Providing ‘value’ in clinical supervision

How an ounce of prevention is worth a pound of cureTracey Tay

Staff Anaesthetist HNE HealthClinical Lead NSW Agency for ClinicalInnovation

June 11, 2014

Key messages

• Clinical supervision is essential work and it takes a lot of time and energy to do this well

• When a trainee is in difficulty, the longer the problems are left unaddressed, the more work is required

• Creating a healthy workplace helps to prevent problems and allows early detection of trainees in difficulty.

A question of attitude…..

A question of attitude

Difficult traineesvs

Trainees in difficulty

Value

• Many definitions

• Prof Michael Porter, Harvard Business School• Value-Based Healthcare Delivery

• Value = patient outcomes per dollar spent

What is ‘value’ in supervision?

• Trainee supervision outcomes per resource expended

Trainee supervision outcomes

• For the trainee₋ Knowledge₋ Skills₋ Behaviours

• For patients and the organisation₋ Safety₋ Appropriate care₋ Efficiency₋ Timeliness₋ Patient-centred care

What are we concerned about?

• Performance

• Conduct

• Impairment

• Grey areas ₋ Professional behaviour₋ Exam preparation₋ Motivation

How do we measure these outcomes?How do we know if a trainee is in difficulty?

For the trainee• Exams – formative, summative• Workplace-based assessments₋ Direct observation of

procedural skills (DOPS)₋ Mini clinical evaluation exercise

(Mini-CEX)₋ Multisource feedback

• Informal discussions with the trainee or other staff

• Informal observation

For patients/organisation• Adverse events• Complaints

Trainee in difficulty

• Rotated away on a number of occasions• Corridor and tea room conversations• “Odd behaviour”, “no insight”• Comments by nurses and other team members• 8 yrs into the program, dept decided to act• Difficult conversation• 6mth remediation program –extra supervision, extra

teaching, formal documented feedback• Trainee not reemployed

Trainee in difficulty

• How fair was this for the trainee?

• Would there have been a different outcome if there had been early intervention?

Early or late?

Early or late?

Intervening early - Coach or referee?

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Time (Quarter years)

Intervening early – feedback conversations

• Daily!• More likely to be specific, timely• Seek training in giving and receiving feedback• Provide a template to get everyone started

Intervening early – a healthy workplace

• Leadership, role-modelling and being accountable₋ Heads of department₋ Supervisors of training ₋ Clinical supervisors

• Processes₋ Clear requirements/criteria for supervision₋ Rostering for appropriate supervision₋ Workload/hours of work

Intervening early – a healthy workplace

• Support structures/people/processes₋ Orientation₋ Peer support/buddy systems₋ Mentors₋ Agreed ‘above and below the line’ behaviours₋ Support for ‘speaking up’₋ Training₋ Early access to specialist help

Intervening early – a healthy workplace

A plea for kindness and compassion

Best ‘value’ in supervision is early intervention

• Spend time and effort to create a healthy environment

• Make giving and receiving feedback an ‘everyday’ thing

• Don’t wait for trainees to make a mistake before you intervene

Remind yourself, if things aren’t going well, this is a person in difficulty NOT a

difficult person

tracey.tay@aci.health.nsw.gov.au