . . This chapter is about perspective. Our interpretation of information depends on the perspective from which we view it. When we present information to other people we have to take into account their perspectives. At the same time, the act of preparing information for presentation

52 • e-Appraisal

to others may alter our own perspectives. Some of the language of this chapter is visual. We explore the task of preparing to present information to another person and talk about how the act of preparation forces you to look at yourself. The metaphor of shop windows and reflection may be a useful one for you to think about, drawing on the way that a glass window lets you see through it and can show you a reflection of yourself.

Shop windows Consider preparing a report of your work as putting your wares in a shop window. Suppose that you have just taken over a handicraft shop, how are you going to show your products to their best advantage? There will be some constraints, like the location of your shop, the size of the window and so on, but that still leaves you a lot of choice. In deciding how to go about this you will want to know what the competition is doing, so you'll go down the street to see what they've got on show. You will also want to get some idea about the shoppers - who walks up and down the street? What sorts of things interest them? What is the best way to get their attention? You will spend some time planning and thinking about what you want to do, but time moves on. You've looked at your stock and decided what you want to display, you've had a look around to see what the competition is doing and worked out (more or less) what you want to do. Your deadline is tomorrow morning and you are working late. Outside it's dark; inside your window space is brightly lit. As you work, moving your stuff around, stopping and thinking, moving it back, you glance up at the big glass pane of the window and you see a reflection of yourself, surrounded by your stuff. Sometimes you will go outside and look in to see what it looks like, but this is a very different view from the reflected image you get from the inside, not least because you are in one view and not the other. The point about this story is that the processes of displaying your wares (i.e. preparing reports for other people to read) is inextricably linked to the process of reflecting on what you have been doing. You reflect on the value of your work, for yourself and for others. In the same way that a sheet of glass can act as a window or a mirror, so the process of presenting information about yourself informs you as well as your audience. The shared reflections are fed back into practice and so improve the quality of practice, this is all part of the clinical governance story.

Reporting and demonstrating • 53

Appraisal and clinical governance That is how clinical governance should work. Its success will depend on practitioners being prepared to share their strengths and development needs openly and honestly. This, in turn, depends on there being trust between people in different parts of the organisation. This is easy to write but difficult to achieve, particularly in large organisations like the NHS. It is also more difficult for practitioners in primary care - who usually work alone with their patient behind a closed door - to share things about their work than it is for practitioners who are used to the more public environment of the hospital ward or outpatients clinic. We have written about the issue of trust and culture earlier in this guide. The role of appraisal is to support practitioners in thinking about their practice and thinking about ways to improve the way that they do things. Appraisal provides this support by encouraging reflection on practice, by offering the opportunity to present both factual data and your reflections on that data to another person, by helping you write a learning and development plan, and by clarifying the resources needed to bring the learning and development plan to fruition. Clinical governance and appraisal go hand in hand. A formative developmental appraisal that is based on the learning needs of the practitioner will encourage trust, openness and sharing, and will gradually change the culture of the organisation. This is the way in which we see appraisal for GPs developing, and the NHS Appraisal Toolkit has been designed to facilitate this development. In the following sections of this chapter we will use the NHS Appraisal Toolkit as the specific example of how reflecting and showing are essential components of appraisal, and how they can be supported by an on-line system.

The NHS Appraisal Toolkit: developing the appraisal statement The appraisal statement is the document that is prepared by the practitioner before the appraisal meeting. It is passed to the appraiser before the meeting and forms a basis for their discussion. In the NHS Appraisal Toolkit, the appraisal statement that is produced is consistent with the GP appraisal forms and the guidance documents developed by the Department of Health. The appraisal statement allows the practitioner to present both 'factual' data and his or her own reflections on that data. It is structured in the following way.

54 • e-Appraisal

The NHS Appraisal Toolkit appraisal statement. 1 Personal details. 2 Details of current medical activities. 3 Record of reference documentation supporting appraisal: • good medical practice (the seven GMC categories: good clinical care; maintaining good medical practice; relationships with patients; working relationships with colleagues; teaching and training; probity; health) • research • report on development action in the past year.

The advantages of a dynamic electronic appraisal record (EAR) The tools in the electronic appraisal record available via the NHS Appraisal Toolkit (www.appraisals.nhs.uk) are: • audit • significant events • prescribing data

Reporting and demonstrating • 55

feedback from patients me and my organisations my learning activities probity health teaching and training research management. One of the most significant advantages of an electronic appraisal record (EAR) is that the appraisal statement is produced automatically by the system, when the appraisee is ready. The appraisal statement is, in effect, a by-product of the data collection activity in the EAR. The data that is entered can be drawn by the system from different parts of the electronic appraisal record. Different users can use the NHS Appraisal Toolkit in different ways because the layout and design where data is entered is not governed by the appearance of the appraisal statement in the way a paper document is. It also means that the practitioner is able to write the story of his/ her last year's work in their own language and the Toolkit will translate that into the appraisal document when the practitioner chooses.

The NHS Appraisal Toolkit: the appraisal questionnaire There are two main places where the appraisee can record information. One is the appraisal questionnaire. This was based on a paper-based system developed by York and Selby PCT and it has been substantially modified as we have developed the Toolkit. The questionnaire has 10 sections: 1 good clinical care 2 good medical practice 3 relationship with patients 4 working with colleagues 5 teaching and training 6 probity 7 management 8 research 9 health 10 overview.

56 • e-Appraisal

The tone of the questionnaire is developmental. The questions are open and encourage reflection. It is designed to encourage the practitioner to tell his or her own story. Throughout the questionnaire, but particularly in the clinical performance section, there are links from the questionnaire to the specific tools in the practitioner tools section of the Toolkit. The purpose of these tools is to provide a place where more factual data are recorded. For instance, the audit tool allows the practitioner to record the date, topic, discussion, action points and review date for each audit done in the practice. Since the on-line Toolkit is accessible throughout the year, practitioners are able to record significant events or learning needs (for example) in the appropriate tool when they arise and reflect on them in the questionnaire section at leisure. Whichever way it is used, the way that the system produces the appraisal statement means that the output will be in the format required for the appraisal. The appraisal statement can be previewed and edited at any time throughout the year. At some point before the appraisal meeting it can be signed off. This means that it is no longer available for editing by the appraisee and it is available to the appraiser, either on paper or as an electronic document.

Using information and the appraisal statement in the appraisal meeting The appraisal statement can be available in the appraisal meeting as either a paper document or on-line if there is an Internet connection available. It is probably easier to share information, and be sure that both parties are looking at the same bit of a document, if the document is on a screen rather than two separate bundles of paper. Another advantage of having the on-line version available is that there may well be parts of the appraisal record that the appraisee has chosen not to include in the signed off version of the statement. As the appraisal meeting proceeds, and hopefully is encouraging the sharing of information, the practitioner may wish to show more information than is on the statement. In addition, there are some tools, for example the checklist and parts of the Me and my organisation tool, that do not contribute to the appraisal statement, but may be of value to the discussion in the meeting. The checklist is a confidence rating scale based on the GMC's Good Medical Practice document. This checklist can be used as a way of profiling needs during the appraisal. If the appraiser thinks that a pattern is emerging from the discussion then running through a part of the checklist may be fruitful in planning future personal development.

Reporting and demonstrating • 57

Signing off after the appraisal The two main outputs from the appraisal meeting are the practitioner's personal learning and development plan for the next year, and the appraiser's summary of the appraisal. These two documents need to be agreed by both parties, and they both depend on what happens in the appraisal meeting. It is unlikely that finished versions of these documents can be produced in the meeting itself, and they are more likely to be written in the days following the meeting. The practitioner's development plan is a dynamic document, which will be amended throughout the year. The version that is presented in the appraisal statement may well be changed in the light of the appraisal meeting, in fact that is the main purpose of the meeting. The appraiser's summary will show commentary on each of the aspects of Good Medical Practice that are included in the GP Appraisal Forms and also agreed action. The two documents are thus inter-dependent. The NHS Appraisal Toolkit simplifies the process of generating and agreeing these two documents. The appraisee prepares a draft development plan, which is made available to the appraiser through the Toolkit. This is done by clicking an on-screen button, there is no need to e-mail or post it. If the appraiser agrees the content of the plan s/he can then sign it off by means of an on-screen button. The appraiser writes the summary of the discussion in the same way, again on a prepared template, and makes the draft available to the appraisee to approve and sign off.

Using the personal learning and development plan throughout the year The personal learning and development plan (PDP) that is produced as a result of the appraisal meeting is a starting point. It lists broad objectives for the following year's professional development, as well as some indication of how these objectives will be met and what resources are required. In the NHS Appraisal Toolkit, this version of the PDP is placed in the 'personal' section of the Priorities and contexts tool. Its purpose is to record the objectives agreed in the appraisal. The PDP is also put into the My learning activities reflection tool. This version can be edited and it sits alongside two other tabulated tools, one of which records learning needs as they arise and the other logs learning

58 • e-Appraisal

activities as they are completed. Together these three items make up a learning portfolio and are the core of the appraisee's tools in the Toolkit. They are all readily available to the practitioner at her or his desk, and they support reflection at different levels. The learning needs tables are structured along the lines of Patients' Unmet Needs (PUNs) and Doctors' Educational Needs (DENs).1 The intention here is to capture learning needs as they crop up during work the practitioner can make a note between patients or at the end of surgery. It allows short-term reflection in action to be captured. Periodic review of the learning needs thus assembled will lead to modification of the PDP, either adding new items or changing existing ones. This more leisurely reflection may be done by the practitioner alone, or s/he may wish to discuss things with the appraiser or perhaps an educational facilitator. At this level of reflection, the log of learning events completed will be relevant too, allowing priorities to be set for the next round of learning and development. This periodic review may be formal or informal. Some practitioners will wish to do this when the mood takes them, others will prefer to have dates set, perhaps with some system of reminders or prompts, others will also wish to arrange regular meetings with an educational facilitator or a local learning set. e-Appraisal can support any of these by generating reminders and prompts and by producing documentation that informs the reviews. Finally, the PDP in its modified state after amendments throughout the year is incorporated into the appraisal statement for the next appraisal meeting. Here it is part of the documentation that feeds into the discussion and will influence the PDP that emerges from that appraisal meeting.

