B3a — Assessment Competency
Assessment has many meanings, even within the local context of rehabilitation. The assessment competency encompasses clinical collection and evaluation of patient data, mainly from the patient, family, and others. Assessment is not only the use of measures, nor is it only the use of structured data-collection tools. It is the purposeful collection of information, the crucial prelude to the formulation. Structured data-collection tools may be part of the assessment and patient management processes. A professional in rehabilitation needs to know what tools are available, how and when to use them, how to choose the best one, and how to interpret the data. Equally importantly, they need to know when not to use them. This page considers the assessment process, focusing on the competency leading to the formulation. A later competency concerning evaluation covers using data collection tools as measures.
Table of Contents
The assessment competency
The competency is that the rehabilitation professional is “Able to collect data about all parts of the biopsychosocial model of illness sufficient to formulate a patient’s situation and likely goals.” This is set in the context of working in a multi-professional rehabilitation team where you may be required to make the initial assessment of a patient. You may need to decide whether the patient needs to see any other team members and, if so, whom, whether the patient can be managed initially by you alone, or whether they do not need to be seen again. All these decisions may be discussed with the team, but you need sufficient information to decide with the team.
A document summarising the expected behaviours, knowledge, and skills and providing relevant references can be downloaded.
Context – measure, assessment, data collection tool.
Before starting, one must (as usual) be clear about the meaning of words. A measure quantifies a phenomenon, sometimes compared with a standard extent of the phenomenon (e.g. a gram against the standard kilogram). Most rehabilitation measures have no universal metric; they can be compared between people or populations, but they are relative, not absolute.
An assessment is, strictly speaking, the process of collecting data for some purpose, such as determining the amount of tax you owe or, in medieval times, the number of soldiers you supplied to the King. In rehabilitation, it is often used to refer to a structured data collection and sometimes, the data can be quantified. In practice, the word assessment is used interchangeably with measure.
Therefore, it is better to refer to a data collection tool, which is precisely that – a device, usually a form, used to collect data. Sometimes the data can be quantified, in which case the data set is also a measure. Often, the data are collected as part of the assessment process, in which case the data set could be referred to as an assessment data set. However, the data collected are not themselves an assessment.
On this page:
- An assessment refers to the process of collecting data for some purpose which might include a measurement
- A measure relates to a specific set of data which can be quantified
- A structured assessment involves collecting and organising data into a fixed framework, often a form.
Assessment competency.
The assessment process is covered on this site, with an additional page discussing person-centred assessment. Much of the competency depends on crucial general professional knowledge and skills, but to be an expert in rehabilitation, the professional also must have a good understanding of the biopsychosocial model of illness to help them collect and interpret the appropriate data.
The primary skill required is communicating well with the patient so that a complete patient-centred account is obtained, covering all aspects of their situation. Another critical skill is collecting and structuring data in real-time as the patient actively gives it in their way; this is much more productive than going through a structured list of questions, which the patient answers passively.
Unfortunately, the assessment process is frequently undertaken as a fixed procedure, “filling in the forms”, using structured assessments suggested or even required by professional guidance, managers, commissioners, or the team. Many patients complain that “all you do is assess” when they have the same measure used on repeated occasions. Many professionals conflate objectivity with being scientific. They contrast structured questioning and using standardised measures, considered objective and scientific, with listening to the patient, which is regarded as subjective, non-scientific and flawed. Many clinicians also only consider seriously the phenomena they can measure, and they ignore or avoid phenomena they cannot measure.
The purpose of this competency is to instil a more balanced approach. During early training, professionals learn a structured approach centred on fixed procedures and standardised measures. This is necessary to embed the biopsychosocial framework into practice and know how measurement may be undertaken when needed. The consequence of this training, an overvaluation of forms and routines, is seen in all professions; an expert can return to focusing on the patient while still using the framework and the measures when needed.
One way to regain a balanced, patient-centred approach is to treat the assessment as an exploration. In the beginning, you explore the lie of the land, as given by the patient, who will usually take you over all the terrain using random routes that reflect what is important to them. As you identify interesting places, you can make a note to return later for greater exploration.
