Part A: Evaluation report from a critical analysis of training and development and performance management in student’s workplace.


 


 


Background of London Health Science Centre


 


            London Health Sciences Centre (LHSC) constitutes a large teaching hospital following the merger of hospitals and clinics in London, Ontario. The focus of LHSC is the development and enhancement of knowledge and skills of healthcare workers on patient care, especially acute care through continuous learning and research. Due to research, LHSC has played an important role in discovering breakthroughs in healthcare and medicine. To facilitate learning, LHSC collaborates with universities and healthcare institutions to provide training and development for around 1,800 healthcare professionals every year. At present, LHSC comprises of a number of hospitals including South Street Hospital, Victoria Hospital, University Hospital, Children’s Hospital, and St. Joseph’s Health Care London together with a number of clinics including the Byron Family Medical Centre and Victoria Family Medical Centre. LHSC also comprise of a number of training and research institutions including the London Regional Cancer Program, Lawson Health Research Institute, and Canadian Surgical Technologies & Advanced Robotics (CSTAR). Included in LHSC are two foundations, which are Children’s Health Foundation and London Health Sciences Foundation. Due to the size of LHSC, the administrative staff and medical health workers of the organization has increased to 10,000 catering to the health care needs of one million patients visiting its hospital and clinics. As a learning healthcare centre, LHSC provides both healthcare services to patients as well as supports the training and development of healthcare professionals. (London Health Sciences Centre, 2008a)


 


Types of Training and Development at London Health Science Centre


            LHSC provides two forms of training and development. One is practical knowledge and skills building and the other is technological training. Both forms of training target different outcomes but are complementary.


            Practical knowledge and skills building is the continuation of theoretical knowledge from the academe. This time the intention is to build knowledge and skills for healthcare delivery practice. Two general groups are beneficiaries or participants of training and development. Future doctors undergo medical training at the hospitals forming part of LHSC in order to earn their license. Training and development works through experiential learning by allowing residents and fellows alike to work the frontline in delivering perioperative services (Joint Commission Resources, 2007). In addition, the resident doctors support in the training of aspiring doctors. Nurses also undergo training and development in the hospitals and clinics under LHSC as part of their academic requirements. LHSC established learning agreements with many universities and schools for the provision of academic training of future medical and nursing professionals and LHSC to sponsor practical training of students. This type of training occurs in the hospital or clinical setting and in actual service delivery via mentoring and precepting. (London Health Sciences Centre, 2008b)


            Technological training involves the enhancement of the capability of healthcare professionals in utilizing innovations on technological tools during healthcare delivery. Lawson Health Research Institute together with Canadian Surgical Technologies & Advanced Robotics takes charge of technological training by engaging healthcare professionals in innovative research as well as training healthcare professionals to utilize tools such as robotics for surgery. Mentoring and precepting are also the means of implementing technological training. (London Health Sciences Centre, 2008b)


            In this sense, the approach to trainings is experiential learning, which constitutes the process of enhancing knowledge by experiencing daily health service situations by healthcare professionals. This means that the interactions, relationships, cognitive processes, mentoring and precepting, and outcome assessment constitute continuous training. As a goal-based training, the intention of experiential training is for healthcare professionals to draw insights or lessons from their experience in actual healthcare settings as well as develop competence for self-assessment. (Brenner, 2004)


            There are four stages in experiential learning integrated into the training program at LHSC. First stage is the concrete experience, where healthcare professionals become active participants or players in actual healthcare situations. During the stage, the trainees assess the situations to identify problems and apply the solutions. Second stage is reflective observation where the trainee ponders on the healthcare delivery experience at the personal level. Third stage is abstract conceptualization, which involves the drawing of general principles that describe the experience using theories. Fourth stage is active experimentation that involves the determination of ways in improving response or actions when faced with a similar experience in the future. The stages form a cycle so that improved responses and actions find implementation in the following concrete experience. (Brenner, 2004)