Some final thoughts In this chapter we have shown how the processes of presentation to others and reflection are inter-linked. In the same way, appraisal and clinical governance (presentation, reflection and practice) support and affect each other. We have also shown how the PDP, having set out learning objectives at the start of the year, can be modified in the light of experience throughout the year and form the centrepiece of a learning portfolio. It is a part of the processes of setting objectives, regular review and measuring success. The PDP can be seen as a reflection tool and also as a means of demonstrating your progress through the year - a bit like a sheet of glass in your shop window.

Reporting and demonstrating • 59

Reference 1

Eve R (1995) Meeting Educational Needs in General Practice: PUNs and DENs. Somerset Postgraduate Centre, Taunton.

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8 GP appraisal and the practice team John Bibby

Key points covered in this chapter •

QP appraisal in the context of the practice How it used to be ...

* What the nurses are up to •

Staff and administrative team appraisals

» Setting practice priorities • Organisational development facilitation * Support through mentoring « Appraisal and revalidation * The role of computers in all of this

In earlier chapters, we have looked at the value and role of appraisal and how the new NHS appraisal for GPs should enhance reflective practice. However, GPs no longer work in isolation. Increasingly in today's NHS, care is delivered by teams. The work of the National Primary Care Development Team (NPCDT) is based on the belief that the success or failure of the system in which the primary care teams operate has a

62 • e-Appraisal

significant effect on the standard of care that patients receive. The rationale for the NPCDT's methodology is based on the evidence that changing the system in which individuals operate as a team has a significant effect on outcomes as demonstrated by Langley and Nolan.1 What has this to do with a GP's appraisal? This chapter will demonstrate that, whilst appraisal is the pivotal point about which improvement of an individual occurs, there are significant external factors that impinge on a GP's effectiveness and to ignore these is to risk patients receiving less than optimal care.

Development plans, the individual and the practice The Government's intention is that the future for primary care education and training will be based around the concepts of the practice professional development plan (PPDP) and lifelong learning with personal development plans.2,3 But how does an individual's appraisal and personal development plan fit in with the practice's business aims, the practice professional development plan and the role of the primary care trusts? This chapter will shed some light on these issues. With the demise of health authorities, PCTs are becoming increasingly important as major stakeholders in the development of primary care personnel. Much has been written about the introduction of personal development plans (PDPs) for GPs, and recently the likely relationship between the PDP, appraisal and revalidation has been described.4 However, little has been written about the relationship between PCT development plans, practice development plans, practice (business) development plans (PBDPs), personal development plans, postgraduate education allowance (PGEA) and appraisal.

Out with the old ... Gradually, the old system of postgraduate education allowance (PGEA) is being superseded by personal development plans. The present PGEA system bears little relation to GPs' actual educational needs and the evidence for effective learning and change in clinical behaviours is limited5,6 so the move to needs based personal development plans is to be welcomed.

GP appraisal and the practice team • 63

Nurse education leading the way Since April 1995 all nurses have been required to compile a personal portfolio (PREP Folder), which the UKCC can request as proof of educational activity.7 District nurses and health visitors have their PREP folders as well as annual appraisals. These appraisals, carried out by the line manager, aim to: • • •

review the previous year's development plan identify the professional development needs for the year ahead agree a plan of action

All community nurses should have clinical supervision arrangements in place.8

... and the administrative team? The practice staff often has a less formal structure. Practices used to provide the health authority with an annual training plan for the staff. The training plans were usually based around an assessment of need carried out by the practice manager. In some cases, this involved annual staff appraisals, in others it was a more ad hoc process. After April 2002, the PCTs became responsible for dealing with the training needs of practice staff. Figure 8.1 shows a diagrammatic representation of the inter-related components of planning to support practice, professional and individual needs in the context of primary care trusts operating with existing national and local priorities.

Practice planning Increasingly, PCTs require each practice to have a practice (business) development plan (PBDP) describing what the practice intends to achieve in the following year. This includes the whole range of activities including premises, personnel, organisation and patient services. For practices on a primary medical services contract this business plan is formalised as the PMS contract. The summation of each of the practice's business plans equates to the primary care investment plan (see Figure 8.2).

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Figure 8.1 A model strategy for practice professional development planning.

Figure 8.2 The primary care investment plan.

GP appraisal and the practice team • 65

PCTs and practice planning in partnership This overarching plan should be based on a needs analysis by the practice and be facilitated by the PCT. There are both external and internal influences to consider in drawing it up.

External influences These include: • National priorities, for example: - The National Plan - National Service Framework (NSF) targets - Guidance from the National Institute for Clinical Effectiveness (NICE). • Locally set priorities, for example: - The Health Improvement and Modernisation Programme (HIMP) - Clinical governance priorities agreed across PCT. • Practice priorities: - the practice itself should have undertaken its own needs assessment.

More about setting practice priorities These vary from a collation of 'gut feelings' drawn from knowledge of the practice demography to a formal needs assessment with full profiling of morbidity and socio-economic characteristics. There may also be areas for development that have been revealed during the PCT's clinical governance visits. In addition, there will also be a series of staff needs. Some practices will also have set up mechanisms to access the views of their patients; those that haven't will need to.

Organisational development facilitation The process from these facilitation. away days, times.

of developing the actual practice business development plan influences may be enabled by organisational development Some PCTs are helping practices by arranging facilitated others use sessions in the monthly PCT protected learning

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The plan should be written in a way that clearly states: the review of the previous year's plan a list of objectives for the coming year timing and deadlines a clear listing of whose responsibility each objective is criteria for evaluation.

Practice professional development planning Following on from the practice business development plan, the practice professional development plan (PPDP) describes the educational and developmental needs of the practice. This plan bridges the gap between collective and individual needs. The two inputs that determine the PPDP: 1 the practice business plan 2 the PDPs of the individual practice members. The PPDP is likely to be facilitated by the primary care trust educational lead with support from the clinical governance team and primary care tutor. Achieving the PPDP will be an essential component necessary to allow the practice business development plan to be achieved. A practice skills assessment (both individual and team) should be carried out. The educational needs, determined by the difference between

Figure 8.3 Primary care trust education/training plan.

GP appraisal and the practice team • 67

the skills that are required in order to achieve the practice business development plan and those that already exist (as revealed in the skills assessment), constitutes the basis of the practice professional development plan. The summation of each of the practice's PPDPs equates to the PCT's education/training plan (see Figure 8.3).

Planning for me ... personal plans Each member of the practice will each have a personal development plan (PDP). This will be based on an assessment of their personal needs but it will also be developed in the context of practice needs and the external influences mentioned above (national, local and practice priorities). The personal development plan will have to be in harmony with the vertical structures of the practice plans and national priorities but also has to be located horizontally as one year's contribution to the individual's lifelong learning portfolio.

Support through mentoring The PDP may be facilitated by mentoring or local peer-led support groups. The mentoring may be carried out by a primary care tutor but initially is likely to be undertaken by someone from the same profession as the person being mentored/supported. For practice staff the mentoring/support may be carried out via the appraisal process with the practice manager. Several practices have adopted an in-house appraisal scheme using a personal development interview. For GPs the PDP forms an integral part of the appraisal and revalidation documentation. The summation of the activities that the individuals will undertake to meet their own individual development plans constitutes the practice's training plan (see Figure 8.4) This plan describes how the practice will achieve the educational needs identified in the PPDP. The first element of any PDP is an educational needs analysis. For practice staff this may be via an appraisal carried out by the practice manager. For clinical members there are several tools that are well described in the literature.9 The PDP should contain evidence of the educational activities undertaken and reflection on the lessons learned. Ideally, evidence of assimilation of learning into practice will also be shown. There are three main elements to the PDP: 1 needs analysis 2 evidence of learning activities (including proof that revalidation criteria have been addressed) 3 reflection and review.

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Figure 8.4 Practice training plan. The needs analysis has a number of dimensions (see Figure 8.5). 1 The needs of the individual as a member of their team. 2 The role specific needs of the individual (e.g. receptionist, nurse, doctor). 3 For doctors, the areas from the GMC's Good Medical Practice document need to be included.10

Figure 8.5 Needs analysis.

GP appraisal and the practice team • 69

4 The 'other role needs' of individuals (e.g. the secretary may be the health & safety coordinator or a GP may be a VTS trainer). 5 Personal needs. A POP should include a needs analysis of the individual under the headings above and as the year proceeds a list of how the needs have been met. The next year's PDP will include a review of the previous year in addition to the elements listed above.