How to assess competently
I have discussed how to undertake a person-centred assessment, including a graphic illustrating the process. I have also considered learning to do a good assessment on the same page. In summary, the ways to learn are as follows.
Knowledge. Communication.
One well-researched helpful technique is to develop the four habits described in 2006 by Edward Krupat and colleagues from Kaiser Permanente, Northern California. The four habits are:
- Invest in the beginning, emphasising the critical importance of the start of any interaction with a patient;
- Elicit the patient’s perspective, highlighting the need to prioritise the patient’s spontaneous narrative over a professional desire to control and systematise the process;
- Demonstrate empathy, recognising that most successful healthcare is based on a personal relationship as much as it is on professional expertise;
- Invest in the end because the patient and family’s impression and memory will be based on their experience over the last part of their interaction.
Their paper lists behaviours that can be used to evaluate how well someone communicates. A graphic Mind Map shows the behaviours.
Skill. Practice with feedback.
As with every other skill, the more you do something, the better you will get. However, improvement depends on feedback, recognising what you did well and what could be improved. This is crucial.
Feedback takes many forms. The simplest is your evaluation of how you did. This will mainly involve learning from your failures, such as realising that you forgot to cover a crucial area. The ultimate direct, personal feedback is whether your assessment allows you, with other team members, to compile a formulation sufficient to plan further actions.
More formal feedback from others is vital. Initially, another professional can sit in, observe, and give feedback. It helps to have a structured observation, and various questionnaires are available. The patient and family can also provide feedback using questionnaires.
One available questionnaire is the Interview Satisfaction questionnaire developed by Katelyn Grayson-Sneed and her colleagues; it has a long 25-item and short 12-item version. The same group developed a coding system to evaluate patient-centred interviewing, and Table 2 in their paper sets out 33 yes/no dichotomous questions for evaluating a professional’s skills.
Clinical practice: The OCCAM – a useful aide memoire.
I will start by acknowledging an interest in this data collection tool. I and others developed and published it; I have no other interest. It is freely available, and no one has a financial interest. You may download the short data collection form, the complete item-by-item guidance, and a simple Excel spreadsheet for your use and adaptation.
I developed the Oxford Case Complexity Assessment Measure (OCCAM) for two reasons. The main one was to have a measure of case complexity that was not based on a clinician’s opinion but on data that was not too liable to bias so that managers could agree it was a measure of complexity. This was intended to assist in understanding and justifying rehabilitation resources.
My approach was based on the INTERMED, an earlier measure of complexity, with evidence to support it. The INTERMED used the biopsychosocial model of illness as a framework but did not cover all domains of the model. It could be improved without lengthening it. It has evolved into a self-assessment version.
The second goal was to help rehabilitation professionals, especially doctors training in rehabilitation in Oxford, learn to incorporate a biopsychosocial approach into their thinking.
This data collection tool was designed to fit in with my practice, where I usually listen 80% of the time with a patient, only asking a few questions to clarify matters or about specific points. I make notes and reorganise information afterwards. I could therefore complete the OCCAM after finishing the primary consultation. It only took a short time, and if necessary, I could ask an additional question if I had overlooked something.
I must stress that the OCCAM was not designed to be completed with a patient, going through items one at a time. That would be inappropriate. It may be used as:
- A method for rating the comparative complexity of patients, which the INTERMED suggests, will also predict future use of healthcare services
- A clinical summary and aide memoire, highlighting
- to others a quick overview of the patient’s situation and the main areas of complexity.
- to the user, areas overlooked in the assessment.
- to the team, possible areas for intervention.
You may see and download the following:
- The guidance for each item
- A form to record the score for each item
- A spreadsheet for recording data
Conclusion
Assessment is a skill often assumed to develop rather than being consciously learned and explicitly trained, yet it is a fundamental skill that influences all rehabilitation practice. Good communication with the patient and family is an underlying vital skill. People have studied the assessment process and identified four habits that, if learned, will improve communication and assessment. Further, people have developed at least two observational questionnaires of assessment quality that check on communication and remaining patient-centred rather than being too professional and controlling in the process. As with almost all aspects of rehabilitation, the biopsychosocial framework is crucial to a good rehabilitation assessment.
