Background: Multisource feedback (MSF) is currently being introduced in the UK as part of a cycle of performance review for doctors. However, although it is suggested that the provision of feedback can lead to a positive change in performance and learning for medical professionals, the evidence supporting these assumptions is unclear. The aim of this review, therefore, was to identify the key factors that influence the effectiveness of multisource feedback in improving the professional practice of medical doctors. Method: Relevant electronic bibliographic databases were searched for studies that aimed to assess the impact of MSF on professional practice. Two reviewers independently selected and quality assessed the studies and

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Factors influencing the effectiveness of multisource feedback in improving the professional practice of medical doctors: a systematic review.

After recent UK policy developments, considerable attention has been focused upon how clinical specialties measure and report on the quality of care delivered to patients. Defining the right indicators alone is insufficient to close the feedback loop. This narrative review aims to describe and synthesize a diverse body of research relevant to the question of how information from quality indicators can be fed back and used effectively to improve care. Anaesthesia poses certain challenges in the identification of valid outcome indicators sensitive to variations in anaesthetic care. Metrics collected during the immediate post-anaesthetic recovery period, such as patient temperature, patient-reported quality of recovery, and pain and nausea, provide potentially useful information for the anaesthetist, yet this information is not routinely fed back. Reviews of the effects of feeding back performance data to healthcare providers suggest that this may result in small to moderate positive effects upon outcomes and professional practice, with stronger effects where feedback is integrated within a broader quality improvement strategy. The dominant model for use of data within quality improvement is based upon the industrial process control approach, in which care processes are monitored continuously for process changes which are rapidly detectable for corrective action. From this review and experience of implementing these principles in practice, effective feedback from quality indicators is timely, credible, confidential, tailored to the recipient, and continuous. Considerable further work is needed to understand how information from quality indicators can be fed back in an effective way to clinicians and clinical units, in order to support revalidation and continuous improvement.

Using quality indicators in anaesthesia: feeding back data to improve care

Assuring fitness to practice for doctors internationally is increasingly complex. In the United Kingdom, the General Medical Council (GMC) has recently launched revalidation, which has been designed to bring all doctors into a governed environment. Since December 2012, all doctors who wish to practice are required to submit and reflect on supporting documentation against a framework of best practice, Good Medical Practice. These documents are brought together in an annual appraisal. Evidence of practice includes clinical governance activities such as significant events, complaints and audits, continuing professional development and feedback from colleagues and patients. Revalidation has been designed to support professionalism and identify early doctors in difficulty to support their remediation and so assure patient safety. The appraiser decides annually if the doctor has met the standard which is shared with the most senior doctor in the area, the responsible officer (RO). The RO's role is to make a recommendation for revalidation every 5 years for each doctor to the GMC. Revalidation is unique in that it is national, compulsory, involves all doctors regardless of position or training, and is linked to the potentially performance moderating process of appraisal. However, it has a long and troubled history that is shaped by high-profile medical scandals and delays from the profession, the GMC, and the government. Revalidation has been complicated further by rhetoric around patient care and driving up standards but at the same time identifying poor performance. The GMC have responded by commissioning a national evaluation which is currently under development.

The United Kingdom's Experience With and Future Plans for Revalidation

© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education Context: Revalidation was launched in the UK to provide assurances to the public that doctors are up to date and fit to practice. Appraisal is a fundamental component of revalidation. Approximately 150 000 doctors are appraised annually, costing an estimated £97 million over 10 years. There is little understanding of the theory of how and why appraisal is supposed to produce its effects. A realist review of the literature was utilised to explore these issues, as they generate context-mechanism-outcome (CMO) configurations, resulting in the creation of theories of how and why appraisal of doctors produces its effects. Methods: A programme theory of appraisal was created by convening stakeholders in appraisal and searching a database of research on appraisal of doctors. Supplementary searches provided literature on theories identified in the programme theory. Relevant sections of texts relating to the programme theory were extracted from included articles, coded in NVivo and synthesised using realist logic of analysis. A classification tool categorised the included articles' contributions to programme theory. Results: One hundred and twenty-five articles were included. Three mechanisms were identified: dissonance, denial and self-affirmation. The dissonance mechanism is most likely to cause outcomes of reflection and insight. Important contexts for the dissonance mechanism include the appraiser being highly skilled, the appraisee's working environment being supportive and the appraisee having the right attitude. The denial mechanism is more likely to be enacted if the opposite of these contexts occurs and could lead to game-playing behaviour. A skilled appraiser was also important in triggering the self-affirmation mechanism, resulting in reflection and insight. The contexts, mechanisms and outcomes identified were, however, limited by a lack of evidence that could enable further refining of the CMO configurations. Conclusion: This review makes a significant contribution to our understanding of appraisal by identifying different ways that appraisal of doctors produces its effects. Further research will focus on testing the CMO configurations.