Good medical practice For GPs, their PDP will be supplemented with a statement of their position in relation to the areas identified in the GMC's document Good Medical Practice.10 1 2 3 4 5 6 7

Good clinical care. Maintaining good medical practice. Relationships with patients. Working with colleagues. Teaching and training. Probity. Health.

Plus, two other areas identified by the Department of Health: 8 Research and development. 9 Management. This information, held in the appraisal folder, will form the basis of the annual appraisal. The responsibility for this appraisal rests with the PCTs.

A look at appraisal and revalidation For GPs, every five years there will be the GMC's revalidation process. Whilst it is essential to see appraisal as supportive and developmental and not judgmental, the information used for the appraisals will contribute to revalidation. We have sought to emphasise in Figure 8.1 how revalidation sits outside the loop of individual and practice development. But it does exist as a near neighbour.

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Figure 8.6 Appraisal and revalidation process.

From Figures 8.1 and 8.6, we can see how external and internal influences relate to the practice business plan, the practice professional development plan and the practice members' personal development plans, with the annual appraisal being the pivotal point of the system.

The role of computers The process of developing the various plans and the appraisal itself are essentially about change management and interpersonal working. So, can the use of computers be helpful to the process? Much to the relief of computer luddites, the use of computers is not compulsory. However, computers can be a very useful tool for several of the processes mentioned above. In addition, they can make these processes easier and more efficient.

GP appraisal and the practice team • 71

Practice business plan As described earlier, the practice business plan is a team event (perhaps facilitated by the PCT) in which the practice's objectives are documented using the external influences (national/local/practice priorities) and internal influences (practice and personal priorities). Several PCTs produce the targets of the national and local priorities in spreadsheet form in order to guide the practices in the business planning process. The completed business plan is usually required by PCTs in electronic format to aid compilation into the primary care investment plan.

Practice professional development plan This plan is essentially a list of the practice's educational needs as determined by the difference between the skills that are required in order to achieve the practice business development plan and those that already exist (as revealed in the skills assessment). Many practices find spreadsheets to be useful in tabulating these (see Table 8.1).

Table 8.1 Using a spreadsheet to tabulate skills and learning needs in the practice Business development area

Skills required

Skills existing

Educational needs in order to meet the business plan

Develop a diabetic clinic

1 Nurse with diabetic experience 2 GP with diabetic experience

No

Attend local diabetic training course

Yes Join local GP support group for ongoing updating

Once all the practice business development areas have been covered, a list of the educational needs required in order to meet the business plan has been easily defined.

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Personal development plan Computers are a useful tool in each of the three components of the PDP: 1 Needs analysis. There are many needs analysis tools described in the literature. Some, such as significant event analysis, make use of the practice clinical system to follow through the event and to determine what happened during the patient's pathway of care. Others such as random case analysis make use of the clinical system in reviewing the case but also may make use of PRODIGY or Mentor in guiding what other clinical options could have been explored. The results of practice audits or Plan, Do, Study, Act' cycles (PDSA) are useful needs analysis tools and again these methods use the practice's clinical system. The NHS appraisal website www.appraisals.nhs.uk has tools to help determine an individual's development needs. Computers can help collate evidence of learning activities (and for GPs proof that revalidation criteria have been addressed). There are two separate uses of computerisation here: •

Use the Internet as a learning resource. There are now many on-line courses and sites of educational material but the best place to start is probably the very detailed National electronic Library for Health www.nelh.nhs.uk. This site can be fully searched from outside the NHS net once a free Athens account has been obtained (this can easily be done by registering on the site using a computer linked to the NHS net). • To document learning activities against the PDP aims. Again to some degree the NHS site www. appraisals .nhs .uk can do this, though there are other sites which also allow documents to be stored, e.g. www.mynhsappraisal.info. There are sites appearing that enable all members of a PCT, whatever their role, to record their learning against their PDP. Several PCTs use the service at www.ukcolt.com. 2 Evidence of learning activities. Learning activities can be recorded in tables, as are provided on the three websites mentioned above. They can also be recorded on spreadsheets or tables generated from Word or other office software packages. 3 Reflection and review. The three sites listed above each have tools to facilitate reflection and review. These all take advantage of the features of the electronic appraisal record that allows easy creation, editing and retrieval of appraisal information. Perhaps the main advantage of using electronic media is not the indivi-

GP appraisal and the practice team • 73

dual examples listed above, but the point that electronically stored information is much more easily coordinated into a report or statement. Practice intranets already facilitate the movement of information and documents around the practice. This allows the sharing of much of the practice-based data that informs individual PDPs. Further, when the software tools become more sophisticated, there is the opportunity for much of the 'paperwork' that is involved in compiling plans at practice level and PCT level to become automated.

Some final thoughts ... This chapter has shown how appraisal is in the centre of practice and individual development planning and how computers have a place as useful tools in the processes described.

References 1 2 3 4

5 6 7 8

9 10

Langley G, Nolan K, Nolan T et al. (1966) The Improvement Guide: a practical approach to enhancing organisational performance. Jossey Bass, San Francisco. Caiman K (1998) A Review of Continuing Professional Development in General Practice: a report by the Chief Medical Officer. Department of Health, London. Department of Health (1998) A First Class Service: quality in the new NHS. Department of Health, London. Rughani A, Field N, Tomson M et al. (2002) PDP-based appraisal and revalidation implementation. UPDATE - The Journal of Continuing Education for General Practitioners. 64(3): 188-9. Berg A (1979) Does continuing medical education improve the quality of medical care? A look at the evidence. J Fam Pract. 8: 1171–4:. Davis D, Thomson M, Oxman A and Haynes R (1992) Evidence for the effectiveness of CME. JAMA. 268: 1111-17. UKCC (2001) The PREP Handbook. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London. UKCC (2001) Supporting Nurses, Midwives and Health Visitors Through Lifelong Learning. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London. Bourdillon P, du Boulay C, Heard S et al. (1999) The Good CPD Guide: a practical guide to managed CPD. Reed Healthcare Publishing, Sutton. General Medical Council (2001) www.gmc-uk.org/standards/good.htm.

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9 Focus on informatics for e-appraisal Key points covered in this chapter * Why and how Informatics has a rote In appraisal * Training and personal development * Using the GP clinical system « The world wide web * Accessing the NHS Appraisal Toolkit * Patient surveys and consumer health informatics * The value of the e-communlty

Why and how informatics has a role in appraisal This chapter offers a comprehensive, but not exhaustive, review of resources for appraisal which are available via the world wide web, professional bodies and organisations and training opportunities. This guide has covered the dimensions of appraisal, using a key example of the NHS Appraisal Toolkit (www.appraisals.nhs.uk) to illustrate the benefits of employing electronic resources to support the appraisal

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process throughout the year. Let's also revisit Box 2.1 in Chapter 2 that points us towards our GP clinical computer software as a resource to populate our appraisal statement and provide useful food for thought, and mirrors for reflection.

Training and personal development Andrew Forrest describes the following formula1: L>D>T>C That is, 'learning is greater than development, which is greater than training which is greater than courses.' Going on a course is part of the journey, but can be the end without motivation and application. This individual learning will then only be translated into organisational learning with the added dimension of competent communication within a culture open to innovation, development and change.

Using the GP clinical system Most existing GP clinical computer software will have adequate (or better!) facilities for running searches and audits. The results of any search or audit will depend on the quality of the data recorded on the system, and a team approach to computerisation will be required within the practice or PCO to get near to quality data and therefore quality searches and audits that will be useful for reflection and showcasing in the appraisal process. For example, reports on clinical activity (what actually happened versus what do I think happened) can usually be easily run in a few minutes from your clinical system and can provide illuminating information. Check your data quality before throwing out the baby with the bathwater though, or before embarking on a complicated new regime for data management. For more on data quality, see the PRIMIS and HIP for CHD websites (www.primis.nhs.uk and www.hipforchd.org.uk). The GP clinical computer system also provides a repository for day-today clinical and administrative information for later use and can enable learning and development through access to clinical knowledge bases such as PRODIGY or Mentor.

Focus on informatics for e-appraisal • 77

The world wide web The information flood can easily be a knowledge drought, as anyone who has been drawn in to leaping from page to page on the Internet will testify. Refining your searching skills is useful, as is having an index of useful starting points from recognised NHS 'brands' that can help you sift the masses of information on the world wide web. Google (www.google.co.uk) is a popular and very efficient 'search engine'. When you type in the URL at the top of your browser, you are offered a box in which to enter a few words or a name that you are looking for. If you type in 'appraisal' and press the 'search' or 'go' button, you will be given a list of everything in its directory relating to and including the word appraisal. Refine your search by entering 'UK NHS appraisal' or similar, and start exploring. You will be offered a list of relevant websites, and one click on the name site on the list will take you directly to that website. Use the 'back' button at the top of your web browser to go back a page, or even to go back as far as your Google search list to check out a different option.

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The Department of Health, the General Medical Council and the Royal College of General Practitioners all have excellent websites which will point you to the latest information produced by that organisation on appraisal. Most sites will also have an e-mail enquiries service, so you can contact someone if you cannot find what you are looking for, or if you have any queries. • Finding out what appraisal is. • Sharing and investigating best (and worst) practice. • What does the NHS say about appraisal? • Stealing ideas and avoiding reinventing the wheel. • Information about education and training programmes.

