Introduction to early indicator checklists

Introduction to early indicator checklists HELPING TRAINEES RESOURCE AND GUIDANCE FOR SUPERVISORS OF TRAINING A series of checklists has been developed for supervisors of training (SOTs) that need to initiate management to assist a struggling trainee. The checklists provide a guide to addressing an issue raised about a trainee or by the trainee themselves, as well as a directory of the resources available to you. Early indicators of a trainee experiencing difficulty almost always fall into one or more of the following categories: Exam failure, or failure to present for an exam. Clinical performance issues. Professionalism and/or insight deficiencies. Illness. Global assessment concerns. How will these checklists help SOTS? Designed to help an SOT faced with an issue that has just been raised, these checklists take you through how to: Confirm there is a problem. Raise the problem with the trainee. Plan the correct course of action to assist the trainee. Sometimes the nature of the issue the trainee is struggling with is not apparent. If this is the case, use the early indicator checklist for global assessment concerns. Please note that if the issues raised relate to professional misconduct or threaten the safety of patients or the trainee, you should contact your head of department as soon as possible. Each checklist will guide you through the steps to addressing concerns about a trainee with respect to the likely issue. You need to meet with the trainee to raise the issue and to discuss an action plan. Preparing for this meeting is very important, as is documentation. The decisions from the meeting may mean you move to initiating a trainee experiencing difficulty (TDP) process, but there may be other options. It is important to identify a struggling trainee early because: There are time constraints within the training program. Addressing difficulties early keeps options open for both remediation and ongoing training. Addressing difficulties early can help prevent maladaptive behavior becoming entrenched. 01 Introduction to early indicator checklists

Helping trainees (continued) Barriers to initiating help for struggling trainees, such as hesitation to commence a formal process and difficulty accessing appropriate resources, create delays in initiating assistance for a trainee, whether this is simple remediation or more formal action. The issue raised may not be well articulated or easy to define. What initially appears to be a clinical issue may be due to other issues, such as illness. Supervisors observing under-performance may be reluctant to have a difficult conversation with the trainee, especially if no critical incident or near miss has occurred. Trainers may avoid addressing an issue in the hope the problem resolves itself. They may lack confidence, time or resources to engage in remediation. When the issue is raised, a trainee may be reluctant or unable to engage in remediation. They may not trust supervisors to engage in remediation due to communication gaps, social or cultural differences, or concern about bullying, harassment or confidentiality. 02 Introduction to early indicator checklists

Checklist steps RISK ASSESSMENT Exclude immediate danger to trainee or patient safety. Risk assessment should first address behaviours requiring immediate intervention: Behaviours indicating immediate risk of harm to patients. - Critical error of judgement leading to a near miss. - Direct evidence of substance abuse by the trainee. Behaviours indicating immediate risk of harm to colleagues. - Aggressive or erratic behaviour. - Bullying, harassment or sexist behaviour. Behaviours indicating immediate risk to the trainee. - Evidence of substance abuse. - Evidence of mental illness. Attention should then be given to other issues that have the potential to harm patients if not addressed in a timely manner. Concerns about the trainee s behaviour when unsupervised This includes after hours, on weekends or while their consultant is not directly supervising them. These concerns may include, but are not limited to: choice of anaesthetic technique; assessment of patient, surgical and anaesthetic complexity; communication of the anaesthetic plan to supervisors and other staff; threshold for requesting assistance; and technical abilities. Key technical skills Examples include: Airway management. Vascular access. Regional anaesthesia. Proficiency with available anaesthetic equipment. Finally, other behaviours which impact upon the trainee s ability to practise as an anaesthetist, but which do not appear likely to compromise patient safety, should be addressed. For example, manner of dress or spoken expression in clinical environments. HISTORY - HOW MIGHT THIS ISSUE BE CLARIFIED Supervisors of training should investigate any concerns regarding trainee s performance by seeking information from several sources. These may include: Workplace-based assessment feedback from clinical supervisors. Multi-source feedback (MsF) comments. Written or spoken comments from clinical supervisors to the SOT. Direct observation. Comments or formal complaints by nursing or other hospital staff. Discussion from critical incident reviews or morbidity and mortality meetings. Results of departmental audits of practice, which may identify an individual trainee as an outlier with respect to complications or success rates for particular interventions. Exam feedback. Trainee s self-appraisal in clinical placement review (CPR) meetings. 03 Introduction to early indicator checklists