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Towards an understanding of how appraisal of doctors produces its effects: a realist review.

McKenzie, C., Borthwick, M., Thacker, M., Shulman, R., Offord, R., Tomlin, M., Bates, I. and McRobbie, D. (2011) Developing a process for credentialing advanced level practice in the pharmacy profession using a multi-source evaluation tool. Pharmaceutical Journal, 286, pp. 1-5.

Developing a process for credentialing advanced level practice in the pharmacy profession using a multi-source evaluation tool.

Beginning in December 2012, all UK doctors will be required to complete a periodic revalidation process conducted by the General Medical Council (GMC) to retain their licence to practise medicine. Regular appraisals, based on the GMC's core guidance for doctors, will be used by responsible officers to evaluate a doctor's practice based on six types of supporting information. Feedback from patients and colleagues, referred to as multisource feedback (MSF), is one element of supporting information that doctors will present at appraisal to support their revalidation.This commentary by the Chair of the GMC expands on the research in this issue by Wright and colleagues to provide an overview of the history of revalidation in the United Kingdom, discuss the role of appraisal in revalidation, and examine the need for and value of MSF in this process. The author highlights the support that the GMC has received from UK patient organizations and ends by focusing on the benefits of revalidation and the expectations for its development in the future.

Commentary: the role of appraisal and multisource feedback in the UK General Medical Council's new revalidation system.

Most doctors in the UK are very good doctors who keep themselves up to date because they are highly motivated and committed to doing their best for their patients. In the past this was accepted on trust, but the world has changed. Revalidation is the process by which doctors in the future will confirm that they are up to date and fit to practise. A BMJ editorial accurately foreshadowed a tumultuous decade for doctors: ‘All changed, changed utterly. British medicine will be transformed by the Bristol case’. 1 Until the highly publicised events in children’s heart surgery in Bristol, it had been assumed that doctors would maintain high standards in their profession by self-regulation. However, in Bristol some doctors had been harming patients by working outside their competence while others knew but had remained silent. Self-regulation had been found wanting and the General Medicine Council (GMC) proposed revalidation as a consequence. The idea that evolved within the GMC at that time envisaged a four-layer model of revalidation: the professionalism of the individual; constructive self-assessment within the clinical team; effective clinical governance and quality improvement within the organisation; and, at a national level, the regulator. These principles still stand today. Revalidation has been a long time coming. The challenge has been to develop a system that is fit for purpose, while being usable by the 218,000 doctors with a licence to practise: revalidation has to work at the front line. The main pillars will be appraisal and multisource feedback (MSF).

Revalidation: a General Medical Council perspective

The revalidation of doctors was introduced in the UK in December 2012, and means that all licensed doctors must demonstrate periodically that they are up-to-date and fit to practise Regular appraisals, based on the General Medical Council’s core guidance for doctors, will be used by responsible officers to evaluate a doctor’s practice based on six types of supporting information, including feedback from patients and colleagues In this commentary, as the Chair of the General Medical Council and Consultant Physician, I provide an overview of the history of revalidation and discuss the role of the new system of checks (which is being watched with interest by regulators around the world) ensuring that medical practice is of a high quality, that doctors are supported in their professional development and, most importantly, that patients can have confidence in the doctors they consult

Peter Rubin

Papers

Commentary: the role of appraisal and multisource feedback in the UK General Medical Council's new revalidation system.

Revalidation: a General Medical Council perspective

Revalidation: A world first in medical regulation.