PicoBlog

In a previous article I provided some general advice on how to maximise the usefulness of supervised learning events (SLEs) and concluded the piece with the intention to write further articles that focus on the indivudal tools.

The RPS Post-registration Foundation Curriculum now has three observational SLE tools for assessing a pharmacist’s clinical practice:

• Acute Care Assessment Tool (ACAT) for observing several patient encounters over a continuous period of practice

• Mini-Clinical Evaluation Exercise (Mini-CEX) for observing a holistic review of an indivudal patient’s medicines and / or an in-depth consultation with them. Questions may be asked to clarify decision making processes, but this tool is not intended to be used to assess clinical knowledge in depth (that’s where the case-based discussion comes into its element)

• Direct Observation of Practical Skills (DOPS) for observing how a pharmacist performs a specific clinical examination / assessment skill (e.g. measuring blood pressure, urinalysis)

I’ll now discuss each tool in a more detail and offer some advice on how they can be facilitated in practice.

The ACAT assesses how a pharmacist performs multiple patient reviews over a continuous period of practice.  Skills such as clinical assessment and reasoning, teamwork, time management, prioritisation and record keeping can be evaluated during this observation.  One of the advantages of this tool compared to other observational SLEs is that it doesn't rely on a particular patient or scenario being available on that day.

The ACAT can be conducted in any setting, with examples including observations of:

• A pharmacist working on ward – this could be part of a multidisciplinary ward round or reviewing patients autonomously

• A pharmacist clinically screening prescriptions in a dispensary (either a hospital or community pharmacy)

• A pharmacist reviewing a case load in clinic or GP surgery

• A pharmacist taking telephone enquiries during a shift in medicines information

Any period where a pharmacist is required to review a series of patients or deal with several enquiries can be used. The scenarios will vary depending on the setting.

The pharmacist and assessor should agree a date and period of time during which the observation will take place.  The Royal Pharmaceutical Society’s ACAT feedback form recommends a minimum of five patients / cases are observed, however, this may not be possible on some occasions (e.g., a quiet period in medicines information).  If the pharmacist did not perform well during an ACAT, a subsequent one can be arranged to assess how they have addressed the feedback provided.

The assessor should avoid being intrusive whilst observing the pharmacist and limit their questioning to confirming how the pharmacist is prioritising problems and justifying their proposed actions.  If a particularly complex case is encountered during an ACAT, it could be used for a Mini-Clinical Evaluation Exercise to provide the pharmacist with more detailed feedback about that particular scenario.

This is a prospective observation (lasting approximately 15-20 minutes) of how a pharmacist provides care for an individual patient.  It is designed to assess their communication skills (with patients, carers and other healthcare professsonals as appropriate), information gathering, problem identification and decision-making.

The Mini-CEX can be undertaken in various practice settings:

• A community pharmacy - at the medicines counter, in a consultation room

• GP surgery

• Primary care clinic

• Hospital - wards, dispensary, clinic

There is no "ideal" patient for a Mini-CEX, but those with limited opportunities for a pharmacist's input will lessen the educational value of the assessment.  The examples below demonstrate the variety of scenarios that could be used (at any stage of the patient’s journey) and do not represent an exhaustive list:

• Where the main focus is reviewing the appropriateness of the patient’s current prescribed medicines:

  • In a community pharmacy this could include the NHS Discharge Medicines Service, the NHS Urgent Medicines Supply Advanced Service or responding to an emergency supply at the request of the patient

  • In primary care this could involve a structured medication review or discharge medicines reconciliation

  • In hosptial practice this could involve the intitial assessment when a pharmacist meets a patient for the first time on a ward, following up interventions made during a previous review or facilitating a safe and seamless discharge. If the latter is used, patients with additional considerations should be used to provide greater scope for the assessment (e.g. continuity of supply for patients prescribed unlicensed medicines or treatment for opiate dependence; communicating changes about a patient’s medicines to primary care)

• Where the focus is a patient consultation:

