Editorial

Citation

Gourlay, R. (2005), "Editorial", International Journal of Health Care Quality Assurance, Vol. 18 No. 3. https://doi.org/10.1108/ijhcqa.2005.06218caa.001

Editorial

Quality assurance is concerned with setting up systems and procedures that can, if properly designed and implemented, assure organisations that what should happen does happen. By following set processes, the outcomes can almost be guaranteed to be achieved. In an “ideal” world the best processes would be installed and religiously followed. Such processes would provide a map for operational work and staff trained in its application. Designing such maps is the easier part – the difficulty comes in ensuring that staff have the competency to do what is required to the standards specified. In other words, are staff competent in all aspects of the work required of them? This raises a whole lot of issues to do with:

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  identifying required competencies in a job;

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  identifying whether staff have these competencies;

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  providing support through training for those who do not have all the required competencies; and

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  monitoring performance to assess whether deficiencies are as a result of a lack of competence or something else.

Identifying requisite competencies of a job

A competency is a mix of knowledge and skill that achieves a specific outcome.

Specifying requisite competencies for a job requires the job to be analysed so that all necessary outcomes can be identified.

This is detailed but important and necessary work. In the UK’s NHS, work has already begun on this. “Agenda for Change”, which is a Government initiative to break down multi-professional barriers, requires that jobs be designed on the basis of competencies required. So, for example, a job defined as that of an everyday practitioner will form the basis of outcomes to be achieved. An “advanced” practitioner will have additional and probably more complex outcomes to be achieved, while a “consultant practitioner” will have even more advanced outcomes to achieve. This is painstaking work involving the Royal Colleges, trade unions and employers’ organisations. The motivation for this scheme is that of additional rewards for staff, and for management the breaking down of traditional barriers to cross functional working.

Identifying whether staff have the requisite competencies

The traditional way of doing this is by testing, observation, or an analysis of past and present outcomes. A useful scale for plotting levels of competency is the following model:

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  Level 1: unconscious incompetence – The individual is unconsciously incompetent. At this level the individual is unaware of the competencies required and is therefore incompetent in their application.

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  Level 2: conscious incompetence – At this level the individual knows what is required but realises they do not have the competency to perform adequately. This can be a helpful state providing the individual is motivated to acquire the relevant competency. If, on the other hand, the individual is very defensive, some more brutal action may be required!

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  Level 3: conscious competency – At this level, the individual knows what is required and possesses the requisite competence. However, in their daily work, the exercise of the competence requires deliberate thought and application of the requisite skills.

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  Level 4: unconscious competency – At this level, the individual has mastered the competencies and their application. The competency is “second nature” and is utilised without conscious thought.

Ideally, the aim is to ensure that competencies are applied from at least level 3. Where they are not, there is a training issue to be addressed. Of course, the real difficulty is determining what levels of competency are already possessed by individuals. For the knowledge element of a competency, tests can be and are being devised to assess the possession of the requisite knowledge.

This is fairly straightforward. More difficult is to test the skills possessed. In this context, such interventions as clinical audit, observation and statistical analysis will serve as useful tools.

Providing support

When the degree of skills and knowledge possessed is inadequate to enable the outcome of the competency to be achieved, support and development of the individual is required.

This can be very demanding, requiring the use of skilled trainers who can design a training experience that is focused on the competency and provides plenty of feedback to the trainee on how well they are performing the competency. As most of the competencies will require “hands on” experience, the ideal way of acquiring them is by treating “real patients”. This cannot always be possible, so one falls back on models and simulation.

This could require significant investment, but the return on the investment could be high in financial terms and safer for the patient.

The NHS Clinical Negligence Scheme for Trusts has demonstrated how investment in competency development can yield significant financial savings.

From an individual’s point of view, maintaining and enhancing their professional competencies stands them in good stead for being allowed to continue to practice.

Conclusion

Quality assurance strategies demand that there are in place relevant schemes for policies, processes and standards. Alongside these there needs to be a systematic approach to the development of requisite competencies in individuals.

This, it is proposed, will require careful analysis of what competencies are required and an “open” assessment of competency already possessed by staff.

Where existing competency levels do not meet requisite demands, then training and other supports need to be provided. While this can be expensive, the pay-off can be a reduction in “adverse incidents” and thereby possible reductions in the annual legal bill.

Robin Gourlay