            Developing the training and development programs of LHSC using the experiential learning approach involved advantages as well as disadvantages. One advantage is motivation (Brenner, 2004) on the part of trainees. The interest in training and development heightens the interests of the trainees when learning occurs at the hospital setting. The interest of trainees means better focus and perceptiveness throughout the training and development process resulting to better outcomes. Another advantage is the expansion of the knowledge and experiences of healthcare professionals in learning through practice. Most of the trainees are intern doctors or graduating nurses who have yet to experience a number of healthcare situations. Every practical experience becomes part of the experience pool of trainees enriching their professional practice. Last advantage is the shift in the polarization of the role of teachers or trainers (Brenner, 2004). In the traditional learning setting, the focal point in learning is the teacher giving instruction. However, in experiential learning the focus shifts to the middle making the participation of trainers and trainees equally important with trainers providing mentoring and precepting while trainees explore knowledge through guided participation. These advantages support the achievement of the goal of LHSC to enhance continuously the knowledge and skills of healthcare professionals to address emerging healthcare issues and contribute to the resolution of long-time healthcare dilemmas. However, there are also disadvantages, or rather areas of weakness that requires consideration for effective training programs. One disadvantage is the reliance of experiential learning on the sufficiency of the academic or theoretical knowledge of the trainees. Experiential learning or practical experience supports training and development of healthcare professionals by augmenting the need for practice. Although, LHSC collaborates with universities and colleges to ensure that its training constitutes the continuity of academic learning, there remains the risk of insufficient academic learning that would likely lead to the failure of the training program in enhancing the practical knowledge and skills of healthcare professionals. Another disadvantage is the reliance of experiential learning on self-monitoring and evaluation. This is because learning comes from the outcome of the cognitive evaluation of the trainees to derive insights or pointers they can practice when experiencing similar healthcare situations. Not all trainees carry a strong appreciation for self-monitoring and in this case the training process may not lead to learning unless the training itself incorporates self-assessment in the process.


            To facilitate the experiential learning approach, the training programs of LHSC involved two related training methods, which are mentoring and precepting. There are similarities and differences between mentoring and precepting but both support experiential learning. Mentoring refers to the one-on-one learning relationship with the mentor making a personal commitment to addressing the learning needs of the trainee (McKinley, 2004; Hayes, 2005). Due to the specific focus, the scope of mentoring covers personal as well as professional issues requiring extended period of learning. The training then involves the determination of the individual needs of the trainee and the determination of the practical situations that would address these learning needs. Precepting constitutes the learning relationship involving one or more trainees that occurs in a limited period but the scope of the learning is specific and based on practical performance or roles (Carroll, 2004). Both mentoring and precepting involves the relationship between a trainer, who is an expert in a certain field or area of expertise, and trainees with general and basic knowledge of a certain field. The difference is in the parties involved and the scope of the learning process. Mentoring involves only two people, the mentor and mentored covering broader scope of professional learning while precepting could involve more than two people covering a specific area of expertise. These give rise to the limitations of mentoring and precepting but by utilizing both in the training and development program of LHSC allowing the coverage of specific and general aspects of professional learning targeting both individual and group needs.


            An example of a mentoring program is the assignment of resident doctors as mentors for interns. A number of resident doctors serve the role of mentors for interns. The scope of the mentoring program covers not only perioperative skills but also handling personal issues such as attitude towards work and balancing conflicting interests. The relationship usually lasts for a long time even after the interns achieved their licenses. A similar mentoring program occurs in the case of nurses, with senior nursing staff taking charge of students training at the LHSC hospitals and clinics in their senior year. The scope of the training is general and the relationship would likely continue especially when the students are absorbed into LHSC hospitals.


            An example of perceptive program is the technical training handled by the Canadian Surgical Technologies & Advanced Robotics that trains surgeons in using robotics for surgery. A trainer who is an expert in robotics for the healthcare setting handles a group of surgeons for developing their knowledge and skills on robotics surgery. The scope of the training is specific and lasts for a defined time.


            Combining mentoring and precepting covers knowledge and skills training in various areas professional practice from professional ethics to best practices in healthcare delivery.


 


Development and Implementation of Training and Development Policy


            The goal of training and development at LHSC is to enhance the knowledge and skills of healthcare professions to take them forward in their careers (London Health Science Centre, 2008c). The development and implementation of training and development at LHSC follows the stages of learning and career development progress.