  • If patients requiring counselling about their medicines are chosen, try to think about why that patient was chosen based the pharmacist’s previous experience (i.e. what is the value of using another patient requiring anticoagulant counselling?) and on any anticipated challenges (e.g. language barriers, patients with known poor adhernce)

  • Patients with poor adherence may be identified by the pharmacist or a colleague. The outcomes of these consultations may require the pharmacist to discuss proposed changes to the patient's medicines (e.g. switching formulation due to palatability issues) with the prescriber and this could also form part of the observation

• When the focus is responding to clinical queries raised by patients or other healthcare professionals

Assessment dates can be pre-arranged, but try to be flexible to facilitate a Mini-CEX when a suitable scenario presents itself – e.g. the pharmacist is asked to speak to a “demanding patient” at the dispensary hatch.  If the assessment has been pre-arranged, identifying more than one potential patient / scenario can help facilitate selection of the most suitable one. I have discussed when the best time may be to schedule these during a rotation / clinical attachment in a recent article in the Pharmaceutical Journal. If the pharmacist did not perform well during a Mini-CEX, a subsequent one can be arranged to assess how they have addressed feedback from the previous one.

Since this is an observation of practice, the assessor should avoid being intrusive and limit their questioning of the pharmacist to confirming how they are prioritising problems and justifying their proposed actions.  Although interjections should be minimised (e.g. if there is a genuine clinical concern about the actions proposed by the pharmacist), other pertinent issues should be discussed afterwards, as part of the feedback for the assessment.  Therefore, pharmacists being assessed should lead the discussion to demonstrate how they synthesise information (rather than read out verbatim the content of the case notes), articulate thought processes and use clinical reasoning. 

This tool can be used for pharmacists to demonstrate competence in a range of individual procedural skills.  It has been adapted from the Direct Observation of Procedural Skills assessment used in medicine (to assess procedures not covered in the GMC’s core procedures list) and therefore, it is more useful for when pharmacists are undertaking independent prescribing training. If an observation involves multiple tasks, then this is not an appropriate tool to use.  In my experience, the DOPS tended to be used for a multitude of tasks where a Mini-CEX or case-based discussion would not have been a suitable tool (including patient counselling and delivery of teaching sessions). However, now that the RPS have expanded the suite of SLE tools available, this should no longer be the case.

The assessment can take place on wards, in clinics or in community pharmacies. 

The Royal Pharmaceutical Society's Post-registration Pharmacist Topic Guide (page 7) contains a list of core clinical assessment skills, for which a DOPS can be used to evaluate a pharmacist's competence in performing them in practice. 

Pharmacists will identify a clinical skill and the assessor should have experience and expertise in this area.  Questions from the assessor should be minimised and restricted to clarifying the pharmacist’s processes when performing the task.  On the feedback form, assessors should indicate the difficulty of the task in relation to the pharmacist’s previous experience. 

The other point to consider is what the purpose of conducting a DOPS is for an individual pharmacist, taking into account their level of experience and competence.  Is the purpose of today's observation to purely assess their approach to performing a particular skill or is it to assess whether they can identify a particular abnormality?  Did a previous DOPS identify areas for development that an assessor wants to check have been addressed? 

Planning DOPS assessments in advance may limit what can be assessed given the unpredictable nature of a case mix on any day. However, if the purpose of the DOPS on that day is to focus on assessing a pharmacist's approach to undertaking a particular clinical assessment (e.g.  measuring blood pressure, checking oxygen saturations) rather than identifying a particular abnormality, then this is acceptable.  If an assessor is satisfied that a pharmacist’s approach to undertaking a specific examination skill is thorough, they may now want to challenge them further by assessing whether they can identify specific abnormalities. In this case the assessment may need to be conducted on a different ward or clinic room and organised at short notice when the assessor identifies a patient with a particular abnormality. 

Having three different tools to assess observations of clinical practice may at first seem confusing, but by taking a step back and thinking about what you’re assessing, you should then be able to use the most appropriate SLE tool for the assessment.

My next article will discuss how to use case-based discussions effectively and how this tool differs from the Mini-CEX.

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