Accessing the NHS Appraisal Toolkit This guide has used the electronic appraisal record and resources available in the NHS Appraisal Toolkit as a primary example of how informatics can support appraisal because it is based on the same fundamental informatics principles of how the GP clinical computer system can support patient care in general practice. It offers a safe place to explore appraisal, access to education and appraisal knowledge bases, it holds relevant data and information securely and confidentially, and

Focus on informatics for e-appraisal • 79

helps produce an appraisal statement as a by-product of this activity. Access and login is via the website at www.appraisals.nhs.uk.

Patient surveys and consumer health informatics Many useful tools to assess patient satisfaction and carry out surveys are available, most via a simple web search using something like Google. Some are signposted from the NHS Appraisal Toolkit, and follow the value of brands for some of the more helpful ones.

The value of the e-community Internet technologies have enabled the development of 'electronic communities of practice', utilising push and pull technology to facilitate a mixture of teaching and learning. Organic growth is an important feature of a learning community, empowering sharing of peer expertise and experience - an integral part of any education strategy and learning cycle. Most formal educational interventions often take the form of courses or meetings. It requires you to be in a certain place at a certain time to participate. Technology offers us the opportunity to meet, participate and exchange information at a time and in a way that suits us. e-Mail lists and discussion groups enable access to a 'community of practice', that is people with similar interests and motivations to us that develops organically and according to need, asynchronously. Appraisal e-communities are developing between peers and colleagues, enabling the sharing of experience and best practice, like an on-line or electronic user group. Some e-communities may offer and be supplemented with face-to-face contact, but this is not a necessity to run a successful discussion and support network of disparately located peers that form a valuable community. It may be worthwhile subscribing to a couple of appraisal-related e-mail lists, and use the functions of your e-mail package to filter the list e-mails into relevantly named folders so you can read and review them at a time that suits you. Most list managers will give you advice on how many e-mails that particular list generates each week, or how to manage your participation, before you subscribe. Most e-communities can be accessed by logging onto a website, and

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following the instructions there. Some e-communities will also offer excellent facilitation but are usually happy to let lurkers' do just that, at least for a while.

Reference 1

Forrest A (1999) Fifty Ways to Personal Development. Spiro Press, London.

10 Training and resources Key points covered in this chapter » Primary care informatics training * Web-based resources * Some useful addresses * Further reading and resources « Lessons from industry

Primary care informatics training This is not an exhaustive list of the resources that are available to you in exploring the possible training options. Many practices and primary care organisations will have training and education leads that may offer a rewarding insight into the available options as a first port of call.

Clinical system supplier training Research carried out at SCHIN (SCHIN 2000) suggested that practices that had on-site training from their clinical system supplier are the practices most likely to embrace and take up using different modules of their computer system. Good clinical system supplier trainers are worth

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their weight in gold and will not only know the software inside out but also their insight into primary care is often invaluable, as they can help identify and map your training needs whilst sharing best practice. A good trainer will have developed a relationship with your practice and locality over time and will be as proficient in facilitation skills as they are at making the software jump through hoops (if this is not your experience of clinical system supplier training, contact your supplier and make sure they know so they can do something about it). The trainer is often a vital link between you and the company so make the most of them. Training from suppliers may be modular and off-the-shelf, or it may be tailormade, but both should come with full supporting training materials and user guides. Discounts are usually available for block bookings across a locality, so it's worth exploring this type of training at PCO as well as practice level.

National and local clinical system user groups There is nothing quite as helpful as finding out what colleagues do and how they tackle specific issues, whether it is applying informatics to clinical governance or how to implement the appointments module. Most major clinical systems have active national user groups, usually offering a useful magazine, annual conference, website and representation to the company as a minimum. Contact yours to see what else is available to help you develop your clinical system use. Many national groups have a network of local groups that meet regularly, often at a practice, and share ideas, showing 'how we do it at our place'. Priceless.

PRODIGY national dissemination office (training programme) PRODIGY is built into existing clinical computer systems, it has the look and feel of your usual software. The accompanying PRODIGY training programme offers 30-minute, one-to-one training to GPs within signed up PCOs. For the technophobe, 30 minutes at their own desk in their own consulting room is a much more comfortable (and likely!) option than giving up half a day to that scary grey box. To the regular computer user, 30 minutes is all it takes to learn the PRODIGY ropes. Your usual GP clinical system supplier trainer, who has been accredited by the PRODIGY team from the University of Newcastle, delivers the training. The trainer will not only cover the key presses, but will also look at some of the concepts and barriers to individual use of PRODIGY and using the computer in the consulting room. More information is available from the PRODIGY NDO or see www.prodigy.nhs.uk.

Training and resources • 83

PRIMIS Data quality is one of the foundation stones to information proficiency, and this well-established and useful programme would be a good starting point. See www.prirnis.nhs.uk.

HIP for CHD The HIP project - health informatics programme for the coronary heart disease national service framework - describes itself as a 'practical example of clinical governance'. HIP for CHD aims to offer a practical and team-based approach, which engenders the skills, software tools, knowledge base and organisational structure for a practice or primary care organisation to successfully deliver the coronary heart disease NSF. See www.hipforchd.org.uk.

NHS clinical governance support team The RAID model is key to this education and training programme that addresses the implementation of clinical governance, culture and the management of change within an organisation. See www.cgsupport.org.

NHS information authority 'ways of working' programme The aim of the NHSIA 'WoW programme is to support local NHS organisations to plan and co-ordinate their education, training and development (ETD) though two national programmes - 'Developing the right skills' and 'Finding the right help'. Each region has an Information Education, Training and Development Adviser (EDA) whose job it is to spread good practice. See www.nhsia.nhs.uk/wowwi.

Web-based resources BAMM: www.bamm.co.uk BMA: www.bma.org.uk EMIS National User Group: www.emisnug.org.uk NHS Appraisal Toolkit: www.appraisals.nhs.uk ScHARR report: www.doh.gov.uk/gpappraisal Performance

Management

and

Appraisal

www.work911.com/performance/index.htm

Resource

Centre:

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The goal of the Performance Management and Appraisal Resource Centre is to provide information on performance management and appraisal, all for free, on the Internet. They provide free articles, book suggestions and services to help with performance management and appraisal issues. This site is dedicated to educating managers, supervisors, human resource professionals and staff so they can maximise the value they gain from performance management and performance appraisal. The 360.co.uk: www.the360.co.uk/ The web sites developed for companies by the360.co.uk enable their employees to complete 360 degree questionnaires on-line, and view feedback reports on-line. Their system enables any 360 degree feedback questionnaire to be distributed, completed and checked.

Some useful addresses Department of Health Richmond House 79 Whitehall London SW1A 2NL Tel: 020 7210 3000 Website: www.doh.gov.uk General Medical Council External Relations Office General Medical Council 178 Great Portland Street London WIN 6JE Tel: 020 7915 3507 Website: www.gmc-uk.org Royal College of General Practitioners (RCGP) 14 Princes Gate London SW7 1PM Tel: 020 7581 3232 Website: www.rcgp.org.uk Sowerby Centre for Health Informatics at Newcastle (SCHIN) The University of Newcastle upon Tyne 16–17 Framlington Place Newcastle upon Tyne NE2 4AB Tel: 0191 243 6100 Website: www.schin.ncl.ac.uk

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Further reading and resources Please note that www addresses, while correct at the time of going to press, can change. If you experience problems, please contact the author via email at [email protected]. The Royal College of Anaesthetists Joint Committee on Good Practice www.rcoa.ac.uk 'Guidance for Appraisal for Anaesthetists'. The JCGP has drawn up a document which outlines some general principles relating to appraisal for both clinical directors who will have responsibility for appraisal and for the individual anaesthetist who will be appraised. It also contains specific step-by-step guidance to clinical directors on different aspects of appraisal including an appraisal form and summary sheet. Royal College of Physicians www.rcplondon.ac.uk/professional/pae/pae_detail_htcaa.htm Royal College of Physicians 'How to Conduct a Consultant/Trainee Appraisal'. This one-day workshop focuses on the fundamentals of appraisal and the key skills necessary for effective consultant/trainee appraisal. Royal College of General Practitioners - Continuing Medical Education www.rcgp.org.uk/rcgp/education/continue_med_ed.asp The aim of continuing medical education is to sustain the professional development of general practitioners and help them to provide high quality patient care throughout their career. GPs are therefore encouraged to keep up to date with developments in general practice. In March 1999 the College awarded a one-year contract to Professor Janet Grant from the Joint Centre for Education in Medicine to undertake the development of a system for accredited continuing professional development. As part of the development of the APD system, Professor Grant also produced a substantial literature review, which is available here to members only. The system known as Accredited Professional Development (APD) is currently being piloted. A Practical Guide to Effective Appraisal and Assessment for Clinicians and Managers www.healthcare-events.co.uk/conferences/confdisplay.asp?id=62 Tuesday 8 January 2002 at the Royal College of Physicians, London. By April 2002, all NHS consultants in England and Wales should have had their annual appraisal. This conference examines the progress that is being made, and challenges that you must address, in developing effective appraisal for both the appraisee and the appraiser.