            A general stage of learning considered in the development and implementation of training and development policy at LHSC involves two general stages, which according to Benner (2004) are teche and phronesis. Techne is the first stage and involves the accumulated knowledge on healthcare deliver processes. This stage of learning involves the practice of rational methods in coming up with outcomes or actualising objectives. The intention of this stage is to transcend mere disinterested understanding and draw trainees to make or do something as part of the learning process. As such, this stage involves the presentation, as an art, of healthcare professional practice. Phronesis is the second stage, which focuses on the development of practical wisdom that comes from moral thought. This process focuses on the ability of the trainees not only to decide the manner of realising an outcome but also to reflect on the outcomes. This extends beyond determining ends but also reflection on actions to achieve improvements and change. The second stage requires more time because it involves the development of habits and deliberation processes directed towards continuous improvement. In this light, the training and development policies of LHSC focus not only on techne but also on phronesis. This justifies the adoption of the experiential learning approach since the two-stage learning process necessitates practical training and development. Since the purpose of training and development is to enhance the knowledge and skills of healthcare professionals, the training and development policies cover the two stages starting with the accumulation of explicit knowledge and moves on to the development of practical wisdom.


            The development of training and development policies also consider the career stages of healthcare professionals. The training and development seeks to help healthcare professionals move from their novice position to the expert position resulting to the policy of progressive learning. Healthcare professionals start out as novices, characterised by the propensity to seek out rules and guidance for action to handle new experiences and address newly experienced issues. Rules and guides serve as the scope and limitations of actions. Student nurses and interns are novices in the healthcare profession. As novice healthcare professionals accumulate practical knowledge and experience, they move to advanced beginner, characterised by seeking of both strategic as well as context-based knowledge. In this stage, there is also already awareness of the situations when rules are broken but learning accumulated from breaking rules in actual practice with awareness of exceptions and choices. As healthcare professionals accumulate the ability to handle issues emerging from professional practice, they advance to the competence stage. At this point, the trainees start to develop skills for self-monitoring of their performance and decision-making during practical situations. During this stage, the trainees consciously ponder about their actions in various practical situations and base decisions on experience-based insight. Further advancement propels healthcare professions into the proficiency stage. With years of experience and accumulated wisdom in healthcare practice, healthcare professionals develop enhanced utilisation of intuition and implicit knowledge to be able to read learning situations with ease and perceive the linkages and explications emerging from healthcare situations. With further learning, healthcare professionals proceed to become experts, characterised by the ability to understand and assess healthcare situations automatically and fluently. This stage involves full adaptability to the healthcare profession resulting in higher degrees of control over situations.


            The training and development policies at LHSC combine the factors of learning and career advancement stages. On one hand, developing training and development policies based on the integration of these stages supports positive results for both healthcare service delivery and healthcare professionals. Progress in learning with career advancement indicate quality healthcare service because continuous learning means the better ability to handle various known and unknown healthcare situations that works for the benefit of patients and hospital management. Progress in learning coinciding with career development also benefits healthcare professionals in terms of motivation and job satisfaction that in turn translate into the voluntary and conscious effort towards self-improvement (Joint Commission Resources, 2005). As such, the integration reflects the strategic plan of the training and development at LHSC to enhance the knowledge and skills of healthcare professionals to get them ahead in their careers.


            On the other hand, there are also complexities and difficulties in integrating these learning and career development stages in training and development policies. One problem is the possible disparity in the transition periods for learning and career development. The disparity has adverse impacts more on the motivation and job satisfaction of healthcare professionals. (Joint Commission Resources, 2005) This could be because of the strong reliance on the voluntary action of healthcare professionals. The success of training and development policies strongly relies on the initiative and participation of the trainees. This means that if trainees do not have a strong desire for training and development to improve their performance and support career advancements, then the training may not achieve the stated purpose. This implies the link between human resource management and training and development. Human resource management encompasses the motivation of healthcare personnel to develop strong links with the healthcare profession to support self-conscious learning and performance assessment, which are important to the success of experiential training and development.  Another problem is the determination of the appropriate standard performance assessment in working with a multi-level progression system in training and development integrating both the stages of learning and career development.


 


Personnel Performance Review Strategies


            LHSC implements three categories of personnel performance review strategies. These performance reviews are multi-level covering the three levels of healthcare positions.