FURTHER ASESSMENT CONSIDER GATHERING FURTHER INFORMATION You may need to gather further information to clarify the issue. This may be done before or after an initial meeting with the trainee. Consider when to speak to the trainee The trainee has the right to know that inquiries about some aspect of his or her performance are being made. Those who brought their concerns about the trainee to you may not have raised these concerns directly with the trainee. Always explore the context Poor performance is often a manifestation of dysfunction in another aspect of a trainee s life rather than being a primary problem. Workplace or training system problems may be placing the trainee under undue pressure, thus provoking poor performance. Refer to the ANZCA Roles in Practice You may consider performance specifically in relation to the ANZCA Roles in Practice. In addition to the attributes of each ANZCA role being defined in the ANZCA training program Curriculum, each of the roles are described in Supporting Anaesthetists Professionalism and Performance. A guide for clinicians. The latter gives examples of poor behaviour and can be used as a guide to identify behavioural markers that might raise concerns about a trainee s performance. See an example of the markers below. Example from Supporting Anaesthetists Professionalism and Performance, Communicator Communicating effectively with patients, families, carers, colleagues and others involved in health services in order to facilitate the provision of high-quality healthcare. Developing rapport and trust Developing positive relationships with patients that are characterised by trust and the involvement of patients and families as partners in their care. Examples of poor behaviours Shows insensitivity when communication is impaired by patient illness, disability or language difficulties Fails to consider patient wishes when planning treatment in poor prognostic situations and end-of-life care Examples of good behaviours Comforts and reassures patients during stressful situations, procedures or during conscious sedation Encourages patients to ask questions and seek information about their condition and care Australian and New Zealand College of Anaesthetists (ANZCA). Supporting Anaesthetists Professionalism and Performance. A guide for clinicians. Melbourne; ANZCA: 2015. 04 Introduction to early indicator checklists

Consider further descriptors Alternatively, the concern raised may be regarding a particular aberrant behaviour. The following descriptors may be helpful. The overconfident cowboy Overconfident and potentially resistant to supervision. Proceeds with management of complex cases without communicating with supervisors. Note it may be difficult to discern an appropriately confident senior trainee with communication deficits from an unprofessional trainee resistant to supervision. The minimiser/optimist Underestimates clinical conditions, or couches their discussion of patients using minimalist terms such as patient s airway is fine when referring to a Mallampatti IV airway with restricted neck movement. Often seen in the trainee who does not want to deliver bad news to superiors. Trainees who get the textbook answer but not the safe answer Tends to gravitate to the most likely diagnosis without considering the worst possible differential diagnosis, causing potential patient safety issues. Often has a history of excelling in standardised examinations. Trainees who attempt to anticipate specialist preference Tend to develop patient care plans that please their supervising clinician rather than one they would put into action if they were practising independently. Ultimately manifests as a trainee who will not commit to a plan of care. Trainees who are overly conservative Orders more investigations than deemed necessary by most clinicians. Afraid to miss a diagnosis and as a result exposes their patients to the risks of additional investigations and prolonged time-to-treatment. PLANNING FOR A MEETING WITH THE TRAINEE When planning to meet with the trainee it is useful to consider how significant the issue may be, and what options for management may be available. From intuition to problem identification from the History When a concern is raised about a trainee s clinical performance, this may be based on the intuition of the individual bringing the complaint and there may not be hard evidence of a shortcoming. It is important to probe for details and if necessary to consult other authorities who may have witnessed the problematic behaviour or attitude in question. From identification to problem definition from Further Assessment Once the existence of a problem is determined, its nature must be clarified. Consider the trainee s perception of their performance and the putative problem. What are the trainee s perceived strengths and weaknesses? What is the trainee s relevant life history? From definition to intervention developing an Action Plan What problems do you wish to address? How do you wish to address the problem? Who should be involved? Is there a need to appoint a clinical mentor? What will be the timeframe for the intervention? Are there employment or contractual implications of any intervention? For example, can the trainee remain on an after-hours roster? How do you plan to evaluate the intervention? How will the intervention be documented and where will records be held? How will due process be assured? 05 Introduction to early indicator checklists

It may be useful to use the following Milton Keynes traffic light guide to assess the level of action required. MILTON KEYNES TRAFFIC LIGHT GUIDE FOR TRAINEES EXPERIENCING DIFFICULTY Using the guide Level of concern about a trainee is categorised as green, amber or red according to assessments and grades. For grading, apply your knowledge of the trainee to performance in the ANZCA Roles in Practice using the five-point grading scale below. Add a + or a to the grade for trainee's insight into their performance in each ANZCA role. Knowledge may be based on standard ANZCA workplace-based assessments (WBAs) and/or additional information gathered in History or Further Assessment. Refer to Supporting Anaesthetists Professionalism and Performance. A guide for clinicians for a list of behavioural markers in line with the ANZCA Roles in Practice as a guide to identify behavioural markers that might raise concerns about a trainee s performance. In some situations you may need to have an initial meeting with the trainee before you can use the guide. Grading scale for ANZCA Roles in Practice 1. Clearly failing. 2. Concerns; inconsistent practice. 3. Performance at level expected for trainee s stage of training. 4. Above expectation for stage of training. 5. Ready for independent practice (specialist). + Has insight into assessed performance. - Has little insight into assessed performance. 06 Introduction to early indicator checklists