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City University, London Staff Development and Training www.city.ac.uk/hr/training/appraisal/clenotes.htm Notes of guidance for appraisers including The Purpose of Appraisal, Preparation for the Interview, Conducting the Interview, After the Interview, Salary Review, Follow-up, Poor Performance, Conclusion. Performance Appraisal Services www.performanceappraisal.co.uk/ A UK company providing performance appraisal services covering computer systems (including 360 degree) customised training courses, OD and HRD consultancy support. They believe that long-term organisational performance improvement is dependent upon linking appraisal to Results Management, HR Development and Change Management. The site provides articles including 'Why conduct a performance appraisal and how', 'Should performance appraisal be scrapped?', 'Performance appraisal systems', 'Performance appraisal model'. Health Courses and Careers Update Online www.healthcourses.co.uk/courses/ Health Courses and Careers Update Online - the web site of Health Courses and Careers Update. This organisation offers training days for 'Managing Appraisals' aimed at ward managers, senior staff nurses, therapists and other healthcare professionals with responsibility for appraising and developing staff. A practical workshop looking at appraisals, clinical governance, learning styles techniques for structuring training and development to meet individual and team needs. Beginners.co.uk http://training.beginners.co.uk/portal/id/184 Appraisal Techniques training course by Begirtners.co.uk. In order to be sure that the needs and overall goals of the organisation are being met, Managers are given targets. By utilising the skills of their team, managers can delegate work which will ensure that the targets are achieved. To do this properly, managers need to review their staff's performance, give them feedback on their overall performance and discover each individual's aspirations. Human Resource Solutions www.human-resource-solutions.co.uk/Areas%20of%20Interest/ Appraisal.htm Human Resource Solutions is a company that can design an appraisal/ performance management system for companies and train managers and staff. The site includes links to 'Appraisal and You' - a handout to assist

Training and resources • 87

staff in preparing for their appraisal, and 'Appraisal Checklist' - a one page checklist for appraisers and sample appraisal documentation. Phoenix Training and Development www.phoenix-training.co.uk/Pages/coursernanage.htmltfAnchorManaging-7638 Phoenix Training and Development: 'Conducting Appraisals Successfully'. Performance appraisal is a key management tool, yet it is poorly understood and seldom carried out effectively. Many managers view appraisal as a nuisance, something to be got through half-yearly or annually. The key aim of this workshop is to provide delegates with the practical skills and strategic understanding to ensure that they get the maximum benefit from the appraisal system, and that it contributes significantly to the achievement of business goals. Q-OPD International www.qopd.co.uk Q-OPD International is a well established organisational and personal development psychology consultancy that helps both companies and individuals to realise their true potential by the application of occupational psychology, neuro-linguistic programming (NLP) and management science. The site includes information on 360 degree appraisal - 'Research has shown that 360 degree feedback when linked to a specific development plan, increases the staff's organisational commitment for up to two years following the assessment' - Professor Beverly Alimo-Metcalfe, Centre for Leadership Studies, University of Leeds. Occupational Performance www.opgroup.co.uk/360_degree_appraisal.htm 'Performance Management and Employee Development - 360 degree Appraisal'. Occupational Performance offer 360 degree appraisal either on a bureau basis or as a module of the focus Employee Success System. The use of focus simply enables our users to undertake individual job/ role profiling using a library of 500+ competencies and skills which in turn automatically creates an individual 360 degree appraisal for each job defined. Focus electronic appraisal, when compared to manual methods, is faster, more effective, more flexible and more relevant. Fenman www.fertman.co.uk/catalogue/product/sap.htm Fenman is a British publisher of resources, tools and ideas for busy trainers. Most appraisal training programmes concentrate on the mechanics of appraisals - who sits where, the location, the agenda and

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so on. But the Fenman 'Skilful Appraisal' video claims to focus exclusively on the most important aspect of all - the appraisers. It provides managers with the ability to conduct skilful appraisals for better business results. Zigon Performance Group www.zigonperf.com/resources/links.html 'Links to Performance Appraisal and Performance Measurement-Related Websites' This group specialises in performance appraisal, performance management and performance measurement systems for hard-to-measure work and teams. They offer on-line resources, books, how-to workshops and custom consulting services to help you measure, manage and improve employee performance. Quorum Training www.quorumtraining.co.uk/Directory/Detail009035.asp 'The Appraisal Interview'. The purpose of the appraisal interview is to recognise achievement, acknowledge success and establish strategic performance objectives for the future growth of the business. Interactive programme covering why appraise, the process, preparation for appraisee and appraiser, the interview - objectives, written notes, milestones, starting again. Total Success Training www.tsuccess.dircon.co.uk/performance_appraisal.htm Appraisal skills, Management Training, The New Manager are some of the courses in London and throughout the UK led by Warren Wint of Total Success Training. He has spent over 15 years training people on strategies to improve productivity and enhance self-development. Real Need Software www.realneedsoftware.co.uk In 1998, Real Need Software was commissioned by Quorum Organisational Psychologists Ltd to develop a major software system for the management of 360 degree appraisals. Quorum Organisational Psychologists is a UK-based psychological and human resource consultancy firm, specialising in 360 degree appraisal, training and individual development services for major organisations. The commissioned software was intended to automate the process of appraisal questionnaire design, data input, data analysis and reporting and also to provide a management system to track the processes of appraiser assignment, questionnaire distribution and questionnaire return.

Training and resources • 89

A Review of Continuing Professional Development in General Practice www.doh.gov.uk/pub/docs/doh/cmodev.pdf Continuing Professional Development (CPD) was defined in the CMO's review as: 'A process for lifelong learning for all individuals and teams which enables professionals to expand and fulfill their potential and which also meets the needs of patients and delivers the health and healthcare priorities of the NHS.' The NHS appraisal process will contribute to the CPD agenda by encouraging more reflection on practice and learning needs and will facilitate forward planning. Supporting Doctors, Protecting Patients (1999) www.doh.gov.uk/pub/docs/doh/consultation.pdf In this document appraisal is described as a positive process which can give someone feedback on their performance, chart their continuing progress and identify development needs. It is a forward-looking process essential for the developmental and educational planning needs of an individual. It is not the primary aim of appraisal to scrutinise doctors to see if they are performing poorly but rather to help them consolidate and improve on good performance aiming towards excellence. However, it can help to recognise, at an early stage, developing poor performance or ill health which may be affecting practice. This document proposed that appraisal should be made comprehensive and compulsory for doctors working in the NHS. It is thought that appraisal will form an important component of the systems required by the GMC for revalidation. It also proposes that the introduction of an NHS appraisal system must be supported by a comprehensive programme of training for all those involved in appraising doctors. However, it does not mention that training will also be necessary for those doctors being appraised. The NHS Plan (England; 2000) www.nhs.uk/nationalplan/nhsplan.pdf In the NHS Plan, the Government support announced its intention that all doctors employed in, or under contract to, the NHS will, as a condition of contract, be required to participate in annual appraisal from 2001. The Plan states that appraisal will contribute to the GMC's five-yearly mandatory revalidation process for all doctors, and proposes that appraisal (and hence revalidation) will link back into CPD by helping individual doctors and their appraisers to identify and address development needs. Primary Care, General Practice and The NHS Plan (2001) www.doh.gov.uk/pdfs/nhsplanprimarycare.pdf Following announcement in the NHS Plan that clinicians will participate

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in appraisal and clinical audit from 2001, this document, specifically for primary care, supports the belief that professional development of clinicians, through a culture of improvement and not blame, will be an important focus of appraisal. Assuring the Quality of Medical Practice: implementing Supporting Doctors, Protecting Patients (2001) www.doh.gov.uk/pdfs/assuringquality.pdf This document states that agreement has already been reached about the appraisal arrangements for consultants and that the Department of Health is currently working towards similar arrangements for all other doctors working in the NHS, including GPs. Appraisal for Consultants Working in the NHS (2001) www.doh.gov.uk/nhsexec/consultantappraisal/consultantsappraisal.pdf This set of documents reflects the agreement on appraisal for NHS consultants. The documentation is designed to provide a systematic approach to the collection and presentation of information for appraisal. Although different issues arise in developing an effective approach for general practice, some of the material may be helpful to those involved in appraisal in the NHS. A Methodology for Recommending Revalidation for General Practitioners - work in progress (2000) www.rcgp.org.uk/rcgp/corporate/consultation/reval_method/reval.doc This document highlights some of the issues still unresolved in relation to the revalidation of doctors. One of the points it makes is that an area requiring clarification is the role of appraisal for doctors, proposed by the Chief Medical Officer for England, and how this will impact on the process of revalidation. The annual review to support professional development and revalidation may or may not be similar to the NHS annual appraisals. If annual appraisals can not be used for revalidation the RCGP will be seeking funding for alternative reviews based on professional mentoring. Good Medical Practice for General Practitioners (2001) Published by the RCGP and available from their publications department. Good Medical Practice (1998–2001) www.gmc-uk.org/standards/good.htm In this document, the GMC promotes the importance of doctors maintaining their performance. Among other aspects, doctors must respond constructively to the outcome of reviews, assessments or appraisals of their performance.