            First, comprise of senior forms covering the assessment of the performance of senior healthcare staff made by attending consultants. There are five types of evaluation forms requiring completion throughout the duration of the junior training including the following:


1) weekly performance feedback form


completed by the senior while on rotation and observance of junior performance


2) senior in-training evaluation report


covering the completion of clinical rotation and reviewed with the senior


3) research in-training evaluation report


completed after a research rotation


4) witnessed communication form


completed while on rotation


5) workplace performance form


covering the attitude and behaviour of the senior healthcare personnel and sent as a report to the program director


 


In the case of senior trainees, there is also the preceptor form, completed by the junior residents after a clinical rotation covering their preceptors. All information from juniors is for tabulation and reporting to the seniors via the Program Director. This means that while the seniors are undergoing training, part of the training is also handling preceptor role for junior healthcare personnel. Training is in itself handling training for subordinates. There is also the RCPSC FITER or the evaluation form filled-up by the Residency Training Committee covering the competencies of the trainee after completing residency. This report ties up the evaluation for the performance of senior healthcare personnel. (London Health Science Centre, 2008c)


            Second, consist of the evaluation form for junior officers, particularly the junior in-training evaluation report for completion by the attending consultant after observing the clinical rotation. The attending consultant discusses the result of the evaluation report with the junior healthcare personnel. (London Health Science Centre, 2008c)   


            Third, comprise of the preceptor form, this time covering the evaluation of the attending consultant by senior and junior healthcare personnel. Completion of the evaluation occurs after the end of the clinical rotation. Tabulation of all filled-up evaluation forms follows before sharing the report to the consultant via the Program Director. Sharing of the report to the attending consultant by the Program Director occurs annually. (London Health Science Centre, 2008c)


            Overall, the personnel review of LHSC revolves around a top-down and bottom-up feedback system that allows the trainer to provide feedback on the trainee and vice versa. The trainee can discuss feedback from the trainer openly. A panel also considers individual evaluations together to ensure objectivity before reporting the outcomes to the party under review.


            The performance review strategies of personnel at LHSC encompass but transcend the components of the traditional performance measures. Traditional performance measures include the following:


 


Measures


Coverage


Targeted Objective


1) input


Use of resources


Service production


2) output


Resulting service


Service production


3) activity


Activities involved in production


Service production


4) efficiency & productivity


Amount of service delivered


Service production


5) service


Addressing customer service needs


Service Delivery


6) quality


Assessment of errors and feedback


Service Delivery


7) explanatory


Sharing of information and exchange of feedback


Service Production-Delivery Link


8) outcome


Accomplishment of goals


Service Delivery


 


These measures find expression in the evaluation criteria in the senior, junior and attending consultant preceptor form. Input measures comprise of the initial knowledge and skills of personnel. Output measures comprise the healthcare services such as consultation and treatment contributed by personnel. Activity involves the processes translating the knowledge and skills to consultation and treatment. Efficiency and productivity refer to the types of consultation and treatment capabilities of personnel as well as patients served during the evaluation period. Service focuses on the ability of consultation and treatment services to address the expectations of patients. Quality targets errors and weakness areas of personnel. Explanatory measures focus on sharing of information and sharing of feedback in a one-way communication and/or two-way discussion. Outcome covers the goals accomplished by personnel. (Hatry, 1999; Joint Commission Resources, 2004)


            By incorporating all these elements into the personnel review process, the review strategy of LHSC reflects its strategic plan. LHSC has six strategic directions. First is to develop and enhance excellence of personnel in caring for patients. This happens by enhancing the knowledge and skills of healthcare personnel by engaging in continuous training and development and determining fulfilment by using personnel performance measures. Second is to integrate education, research and patient care. Again, experiential learning allows the distinction of LHSC personnel in the area of education, research, and patient care and the extent of distinction through performance measures. Professional networks as well as sharing of evidence-based information through training and development supports the achievement of this strategic direction. Third is development of a progressive workplace in order to fulfil the mission and vision of LHSC for the healthcare facility and service in the community. Performance measures determine the achievement of the mission and vision. Fourth is adjustability or flexibility to the evolving role of the institution and its personnel in strengthening community-based health care delivery. By supporting the training and development of healthcare personnel together with its community partners, such as universities and community organisations, it can strengthen healthcare service to the community as shown in personnel performance evaluations. Fifth is the continuous assessment of its organisational structure in order to renew its directives as needed in addressing emerging problems. The effectiveness of the organisational structure has a relationship with the performance of its personnel and the link is shown by the assessment of the performance of personnel. Sixth is the alignment of resources with existing and changing priorities. This means readying personnel to meet impending healthcare service challenges and the readiness of personnel becomes apparent from personnel performance reviews. As such, the performance review strategy of LHSC reflects and supports the determination of the achievement of its strategic directions. (London Health Science Centre, 2008c)


            In addition, the performance review strategy of LHSC also integrates feedback exchanges in practice to have a two-way review process (Joint Commission Resources, 2004) with the personnel under review able to provide feedback to the reviewer on matters subject to consultation. This differs from the traditional evaluation methods of using the performance measures in a one-way assessment. Doing so also supports the achievement of its strategic directions since change in the performance of personnel towards the strategic directions are achieved in an easier manner when there is agreement over the areas of change. The performance assessment strategy of LHSC links the training and development efforts to the achievement of its strategic directions.


