The Basics of Appraisal and Assessment

Appraisal and assessment are integral parts of any quality assurance programme. Superficially, it would seem that appraisal is for the benefit of the individual and assessment is something entirely different, being a method whereby the organisation and the public ensure that the individual or team is measured against some external standard. In fact, the reason for both is to ensure the delivery of a quality service to patients, one that reflects on what has been achieved as well as on the achievements of others in similar fields. Therefore, there is constant refreshment of practice, influenced by feedback from internal and external audit resulting in the maintenance of the highest standards in an ever-changing environment.

In medicine, appraisal and assessment deal with much more than purely clinical matters, but as well they broach interpersonal skills and ethical issues involving as they do feedback from as many sources as possible. Most importantly patients must be empowered to contribute. Appraisals are also about identifying likely risks to patients and taking immediate action before any serious problems develop. If a number of appraisals on an individual have been positive, showing appropriate growth and development, then they form the basis of an end point assessment or revalidation programme.

So what is the difference between appraisal and assessment? Both are used to drive learning and keep up performance, but they are fundamentally different in the way they operate. Both require the gathering of evidence of performance in a variety of areas and also demand a period of reflection. Appraisal is an ongoing dynamic process involving two-way communication by discussion and allowing for course corrections as circumstances change. It involves the three C's: cooperation, collaboration and compromise in order to inform, guide and develop an individual's potential, usually in line with the strategic objectives of the healthcare system. It should facilitate growth in other directions and, because of the two-way feedback, may well influence the setting of future directions by management. This is vital for the service to remain dynamic and keep abreast of professional trends. The emphasis is therefore on individual growth, development and performance and is basically for internal consumption.

Assessment has a different driving force. It can be seen as a snapshot in time, providing evidence for external consumption of levels of training and quality within the organisation. It is no longer two-way but involves judgement of the worth or value of a particular performance. It is used to make decisions based on the moment it is carried out. It is checked against external standards and is not usually subject to two-way feedback at the time, although it may be later through an appeals process. The three C's of appraisal are not much in evidence, but rather the fourth C of confrontation may be more obvious when things go wrong!

A revalidation system should be a mixture of both. There are many reasons why a single snapshot in time may not give a valid picture of overall performance. On the other hand some check of competence must be made to ensure quality standards are maintained. Revalidation should be based on multiple appraisals and assessments so that the end result does not contain any surprises. The combination of both appraisal and assessment starts a culture of setting objectives and standards as well as giving feedback of a positive nature to help growth. The whole intention is to identify any potential problems as early as possible, to identify training and development needs and to ensure these are carried out in order to provide a sound basis for revalidation.

Benefits of an Appraisal System

Even the suggestion of the introduction of an appraisal or assessment system can provoke fear, suspicion and cynicism amongst staff, leading at least to resistance and potentially refusal to fully participate or give the process more than lip service. Some may see the introduction of such a system as being an imposition and infringement of their rights, because they feel it is going to be imposed as a management tool for disciplinary purposes. They do not regard it as being something developed in collaboration with them and see no positive benefits either to their patients or, it must be said, to themselves.

The purpose of the exercise is to improve the organisation's performance, specifically by enhancing the performance of individuals, and this needs to be communicated in a positive way. A process is needed which avoids anger and unnecessary confrontation, as this leads to low morale and demotivation. The intention is to guide individuals in a particular direction in keeping with Health Service targets. If this is done badly it creates tension within a hospital, leading to bad relationships between peers and management, and can result in undue importance being given to frivolous issues.

Well motivated staff with high morale is essential for any organisation to move forward. Motivation and professionalism must pervade the management structure.

Appraisal will work best if it is seen to involve sharing and solving as opposed to calling to account. A motivated workforce is characterised by a drive to develop, helping each other to move forward in a system which rewards progress and achievement fairly and consistently. Nevertheless, appraisal must be capable of identifying and supporting individuals when level of performance seems to be an issue.

This is achieved in the first instance by the production of an agreed personal development plan, usually on an annual basis, which creates focus and clearly targets the expectations of the staff, letting them know where they are going and what is expected of them. These objectives are written down and provide boundaries as well as defining expectations. The personal development plan also contains a commitment from management which may be in terms of finance, appropriate equipment, a good working environment with adequate support staff, or the provision of training as necessary. In other words, management agrees (in what is in fact a contract) to commit appropriate resources.

The appraisal interview is structured in order to highlight achievement and to acknowledge when expectations have been exceeded. It is a review against levels of job performance and outcomes which have been previously agreed. Any lack of performance should also become obvious, but the nature of the two-way discussion and feedback allows full exploration of the reasons why such deficiencies have occurred and whether or not the cause was external to the appraisee. Professionals therefore have the opportunity to feed back to management any constraint and limitation on their performance, due for instance to lack of equipment or staff which should be considered to be management issues. There is also the opportunity to highlight problems which may be arising in other areas or support departments such as a laboratory.

Setting such targets and having them agreed in writing in advance is a very powerful form of protection for the professional from undue criticism. It replaces innuendo with a process that can be seen to be both open and fair, providing an equitable situation which can be demonstrated externally. There is better communication at all levels giving an early warning of problems or indeed grievances.

One of the positive benefits of a clear appraisal system is that areas of concern can be identified fairly quickly before there are consequences that damage the reputation of the organisation. This will only occur in an open, supportive environment. In a punitive system, people are inclined to hid problems until they become so obvious that they simply burst through their protective wall and create havoc. A system that respects its workforce but yet has very clear guidelines of behavioural standards which are transparent, moral and at the same time are seen to be fair, is most likely to result in identifying those who, for one reason or another, are underperforming at a particular time. They can be helped to come to terms with the problem, assisted in their development by retraining or redeployment or enabled to make other creative decisions before there are unacceptable outcomes for patient care.

An important benefit of appraisal and assessment from the management point of view is the agreement of action plans and deadlines. This extrinsic drive encourages people to finish the tasks they have agreed. This is vital if different people or departments are required to complete tasks in a particular sequence, because if one person does not finish their portion in time then others cannot complete or, in some cases, even start the next stage.

Both appraisal and assessment drive learning and behavioural change. The bottom line is that by working with its resources, most management, especially human resources is aiming to ensure the safe and effective functioning of the unit and delivery of healthcare. Appraisal is the basic tool.

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