Early assessment for safety and learning (EASL)
Standard 1.1 of the Standards for general practice training requires that: ‘Supervision is matched to the individual registrar’s level of competence and learning needs in the context of their training post'. Registrars enter their first general practice placement (GPT1) with varying levels of experience and clinical competency and may be unfamiliar with working in Australian general practice. Supervisors cannot assume they are competent and safe to manage patients in all areas of practice without direct supervision at the start of their training.
The EASL suite of tools assesses the level of competence of a registrar in early GPT1, identifying areas where closer supervision and guidance may be needed, and if the registrar is able to recognise their limitations and seek help appropriately when required (Figures 4 and 5). Data from the EASL tools inform the development of an appropriate supervision plan tailored to the individual registrar's level of competence and learning needs in the context of the training practice.
The main objectives of the EASL are to:
- support patient and registrar safety
- collect evidence of the registrar’s performance and current level of competence
- begin to identify learning needs and potential knowledge gaps
- match supervision to the registrar’s level of competence and learning needs
- inform the development of the registrar’s supervision and teaching plan
- identify if a registrar is performing below the level expected at the beginning of their first general practice placement to enable appropriate support to be given.
Timing for completion of EASL activities is driven by the supervisor.
The EASL can be completed at any time within the first four weeks of GPT1. This allows time for orientation of the registrar to the practice and practice processes; for the registrar to gain an understanding of local patient demographics, resources, and services; and for the initial workplace-based assessment to be completed.
Supervisors have the authority to determine the appropriate supervision requirements at any time during this four-week period using the EASL suite of tools and any other data available to them to support the decision. Additional data might include but not be limited to feedback from practice staff and patients, discussions with the registrar, and a ‘call for help’ list. The EASL may identify the need for closer supervision for certain areas of practice such as paediatrics, mental health or women’s health, or certain procedures.
The EASL comprises three components:
- a multiple-choice question (MCQ) assessment with an integrated self-confidence rating
- direct observation of consultations by the supervisor
- daily case review and debriefing conducted by the supervisor.
Figure 4 - Overview of EASL
The first component of the EASL is the MCQ, which comprises an assessment of applied knowledge and self-confidence through 70 multiple-choice questions, delivered online and preferably completed prior to commencing the first general practice placement. The questions focus on acute and serious illness and common presentations in general practice. The test is blueprinted against BEACH and ReCEnT data and the ‘call for help’ list, which was developed through qualitative research involving supervisors, registrars, and medical educators. A self-assessment confidence rating grid is embedded into the test to provide insight into the registrar’s self-awareness and potentially reveal any unconscious incompetence. Knowing when to ask for help is an important aspect of patient safety.
At the completion of the MCQ test, a report is generated for use by the registrar, supervisor, and medical educator. This report allows the registrar and medical educator to identify learning needs early in training, especially in areas that are critical to patient safety. It can be used as a baseline measure to prompt discussion, facilitate self-reflection and allow monitoring of performance over time. The supervisor may find this report useful to identify areas to include in in-practice teaching and where the registrar may require closer supervision.2
Note that the MCQ is not a WBA but has been included as it is part of the EASL.
EASL direct observation of consultations
Direct observation of consultations takes place early in the first general practice placement. Direct observation allows the supervisor to assess registrar performance especially in areas with an increased risk of adverse outcomes.7 Supervisors are required to complete and document direct observation of the registrar performing a minimum of four consultations.8
Supervisors should consider the following areas during the EASL direct observation:
- communication skills
- consultation skills
- clinical management and therapeutic reasoning
- general practice systems and regulatory requirements.
Direct observation includes review of the registrar’s clinical notes, scripts and referrals. Additional direct observation may be required to enable the supervisor to assess registrar safety and competency across a broad range of consultations, such as paediatrics, mental health or other areas considered relevant to the practice setting. The need for additional direct observations will be determined by the supervisor.2
EASL daily case review
When a registrar begins their first general practice term, it is recommended that each day the supervisor and registrar discuss the care of a selection of the registrar’s patients seen that day. This can take place either during or at the end of the day. These case reviews will provide useful information to the supervisor about the registrar’s level of competence and learning needs and inform the supervision plan. These discussions do not need to be formally documented unless the supervisor considers it necessary.
It is recommended that the registrar take notes about the cases reviewed and the feedback received during these sessions. This will allow the registrar to record, analyse and set learning goals and to review their performance and progression in the future.
The supervisor determines when routine daily review of cases is no longer required.
Using the EASL
The EASL suite of tools has been designed to provide valuable information about a registrar’s current clinical competence as they undertake their first general practice placement. Registrars will be provided with formative feedback on all components of the EASL. The data from the three components of the EASL will help the supervisor and registrar plan learning, develop the supervision plan and identify if the registrar needs additional support.2
The local medical educator is also available to guide the registrar and support the supervisor in this process. If the supervisor is unable to decide on the level of supervision the registrar requires then further assessment, such as an early external clinical teaching visit (ECTV), can be undertaken in discussion with the local team.
The EASL is considered completed when the supervisor has decided the appropriate supervision required to support both patient and registrar safety, or when the registrar is identified as requiring further assistance. At this stage, the supervision plan is completed.
Figure 5 - The EASL at a glance