Training and resources • 91

Revalidating Doctors: ensuring standards, securing the future (1999/2000) www.gmc-uk.org/revalidation/gileaflet.pdf This states that all doctors will have to collect a folder of information to show how well they are performing, that their skills are up-to-date and that they are therefore safe to treat patients. Each doctor will have an annual appraisal to discuss their performance over the next year and any problems they have experienced. Royal College of Surgeons of Edinburgh (2001) Career advice - the role of appraisal /R Coll Surg Edin. 46: 213–15 www.rcsed.ac.uk/journal/vol46_4/4640007.htm The purpose of this article is to discuss the benefits of and to illustrate a framework for appraisal. The place of career advice in this process is mentioned, as is a brief discussion on assessment. From the point of view of the individual doctor, information to help him/her choose an appropriate career path should be readily available. It is more likely that a doctor will perform well throughout their career if in a career or occupation that suits them. Performance Appraisal - a necessary evil? Finnigan M, Marketing Magic www.tka.co.uk/magic/archive/feahire7.htm Performance appraisal is one of those difficult areas of business that seems to be a necessary evil - all the books say that a company should have a performance appraisal system, employees often express the desire for one, and (if my workload is any indication) businessmen are keen to find out about them. Why then is performance appraisal one of the areas of management most commonly complained about by employees and managers alike? Appraisals Pocketbook www.pocketbook.co.uk/manager-series/manager_series_6.htm The Appraisals Pocketbook adopts a strongly practical approach in explaining how to set up and run an appraisal system. Skilful goal setting lies at the heart of a successful appraisals system, argues the author, Frank Scott-Lennon. Using a helpful five-stage model, he deals with how to identify the job objective and key result areas, how to set clear achievable goals, and how to structure and conduct the performance discussion. 'This Pocketbook shows how performance appraisal can be a vehicle for improving performance and enhancing the growth of individuals', says Scott-Lennon.

92 • e-Appraisal

Managing Your Appraisal Pocketbook www.pocketbook.co.uk/personal-development /personal_development_2. htm The Managing Your Appraisal Pocketbook is written from the appraisee's standpoint. It encourages people to take charge of their own career development by preparing for and properly using appraisals. Its author is Max Eggert, a management psychologist who specialises in assisting organisations and individuals to achieve their best. He looks at the dangers and benefits of appraisals, how to prepare for them, performance measurement, feedback, the appraisal interview structure and types of questioning. Good Performance www.goodperformance.com/reading_lists.htm Performance appraisal reading list.

Additional reading •

Haman H, Irvine S and Jelley D (2001) The Peer Appraisal Handbook for General Practitioners. Radcliffe Medical Press, Oxford. This handbook for general practitioners provides a rigorous and practical approach to supporting all doctors throughout the appraisal process, containing detailed advice on how to carry out peer appraisal in general practice.

•

Martin D, Harrison P, Josebury H and Wilson R (2001) Appraisal for GPs. School of Health and Related Research, University of Sheffield. In 2000, ScHARR were commissioned by the Department of Health to produce guidance for the NHS on appraisal for GPs and proposals for its implementation. The guidance deals with the definition and practice of appraisal and its connection to other processes in the NHS, and draws upon lessons from history and other settings to inform the development and implementation of a model for GPs.

•

BAMM (1999) Appraisal in Action. British Association of Medical Managers, Stockport. This guide has been developed for doctors undertaking appraisal and to provide help, ideas and encouragement for medical managers. A version of this publication, specifically for primary care, is currently being produced. An appraisal support group is being set up by BAMM to explore best practice appraisal, identifying the major

Training and resources • 93

challenges and ways of addressing them. The group will meet 3–4 times each year and it welcomes all BAMM members. •

SCOPME (1996) Appraising Doctors and Dentists in Training. Standing Committee on Postgraduate Medical and Dental Education, London. SCOPME considers appraisal to be a vital element in making postgraduate medical and dental education a more planned, managed and purposeful process. This report sets out some principles to guide the development of appropriate appraisal systems and to make broad recommendations about implementation, monitoring and evaluation.

•

Edis M (1995) Performance Management and Appraisal in the Health Services. Kogan Page, London. This book explains the ideas behind performance management, with an assessment of its value in healthcare practice. Areas including appraisal, objective setting, team building and individual development are covered in depth, with practical advice for managers.

•

Mihill C (2000) Shaping Tomorrow: issues facing general practice in the new millennium. British Medical Association, London. In this book, Sir Donald Irvine affirms that formal peer appraisal will have to become a professional management tool that all GPs are versed in. In the next two years it is important that every general practitioner and every consultant in the health service learns the basic skills of appraisal. Each practitioner must learn to appraise those they are supervising and training, and learn to be appraised by their colleagues.

• Jelley D (2001) Appraisal. In: J Harrison, R Innes and T van Zwanenberg (eds) The New GP: changing roles and the modern NHS. Radcliffe Medical Press, Oxford. This book chapter provides an introduction to peer appraisal in general practice and discusses it in relation to other processes including assessment, mentoring and supervision. •

Marjoram J and Strachan B (2001) Appraisals in general practice: the way forward. In: S Field, B Strachan and G Evans (eds) The General Practice Jigsaw: the future of education, training and professional development. Radcliffe Medical Press, Oxford. This book chapter considers the importance of appraisal in professional development and general practice education, and it addresses some of the issues involved when appraising general practitioners.

94 • e-Appraisal

•

Haman H and Irvine S (1998) Appraisal for general practice development. Educ Gen Pract. 9: 44–50. This article addresses the need for training general practitioners in the appraisal process.

•

Jelley D and van Zwanenberg T (2000) Peer appraisal in general practice: a descriptive study in the Northern Deanery. Educ Gen Pract. 11: 281-8. This paper describes the content and process of peer appraisal in the Northern Deanery, UK.

•

Pitts J and Percy D (1997) A glossary of educational terms. Educ Gen Pract. 8: 140–3. This article considers what is meant by appraisal and other terms used within CPD and educational literature.

•

Burton J (2001) Appraisal, supervision and mentoring. Educ Gen Pract. 12: 139–43. A follow-up to the above article by Pitts and Percy revisiting the area, reviewing the concept of appraisal in comparison with other one-toone 'educational' relationships.

•

Argyris C (1993) Teaching smart people how to learn. In: R Howard (ed.) The Learning Imperative. Harvard Business Review Books.

•

Driscoll M (1998) How to pilot web-based training. Training and Development. November.

•

Faint R (1998) Intranets for learning. IT Skills. September.

•

Forrest A (1999) Fifty London.

•

Malone SA (1996) Learning to Learn. CIMA, London.

•

Mayo A and Lank E (1994) The Power of Learning. IPD, Phoenix, AZ.

•

Steed C (1998) Web-based Training. Gower, Aldershot.

Ways to Personal Development. Spiro Press,

Lessons from industry •

Ainsworth M and Smith N (1993) Making It Happen: managing performance at work. Prentice Hall, Sydney.

Training and resources • 95

•

Anderson GC (1993) Managing Performance Appraisal Systems. Blackwell, Oxford.

•

Armstrong M (1994) Performance Management. Kogan Page, London.

•

Balzer WK and Sulsky LM (1990) Performance appraisal effectiveness. In: KR Murphy and FE Saal (eds) Psychology in Organizations. Erlbaum, Hillsdale, NJ.

•

Beaumont PB (1993) Human Resource Management. Sage, London.

•

Bernardin HJ and Beatty RW (1984) Performance Appraisal: assessing human behaviour at work. Kent, Boston, MA.

•

Bernardin HJ, Kane JS, Ross S et al. (1995) Performance appraisal design, development and implementation. In: GR Ferris, SD Rosen and DT Barnum (eds) Handbook of Human Resource Management. Blackwell, Oxford.

•

Cardy RL and Dobbins GH (1994) Performance Appraisal: alternative perspectives. South-Western, Cincinnati, OH.

•

Costello SJ (1994) Effective Performance Management. Irwin, New York.

•

Dulewicz V and Fletcher C (1989) The context and dynamics of performance appraisal. In: P Herriot (ed.) Assessment and Selection in Organizations. Wiley, Chichester.

•

Eccles RG (1991) The performance measurement manifesto. Harvard Business Review. 68(1): 131-7.

•

Farr JL (1993) Informal performance feedback: seeking and giving. In: H Schuler, JL Farr and M Smith (eds) Personnel Selection and Assessment. Erlbaum, Hillsdale, NJ.

•

Fletcher C (1993) Appraisal: routes to improved performance. Institute of Personnel Management, London.

•

Fletcher C (1994) Performance appraisal in context: organizational changes and their impact on practice. In: N Anderson and P Herriot (eds) Assessment and Selection in Organizations. Wiley, Chichester.

•

Fletcher C (1997) Appraisal. Chartered Institute for Personnel Development, London.

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•

France S (1997) 360° Appraisal. The Industrial Society, London.

•

Gatrell J and White T (2000) Medical Appraisal, Selection and Revalidation. Royal Society of Medicine Press, London.

•

Greenberg J (1986) Determinants of perceived fairness of performance evaluations. / Appl Psychol. 71(2): 340-2.

•

Guinn K (1987) Performance management: not just an annual appraisal. Personnel. August: 39–42.

•

Henderson RI (1984) Performance Appraisal (2e). Reston Publishing Co., Reston.

•

Hinrichs JR (1996) Feedback, action planning and follow-through. In: AI Kraut (ed.) Organizational Surveys. Jossey-Bass, San Francisco, CA.

•

Hudson H (1999) The Perfect Books, New York.

•

Institute of Personnel Management (1992) Performance Management in the UK: an analysis of the issues. Institute of Personnel Management, London.

•

Latham C and Marchbank T (1994) Feedback techniques. In: G Lee and D Beard (eds) Development Centers. McGraw-Hill, Maidenhead.

•

Lockett J (1992) Effective London.

