Assessment is a crucial component of the Foundation Programme Curriculum (the Curriculum). It is the duty of the foundation doctor to demonstrate engagement with the assessment process. This means undertaking appropriate assessments and documenting them in the e-portfolio. Individual assessments are formative and represent an important opportunity for learning and reflection on practice. The end of placement/final supervisor’s report will draw on the outcomes of multiple assessments. Participation in the assessment process, coupled with reflective practice, is the best way to demonstrate progression towards the outcomes expected of the programme.

i Purpose of assessment:

• to highlight achievements and areas of excellence
• to emphasise the need for feedback
• to supply and demonstrate evidence of progression linked to the Curriculum
• to identify doctors who may need additional help.

ii Assessment methodology

Continuous assessment

The assessment tools are formative, thus designed to help foundation doctors improve their practice. Foundation doctors are expected to demonstrate improvement and progression during each attachment. Therefore, they should arrange for these assessments to be evenly spread throughout each attachment. Improvement in clinical practice will only happen if regular assessment leads to constructive feedback. Thus continuous assessment is a fundamental part of the Foundation Programme.

The educational/clinical supervisor’s overall assessment and judgement of the foundation doctor must be based on multiple assessments by many observers. Within any attachment an individual assessor is unlikely to build up a coherent picture of competences, let alone performance of an individual foundation doctor. Therefore the local Foundation Programme training director/tutor should ensure that there is a local faculty responsible for forming a balanced judgement of a doctor’s performance supported by the assessment results. Such an approach will prevent any individual having undue influence over a doctor’s progression. To ensure fairness and equality of opportunity, all assessments will be subject to monitoring.

Self assessment

Foundation doctors have a personal responsibility to make self assessment an integral part of their professional life. It is good educational practice for this to be stated clearly and discussed fully during induction.

Foundation doctors, with the support of their supervisor(s), are responsible for arranging performance appraisals, having the outcomes recorded and documenting ways to improve.

Assessment differences between F1 and F2

The assessment methods are the same in F1 and F2, but different standards pertain. The judgement about whether or not a foundation doctor has met the required standard for satisfactory completion of F1 or the Foundation Programme will involve a sample of the detailed competences and will not include a formal assessment of each one. Nevertheless, doctors about whom there are concerns, or who are felt to be performing sub-optimally, will need more of their practice sampled than those who are performing consistently well.

F1

The outcomes recorded following clinical performance reviews or assessments will feed into the overall performance report at the end of the year. This report confirming overall satisfactory performance of the F1 doctor will inform the medical school as to whether they should complete the GMC Certificate of Experience. Once the Certificate is issued, the doctor is eligible to apply for full registration with the GMC. The GMC expect competence in all the domains set out in The New Doctor and reproduced in the Syllabus and competences.

F2

The overall judgement of satisfactory completion of F2 will allow the doctor to be eligible to enter core or specialty training. This judgement will include an assessment of a foundation doctor’s ability to take on increasing levels of responsibility. During assessments, doctors will be expected to discuss or demonstrate achievement in each of the headline competences (see Syllabus and competences). The assessment process is not designed to rank the performance of doctors in training.

E-portfolio

The e-portfolio is the record of a foundation doctor’s assessments, achievements and other evidence demonstrating completed outcomes as specified by the GMC. The deanery will specify which e-portfolio is in use. It is essential that foundation doctors populate the e-portfolio with assessments, achievements and other evidence as it will be used to inform the end of year report by the foundation school director. It may also be used during interviews for appointment to specialty training.

Assessors

• assessors must be trained in giving feedback, understand the role of the tool being used, assessment methodology and be competent in the competence they are assessing
• most assessors should be supervising consultants, GP principals and doctors in training who are more senior than the foundation doctor, experienced nurses or allied health professional colleagues
• foundation doctors should usually agree the timing and the clinical case/problem with the assessor
• assessors should also carry out unscheduled assessments.

Assessment Tools

A. Multi-Source Feedback

Team Assessment of Behaviours (TAB)

• this consists of the collated views from a range of co-workers (previously described as 360-degree assessment). It will be mapped to a self-assessment tool with identical domains
• MSF should usually take place at least once a year. Deaneries have the option of increasing the frequency
• it is suggested that both F1 and F2 TAB be taken in the first four months of the year’s training. If there is a risk of “rater fatigue”, ie overburdening of a small number of colleagues, then F2 TAB could be undertaken in the second four months of training. If there are concerns about any foundation doctor, TAB can be repeated in the last four months of training.
• for each assessment, the foundation doctor should nominate 15 raters. A minimum of 10 returns are required. No other foundation doctor can be a rater. Recommended mix of raters/assessors is as follows:

• 2–8 doctors more senior than F2, including at least one consultant or GP principal
• 2–6 senior nurses (band 5 or above)
• 2–4 allied health professionals
• 2–4 other team members including ward clerks, secretaries and auxiliary staff.

Two tools can be used to assess doctor/patient encounters:

• Mini-clinical evaluation exercise (mini-CEX)
• Direct observation of procedural skills (DOPS).

Foundation doctors are required to undertake a minimum of nine observed encounters in both F1 and in F2. At least six of these encounters each year should use mini-CEX.

i Mini-clinical evaluation exercise (mini-CEX)

This is a structured assessment of an observed clinical encounter.

• foundation doctors should complete a minimum of six mini-CEX in F1 and another six in F2. These should be spaced out during the year with at least two mini-CEX completed in each four month period
• a different assessor should be used for each mini-CEX wherever possible, including at least one of consultant or GP level, per four month placement
• each mini-CEX must represent a different clinical problem, sampling one of the acute care, chronic illness, psychiatric care, etc. (categories listed in the Syllabus and competences).

ii Direct observation of procedural skills (DOPS)

This is a structured checklist for assessing the foundation doctor’s interaction with the patient when performing a practical procedure.