Green Light Amber Light Red Light Assessments Grades Concerns Action Maintaining TPS targets with good performance Appropriate progression of skills Inadequate number of WBAs; borderline assessments; not maintaining TPS requirements; some concerns about appropriateness of behaviours Failure to engage with TPS requirements or assessments Unsatisfactory progress Not reaching expected standard for stage of training 3+ in all roles in practice 1 or 2 in any one role in practice One area may be (-) for insight 1 or 2 in more than one role in practice Poor insight (-) in multiple roles in practice None Some Significant Continue with usual monitoring Interview with SOT, trainee, mentor Set specific targets/wbas with more frequent review and monitoring (interim CPR) Consider TDP if no improvement after set timeframe Interview with SOT, trainee, mentor, possibly head of department Discuss with education officer. Commence TDP. Agreed, achievable goals with agreed, defined timeframe for change or improvement including dates for follow-up meetings 07 Introduction to early indicator checklists

Consider the following action plan options to discuss with the trainee at the meeting. Avenues of remediation a. No difficulty therefore no action required currently. b. Simple remediation. c. Trainee experiencing difficulty process (TDP) offered. d. Trainee experiencing difficulty process (TDP) mandated. e. Trainee performance review (TPR) requested via education officer. Training time options a. Continue in training. b. Consider interrupted training. c. Leave options. Rostering a. Consider workload and after-hours responsibilities. Other actions. Additional notes While it is useful to have considered all of the above issues in general terms prior to meeting with the trainee, it is important not to present any plan for remediation to the trainee as a fait accompli. Ideally, after determining that it is reasonably likely that a problem exists, the SOT will arrange to meet with the trainee in order to work through the definition and intervention phases outlined above. Timely involvement of the trainee helps them to feel as though problem definition and remediation is a process with which they can engage, rather than one that is to be forced upon them. When invited to meet with the SOT, trainees should be aware of the purpose of the meeting and may be offered an opportunity to bring a support person to the meeting. In the early stages of problem definition and intervention planning it is best to avoid widespread knowledge of a trainee s potential difficulties, therefore staff members without direct responsibility for the trainee s progress should not be involved unless this is the trainee s wish. If there are potential employment implications of clinical under-performance then human resources from the employing hospital may need to be involved. If there are immediate concerns regarding patient safety or grave misconduct, such involvement may be early in the process; otherwise the human resources may be invited to subsequent meetings after an initial meeting between the trainee and SOT. DURING THE MEETING WITH A TRAINEE Discussion When addressing concerns regarding trainees clinical performance, discussion should encompass: The issue of concern: The specific behaviour(s) or attitude(s) that have caused concern. The reason this behaviour is concerning. A comprehensive list of all occasions for which evidence of clinical under-performance is believed to have occurred. The trainee s awareness and understanding of relevant professional standards or codes of conduct, such as the ANZCA Roles in Practice, which relate to the issue of concern. To what extent does the trainee have insight into the problem? 08 Introduction to early indicator checklists

To what extent does the trainee accept the need for remediation? The context: Has the trainee s work environment contributed to the problem? Is there a need for system change? This may be within the department, or more broadly within the local health system. Has the trainee s home environment contributed to the problem? Has the trainee s physical health contributed to the problem? Has the trainee s mental health contributed to the problem? Have concerns been raised regarding substance abuse? Options regarding course(s) of action: What can the trainee expect to happen next? Does the trainee feel they have had their perspective heard? What are the implications for failed remediation in terms of continuation in training and continuation in their current workplace role? Who will be informed about the issue and the plan for remediation, both from the training staff and the human resources staff? Action plan Discuss options appropriate to the nature and level of concern, trainee s insight and stage of training. Identify whether the safety of the trainee or their patients would be jeopardised by them continuing to work pending successful remediation of their under-performance issue. a. If yes, implement a plan for clinical remediation. b. If no, discuss with clinical director. Consider options including removal from on-call roster, recommendation for leave, or removal from clinical duties. These are employment issues to be dealt with by the clinical director and the human resources department. Consider training options, including interrupted training. Interventions may include: a. Targeted clinical skills training, with or without simulation training. b. Targeted communication skills training. c. Cultural competence training. d. Enhanced supervision. e. Increased exposure to particular clinical situations. f. Prescribed reading or study. A plan for monitoring progress should be outlined, and may include: a.audit of clinical documentation. b.prescribed workplace-based assessments. c. Clinical supervisor reports. d.trainee reflective journal. e. Mandated multi-source feedback with or without directed responses from particular individuals. An end point needs to be agreed on; initially this may simply be a review date. Documentation It is important to make clear documentation including meeting notes, outlining issues and action points to trainee. Both parties should sign these documents with the aim of ensuring a shared understanding. A template for documentation can be found as Appendix 3 to the Handbook for Training and Accreditation. 09 Introduction to early indicator checklists

Meeting notes should include: The issue requiring remediation. A plan for addressing the issue. A plan for monitoring progress. The expected timeframe for the intervention. The criteria for success of the intervention and for return to normal levels of supervision/ independence of practice. RESOURCES DIRECTORY Each checklist provides links to ANZCA and external resources to assist a SOT, their trainee and the department in addressing issues raised. The core College documents the Handbook to Training and Accreditation, regulation 37 and the Networks online resource for Supporting SOTs provide essential guidance. 10 Introduction to early indicator checklists