•

Lundy O and Cowling A (1996) Strategic Human Resources Management. Routledge, London.

•

Mabey C and Salaman G (1995) Strategic Human Resources Management. Blackwell, Oxford.

•

Meyer MW and Gupta V (1994) The performance paradox. Research Organiz Behav. 16: 309–69.

•

Mohrman AM, Resnick-West SM and Lawler EE (1989) Designing Performance Appraisal Systems. Jossey-Bass, San Francisco, CA.

•

Murphy KR and Cleveland JN (1995) Understanding Appraisal. Sage, Thousand Oaks, CA.

Appraisal. Random House Business

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Kogan Page,

Performance

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RCGP (2002) Accredited Professional Development: preparing for revalidation. Radcliffe Medical Press, Oxford.

•

Rogers S (1990) Performance Longman, Harlow.

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Rummler GA and Brache AP (1995) Improving Performance (2e). JosseyBass, San Francisco, CA.

•

Schneier CE, Beatty RW and Baird LS (1986) How to construct a successful performance appraisal system. Training and Development Journal. April: 38–42.

•

Spangenberg H (1994) Understanding and Implementing Management. Juda, Cape Town.

•

Taylor G (1997) Effective Appraisal Skills. David Grant Publishing, Kent.

•

Taylor MS, Fisher CD and Ilgen DR (1984) Individuals' reactions to performance feedback in organizations. Research Personnel Human Resources Man. 2: 81-124.

•

Templar R (2000) Fast Thinking Appraisal. Prentice Hall, Hemel Hempstead.

•

Torrington D and Hall L (1995) Personnel Management: HRM in action (3e). Prentice Hall, Hemel Hempstead.

•

Walters M (1995) The Performance Management Handbook. Institute of Personnel Management, London.

•

Williams RS (1998) Performance Management: perspectives on employee performance. International Thomson Business Press, London.

Management

in Local

Government.

Performance

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Index Page numbers in italic refer to boxes, figures and tables. active listening 46 addresses 84 administrative teams 63 adult learning 7, 25 appraisal definitions and meanings 13-14 appraisal checklists 48, 56 Appraisal for Consultants Working in the NHS (2001) 90 Appraisal for GPs (ScHARR) 92 Appraisal in Action (BAMM) 92-3 appraisal questionnaires 50, 55-6 appraisal statements 47-8 NHS Appraisal Toolkit 53-4 structure 54 utilising in meetings 56 Appraisal, supervision and mentoring (Burton) 94 Appraisals in general practice: the way forward (Marjoram and Strachan) 93 Appraisals Pocketbook 91 appraisees roles after appraisal 34, 36 in appraisal 32-3 in appraisal meetings 33–4 openness 32-3 personal development plans 34, 36 preparation 33 appraisers 14 external 16 feedback from 31, 34

internal 16 peers 16,19–20 roles after appraisal 34, 36 in appraisal 32-3 in appraisal meetings 33–4 facilitative 34 learning, planning 34 meeting summaries 34, 36 openness 32-3 preparation 33 security responsibilities 44 Appraising Doctors and Dentists in Training (SCOPME) 93 arenas, Johari window 31-2, 42 art of appraisal 37-8 assessments performance 15, 16–17 skills 66–7 summative 39 assumptions, avoidance of 47 Assuring the Quality of Medical Practice: implementing Supporting Doctors Protecting Patients (2001) 90 attitudes to appraisal 24–5 audits 7, 76 avoiding issues 47 balanced appreciations 47 BAMM 83 Beginners.co.uk 86 beginners' guide 23–4

100 • Index

behaviour, evasion 47 benefits, computers 7 bias 47 blame cultures 33, 43, 53 blind spots, Johari windows 31-2 BMA83 building information 45–6 business development plans see practice (business) development plans change enabling 8 external 39 internal 39 City University, London Staff Development and Training 86 clarifying information 46 clinical computer systems 5-6 clinical governance 24 appraisal and 9–10,19, 20, 53 evidence 9-10 information 9-10 NHS support team 83 primary care trust priorities 65 reflection encouraged by 10 service-led education 26 clinical system suppliers training 81-2 communication 10 in meetings see meetings community nurses clinical supervision arrangements 63 complaints 24 completed learning activities 57-8 computers 4–5 advantages 72-3 audits 7, 76 benefits 7 clinical systems 5-6 decision support software 48 learning activities, documenting against PDP aims 72 personal development plans 72 practice (business) development plans 71 practice professional development plans 71 role 70-3 routine jobs 7 searches 7, 76 security 43–4 technology 6 using 6–7

confidence in appraisal 4 confidentiality e-appraisal 43–4 openness and 42-3 trust and 42-3 constructive criticism 47 consultants Appraisal for Consultants Working in the NHS (2001) 90 consumer health informatics 79 continuing professional development (CPD) CMO's review 89 contractual issues appraisal and 20, 21 performance checks 24 counselling 17-18 courses 76 CPD see continuing professional development criticism, constructive 47 culture of organisations 33 data entered and retrieved 10 decision support software 48 DENs (Doctors' Educational Needs) 58 Department of Health 18 address 84 policy statements 20 website 78 development organisational, facilitation 65–6 performance 16–17, 20 plans primary care trusts 62 see also personal development plans; practice (business) development plans; practice development plans; practice professional development plans dialogue, appraisal as 19 dimensions of appraisal 15-18 direct questions 46 discussion groups, Internet 79 district nurses, PREP folders 63 doctor-patient relationship 24 Doctors' Educational Needs (DENs) 58 documentation driving process 33 DoH see Department of Health

Index • 101

e-communities 79–80 e-lists 5 e-mail 5 lists 79 EAR see electronic appraisal records education see also learning; training appraisal links to 17, 21 learner-centred 25 needs analyses, practice teams 67, 68-9 practice professional development plans 66-7 nurses 63 plans primary care trusts 66, 67 postgraduate education allowance (PGEA) 62 service-led 26 stakeholders in 26 teacher-centred 25 educational facilitators 58 educational framework for appraisal learning needs 25-7 effectiveness of learning 26 effects questions 47 electronic appraisal records (EAR) 27, 34–6 appraisal meetings 35 dynamic 54–5 preparation for appraisal 35, 48 recording events or ideas on occurrence 49 reflection, helping with 49-50 EMIS National User Group 4, 83 empathic statements 45 encryption 43 evaluation criteria practice (business) development plans 66 evasion behaviour 47 evidence clinical governance 9-10 sources 10, 16, 19 expectations 9 experience 8 appraisal 14-15 explicit expectations 9 explicit standards 9 external appraisal 16 external change 39

external factors affecting performance, confusing with internal factors 47 impinging on GPs' effectiveness 62 external peer appraisal 14 facades, Johari window 31-2 facilitative roles, appraisers 34 facilitators, educational 58 feedback 6, 8, 19 appraisal meetings 33 from appraisers 31, 34 honest 32 feelings information 45 questions 47 Fenman 87-8 Fifty Ways Towards a Learning Organisation (Andrew Forrest) 7, 8 firewalls 43 formal supervision 17 formative appraisal 16–17, 20, 26 formative developmental appraisals 53 general information questions 47 General Medical Council (CMC) address 84 website 78 General Medical Services (GMS) 21 general practice, development of 24 general practitioners see also appraisees attitudes to appraisal 24–5 external factors impinging on effectiveness 62 revalidation see revalidation self-employment 24 workload 26 giving information 45–6 A glossary of educational terms (Pitts and Percy) 94 GMC see General Medical Council GMS (General Medical Services) 21 Good Medical Practice (GMC) 48, 56, 57, 69, 90 Good Medical Practice for General Practitioners (2001) 90 Good Performance 92 Google 77 GPs see general practitioners halo effect 47

102 • Index

health authorities, policies 30 Health Courses and Careers Update Online 86 Health Improvement and Modernisation Programme (HIMP) 65 health informatics 1, 5 health visitors, PREP folders 63 HIMP (Health Improvement and Modernisation Programme) 65 HIP for CHD 76, 83 Human Resource Solutions 86–7 implicit expectations 9 implicit standards 9 improvement, quality of care 20 in-house appraisals practice teams 67 individual learning appraisal links 21 role 7-8 industry, lessons from 94–7 informatics 3–5,10 see also computers; Internet appraisal role 75-6 consumer health 79 e-communities 79–80 knowledge management 8 meaning and nature 5–6 organisational learning 7 patient surveys 79 personal development 76 teamwork 7 training 76 information 10 see also questions building 45–6 clarifying 46 clinical governance 9-10 feelings 45 insufficient 47 management 8 paper-frugal practices, requirements 7 patients, sharing with 10 security 43–4 seeking 46 support 45 use 8 in meetings 56 insufficient information 47 internal and external factors affecting performance, confusing 47

internal appraisal 16 internal change 39 Internet 5 discussion groups 79 as learning resource 72 web-based appraisal portals 6 web-based resources 83–4 world wide web 5, 77-8 interviews, personal development practice teams 67 see also meetings intranets 73 investment plans primary care trusts 63, 64 issue avoidance 47 Johari window 6, 31–2, 41–2 knowledge management 8 learner-centred education 25 learning see also education; individual learning; lifelong learning; organisational learning; training activities 57-8, 72 adult 7, 25 communities 79 completed activities 57-8 documenting activities against PDP aims 72 effectiveness 26 evidence of activities 72 needs 39 appraisal links 21 defining 26–7 educational framework for appraisal 25-7 periodic reviews 58 recording as arising 57 tables 58 objectives 44 personal development plans 39 organisations, definition 7 planning 34 portfolios 58 protected times 65 self-managed 8–9 work-related 26 lessons from industry 94–7