            Based on the description of the performance review strategy of LHSC, this appears to be a combination of aspects of balanced scorecard, performance dashboard, program logic, and benchmarking. The following table shows a comparison of different performance review methods:


 


Personnel Performance Review Methods


Strengths


Weaknesses


Balanced scorecard


Based on goal achievement


Limited to measurable goals


Performance improvement measurement model


Based on goal achievement


Limited to customer feedback


Performance dashboard


Financial & non-financial considerations


Limited to strategy deployment


Program logic model


Collaboration-based


Limited to the strategy planning stage


Family of measures model


Financial & non-financial considerations


Limited to the service delivery stage


Benchmarking


Based on self-improvement


Limited to long-term implementation and not suitable for measuring immediate performance


 


There are six general performance measurement systems with respective strengths and weaknesses, four of which find expression in the performance evaluation strategy of LHSC. First is the balanced scorecard that focuses on the extent of achievement of goals but this is limited to goals that are measurable (Kaplan & Norton, 1996) such as hours of work, number of patients, cases handled and other measurable performance factors . Second is performance dashboard that looks into financial and non-financial measures such as costs and returns from performance evaluation but limited to the deployment of strategy. Third is program logic model that focuses on the extent of collaboration among healthcare personnel but limited only during the planning stage. Fourth is benchmarking that targets self-improvement by focusing on comparative strengths and weaknesses based on best practices or standards. (Hatry, 1999)


            There are two other performance measures not included in evaluation strategy of LHSC. Fifth is the performance improvement measurement that also focuses on the achievement of goals but limited to external source or feedback from patients. Sixth is the family of measures also considers financial and non-financial measures but limited only to the implementation stage. (Hatry, 1999)


            The combination of performance methods provides a number of benefits to LHSC. One benefit is the focus on multiple factors including strategy planning, strategy deployment, implementation, and self-improvement to ensure a comprehensive evaluation strategy (Joint Commission Resources, 2005). Another benefit is the consideration of feedback from various parties including the person under review and external parties to ensure objectivity. However, there are still limitations, including the focus on internal feedback, either from the attending consultant or from the personnel under review but without considering feedback from patients. Another limitation is one way performance evaluation for attending consultants when the evaluation of junior and senior personnel undergoing training and development


 


 


 


References


Benner, P. (2004). Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bulletin of Science, Technology & Society, 24, 188-199.


Carroll, K. (2004). Mentoring: A human becoming perspective. Nursing Science Quarterly, 17(4), 318-322.


Hatry, H. (1999). Performance measurement: Getting results. Washington: Urban Institute Press.


Hayes, E. F. (2005). Approaches to mentoring: How to mentor and be mentored. Journal of the American Academy of Nurse Practitioners, 17(1), 442-445.


Joint Commission Resources. (2004). Overcoming performance measurement challenges in behavioral health care. Oak Brook, IL: Joint Commission Resources.


Joint Commission Resources. (2005). Environment of care essentials for health care: Improving health care quality and safety. Oak Brook, IL: Joint Commission Resources.


Joint Commission Resources. (2007). Certification central: Health care staffing services requirements for periodic performance review. Joint Commission: The Source, 5(6), 7-8.


Kaplan, R.S., & Norton D.P. (1996). The Balanced scorecard – translating strategy into action. Boston: Harvard Business School.


London Health Sciences Centre. (2008a). Research and training. Retrieved October 30, 2008, from http://www.lhsc.on.ca/Research_Training/LHSC/index.htm


London Health Sciences Centre. (2008b). Evaluation. Retrieved October 30, 2008, from http://www.lhsc.on.ca/programs/critcare/pge/evalu.htm


London Health Sciences Centre. (2008c). Strategic directions. Retrieved October 30, 2008, from http://www.lhsc.on.ca/About_Us/LHSC/Publications/2008/3.htm


McKinley, M. G. (2004). Mentoring Matters: Creating, Connecting, Empowering. AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 15(2), 205-214.


 


 



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