• foundation doctors may submit up to three DOPS as part of the minimum requirements for evidence assessing doctor-patient encounters. However there should also be a minimum of six mini-CEX per annum
• different assessors should be used for each encounter wherever possible
• each DOPS could represent a different procedure and may be specific to the specialty
• although DOPS was developed to assess procedural skills, its primary purpose in foundation is to assess the doctor/patient interaction.

C. Log book

The GMC requires demonstration of competence in a series of procedures in order for a provisionally registered doctor with a licence to practise to be eligible for full registration. These will be recorded and signed off in a log book, which is found in the e-portfolio. A completed log book is also required for successful completion of the Foundation Programme.

D. Developing the clinical teacher

This is a form to aid the assessment of a foundation doctor’s skill in teaching and/or making a presentation.

E. Case based discussion (CBD)

• This is a structured discussion of clinical cases managed by the foundation doctor. Its strength is assessment and discussion of clinical reasoning.
• a minimum of six CBDs should be completed with at least two CBDs undertaken in any four month period
• different assessors should be used for each CBD wherever possible
• assessors should have sufficient experience of the area under consideration, typically higher specialty training, with variations between specialties
• each CBD must represent a different clinical problem, sampling one of the acute care, chronic illness, psychiatric care etc (categories listed in Syllabus and competences).

F. Feedback and debriefing

Feedback is a key component of the interactions between supervisors and foundation doctors. Giving and receiving feedback and engaging in constructive conversations about learning, successes, difficulties and progress are all part of an effective professional learning environment. Improvement in clinical practice will only happen if regular review leads to constructive feedback. As indicated above, unscheduled assessments are a good opportunity for immediate feedback. This is particularly true of DOPS and mini-CEX which may be opportunistic. It is essential that trainers provide, and foundation doctors receive, structured feedback.

G. Personal responsibility

The foundation doctor, with the support of the supervisor(s), is responsible for arranging assessments, having them signed off and recording results. The evidence should be used to stimulate immediate or early feedback and to provide a basis for discussion with the clinical and/or educational supervisor.

Final assessment

Towards the end of a placement, the foundation doctor and educational supervisor will meet again for an overall assessment. They will need to review the e-portfolio and the results of assessments made during the placement. This process will involve reviewing evidence from colleagues who have observed the doctor’s performance in practice and/or in individual assessments. If the educational supervisor is different from the clinical supervisor, there should be a robust communication system to ensure a continuous, appropriate, and timely flow of evidence. This should include a ‘sign off’ document confirming satisfactory performance and progress. It should detail any outstanding issues that still need to be addressed. Refer to section 10 in Reference Guide.

The educational supervisor’s role includes having an overview of the foundation doctors’ assessments. The results of these assessments will be drawn together and included in a formal structured educational supervisor’s report. This will cover the overall performance of the doctor in a placement. Whilst WPBA will be taken into account, the overall judgement will include a triangulated view of the doctor’s performance, which will include their participation in (and attendance at) educational activities, appraisals, the assessment process and recording of this in the e-portfolio.

The outcome of the final assessment discussion should be agreed by both the foundation doctor and the educational supervisor and recorded in the doctor’s e-portfolio “End of placement review” form.

Placement reports put together in an annual report will form the basis of the foundation training programme director/tutor’s recommendations of satisfactory completion of F1 and the Foundation Programme.

Lack of progress

Most foundation doctors should achieve the required F1 competences by the end of their first year, and the F2 competences by the end of their second year.

Deaneries/foundation schools will make sure that there are systems in place to help doctors who may need additional support. Such doctors may be identified by:

• concerns raised by the doctors themselves, which might include problems relating to their training or assessment
• information transferred from undergraduate schools by foundation doctors (refer to GMC guidance)
• periods of prolonged absence (refer to the Reference Guide for further detail)
• judgments about their practice arising from the assessment tools
• reluctance/failure to take part in educational processes
• reluctance/failure to engage in the assessment process
• concerns raised by educational and/or clinical supervisors
• serious incidents/events/complaints from patients, colleagues or carers.

These issues must be discussed with the doctor concerned. The educational supervisor should follow local processes and seek early advice when necessary. Further work may be needed for the few doctors still experiencing difficulty despite extra support. They may carry out more assessments (of competence, performance or knowledge). Doctors who do not make progress may need more education and training, with further assessments. Training may be extended for up to a maximum of one year (or equivalent for part-time foundation doctors), at the discretion of the deanery/foundation school.

If there is still no progress, then the doctor will be deemed to have failed. This means that the doctor will not have satisfied the requirements of the Foundation Programme. The postgraduate dean/foundation school director will be unable to sign off the doctor for the specific component of training and will initiate career management discussions with the foundation doctor. It should be mutually determined whether medicine is the right career for that individual – a change of career may be necessary. Deaneries/foundation schools will have an appeal process for doctors who are unable to satisfactorily demonstrate completion of this stage of their postgraduate medical training. Further information can be found in the relevant section of the Reference Guide and in GMC’s Standards for Training in the Foundation Programme (in The New Doctor).

The employer is also responsible for assessing and determining the employability of the foundation doctor. The individual may not be employable in the foundation post or programme where particular concerns or problems have been identified.

In the above circumstances the employer must inform the deanery, and in normal circumstances an agreement would need to be reached over referral of the doctor concerned to the GMC so that the GMC can determine whether or not the doctor can remain on the professional register.