Index • 103

lifelong learning 39, 62 portfolios 67 listening 19, 46 local clinical system user groups training 82 management, performance 15,16–17,18 management-driven appraisal 15,18–19 Managing Your Appraisal Pocketbook 92 meetings 30 appraisal checklists 48 appraisal statements 47-8 utilising 56 centrepiece of appraisal 44 communication in clarifying information 46 exchange 44–5 giving information 45-6 purpose 47 seeking information 46 decision support software 48 e-appraisal 47–8 preparation 48–9 electronic appraisal records 35 feedback 33 information, utilising in 56 personal development plans, output of 44 roles in 33–4 summaries 34 Mentor 76 mentoring 15 appraisal and 17-18, 18, 21 practice teams 67 A Methodology for Recommending Revalidation for General Practitioners work in progress (2000) 90 misunderstandings 47 monitoring 15 quality of care 20 national clinical system user groups training 82 National electronic Library for Health (NeLH) 72 National Institute for Clinical Excellence (NICE) 65 National Plan 65 national policies 30 National Primary Care Development Team (NPCDT) 61–2 National Service Frameworks (NSFs) 65

needs analyses, personal development plans 72 educational see education learning see learning NeLH (National electronic Library for Health) 72 The New GP: changing roles and the modern NHS (Jelley) 93 NHS Appraisal Toolkit 4, 34–6, 49, 83 accessing 78-9 appraisal checklists 56 appraisal questionnaires 50, 55-6 appraisal statements 48, 53–4 Me and my organisation tool 56 My learning activities tool 57 personal development plans 41 signing off 57 using throughout year 57-8 Priorities and contexts tool 57 summaries of appraisals, signing off 57 NHS clinical governance support team 83 NHS Information Authority 'ways of working' programme 83 NHS Net 5 The NHS Plan (England; 2000) 89 NHSIA see NHS Information Authority NICE (National Institute for Clinical Excellence) 65 non-directive counselling 17 NPCDT (National Primary Care Development Team) 61-2 NSFs (National Service Frameworks) 65 nurse education 63 objectives learning see learning practice 10 practice (business) development plans 66 Occupational Performance 87 open questions 46 openness confidentiality and 42-3 trust and 32–3, 42–3 organisational culture 33 organisational development facilitation 65–6 organisational learning informatics 7 role 7-8 over-influence 47

104 • Index

paper-frugal practices 7 paraphrasing 46 passwords 43 patients doctor-patient relationship 24 information sharing with 10 surveys 79 Patients' Unmet Needs (PUNs) 58 pay, appraisal links to 17, 20–1 PBDP see practice (business) development plans PCTs see primary care trusts PDPs see personal development plans peer appraisal 14,15–16,19–20 performance assessment 15,16–17 checks 24 confusing external and internal factors affecting 47 development 16-17, 20 management 15,16-17,18 problems 20 Performance Appraisal - a necessary evil? (Finnigan) 91 Performance Appraisal Services 86 Performance Management and Appraisal in the Health Services (Edis) 93 Performance Management and Appraisal Resource Centre 83–4 periodic reviews of learning needs 58 personal development 30 informatics 76 interviews, practice teams 67 training and 76 personal development plans (PDPs) 26 appraisal meeting output 44 appraisees' roles 34, 36 computers 72 dynamic 57 learning activities, evidence of 72 learning objectives, medium term statements of 39 modifying during year 39 needs analyses 72 NHS Appraisal Toolkit 41 practice development plans, contributing to 41 practice teams 62, 67 educational needs analyses 67, 68-9 mentoring 67 personal development interviews 67

reflection 58, 72 review 72 signing off 57 template 40 using throughout year 57-8 personal learning and development plans see personal development plans Personal Medical Services (PMS) 19, 21 personal portfolios, nurses 63 perspective 51 PGEA (postgraduate education allowance) 62 Phoenix Training and Development 87 planned learning 34 PMS (Personal Medical Services) 19, 21 policies national 30 statements, DoH 20 portfolios learning 58, 67 nurses 63 postgraduate education allowance (PGEA) 62 PPDP see practice professional development plans A Practical Guide to Effective Appraisal and Assessment for Clinicians and Managers 85

practice (business) development plans (PBDP) 62, 63 computers 71 evaluation criteria 66 objectives 66 process 65 responsibilities for objectives 66 review 66 practice development plans 30 personal development plans contributing to 41 see also practice (business) development plans; practice professional development plans practice professional development plans (PPDP) 62 computers 71 educational needs 66-7 facilitation by primary care trust educational lead 66 model strategy 64 skills assessments 66–7

Index • 105

practices see also practice (business) development plans; practice development plans; practice professional development plans appraisers' understanding of 19 objectives 10 organisational development facilitation 65-6 paper-frugal 7 priorities 65 teams administrative teams 63 development plans 62 in-house appraisals 67 lifelong learning portfolios 67 nurse education 63 PCX planning and 65 training plans 67, 68 prejudice 47 PREP folders 63 preparation for appraisal 9, 30, 38 appraisees' roles 33 appraisers' roles 33 e-appraisal 48–9 electronic appraisal records 35, 48 reflection 30–1 primary care 24 informatics 3–5 training see training organisation policies 30 Primary Care, General Practice and The NHS Plan (2001) 89–90 primary care trusts (PCTs) clinical governance priorities 65 development plans 62 education/training plans 66, 67 educational lead 66 investment plans 63, 64 policies 30 practice planning and 65 protected learning times 65 PRIMIS 76, 83 privacy see confidentiality process of appraisal 30, 38 PRODIGY 76 national dissemination office 82 proposals questions 47 protected learning times 65 protocols 30 public awareness of health issues 24

PUNs (Patients' Unmet Needs) 58 purpose of appraisal 1–2,16,19, 37–8 Q-OPD International 87 quality Assuring the Quality of Medical Practice: implementing Supporting Doctors Protecting Patients (2001) 90 monitoring and improvement 20 standards 9 questionnaires 50, 55–6 questions direct 46 effects 47 feelings 47 general information 47 open 46 proposals 47 reflective 46 Quorum Training 88 RCGP see Royal College of General Practitioners reading resources 85–94 Real Need Software 88 recording learning needs as arising 57 reflection 6, 8, 46, 52 appraisal encouraging 53 clinical governance, encouraged by 10 electronic appraisal records helping with 49-50 methods 49 My learning activities tool 57 personal development plans 58, 72 preparation for appraisal 30-1 tools 10, 58 reflective questions reports 52 resources 3 reading 85-94 web-based 83–4 responsibilities for appraisal 18–19 revalidation 39 appraisal links 19, 20, 69–70 A Methodology for Recommending Revalidation for General Practitioners work in progress (2000) 90 performance checks 24 Revalidating Doctors: ensuring standards, securing the future (1999/2000) 91

106 • Index

reviews learning needs 58 personal development plans 72 practice (business) development plans 66 risk management 10 roles appraisees see appraisees appraisers see appraisers computers 70–3 individual and organisational learning 7-8 informatics 75–6 routine jobs, computers 7 Royal College of Anaesthetists Joint Committee on Good Practice 85 Royal College of General Practitioners (RCGP) address 84 resources 85 website 78 Royal College of Physicians workshop 85 Royal College of Surgeons of Edinburgh (2001) Career advice - the role of appraisal 91 ScHARR report 16–17, 20, 83 SCHIN (Sowerby Centre for Health Informatics at Newcastle) 81–2, 84 searches 7, 76 security appraisers' responsibilities 44 computers 43–4 of information 43–4 seeking information 46 self-awareness, Johari window 31-2 self-managed learning 8–9 service-led education 26 Shaping Tomorrow: issues facing general practice in the new millennium (Mihill) 93 sharing knowledge 8 shop windows 52 skills assessments 66–7 Sowerby Centre for Health Informatics at Newcastle (SCHIN) 81–2, 84 spreadsheets 71 stakeholders in education 26 standards 9 strengths 33, 42

summaries of appraisals 34 signing off 57 summarising 46 summative appraisal 16–17 summative assessment 39 supervision 17 support information 45 Supporting Doctors, Protecting Patients 89 systems views 33, 43 talking to others 31 targets 30 setting, appraisal links 19 teacher-centred education 25 teamwork informatics 7 see also practices: teams technology, computers 6 The 360.co.uk 84 tools 5–6 meetings 48 reflection 10 Total Success Training 88 training see also education; learning appraisal links to 17, 21 informatics 76 personal development and 76 plans practices 67, 68 primary care trusts 66, 67 primary care informatics clinical system suppliers 81-2 clinical system user groups, national and local 82 HIP for CHD 83 NHS clinical governance support team 83 NHS Information Authority 'ways of working' programme 83 PRIMIS 83 PRODIGY national dissemination office 82 vocational 39 trust clinical governance 53 confidentiality and 42-3 doctor-patient relationships 24 openness and 32-3, 42-3 useful addresses 84

Index • 107

vocational training 39 voluntary appraisal 15-16 'ways of working' (WoW) programme 83 weaknesses 33, 42 web see Internet

work-related learning 26 workloads 26 world wide web see Internet WoW programme 83 Zigon Performance Group 88