About Workplace Based Assessment

What is a WBA?

WBA is a form of authentic assessment that tests performance in the real environment that doctors face in their everyday clinical practice. WBA should enable international medical graduates to demonstrate their progress in integrating clinical knowledge and skill as a basis for effective clinical judgments and decisions. It should also track their development towards becoming an independent, self-monitoring clinical practitioner in the Australian setting, which includes effective communication, respect for patients, working productively within a team of healthcare professionals, and applying risk-management skills.

How this form of assessment relates to other forms of assessment is clarified by reference to Miller’s Pyramid. In 1990 Miller used a pyramid to provide a framework for clinical assessment which is shown at Figure 1. Relative to the levels of assessment in Miller’s Pyramid, written examinations assess candidates at the ‘knows’ and ‘knows how’ levels, and clinical assessments assess at the ‘shows how’ and ‘does’ levels. WBA is an assessment at the ‘does’ level, as its focus is on performance in the workplace setting.

The AMC CAT MCQ examination is at the ‘knows how’ level of the pyramid which tests clinical decision-making skills and the ability to apply knowledge to clinical problems.

The clinical examination is in an Objective Structured Clinical Examination (OSCE) format. It is at the ‘shows how’ level, as it assesses candidates’ ability to perform in simulated situations.

WBA measures what a doctor does in practice.^2,3 WBA contributes important information about overall suitability for independent practice in Australia.

Objectives of WBA

The WBA is used to:

• monitor progress through the required supervised pathway and signify satisfactory completion of the program
• provide guidance for specific learning needs of international medical graduates
• determine whether and when international medical graduates are ready to proceed to independent (or more independent) practice in Australia.

Principles underpinning WBA

WBA involves the measurement of abilities and attitudes within highly complex areas of activity. To be effective, performance in a complex area of activity requires focused observation of international medical graduates in clinical practice by assessors drawn from a team of clinicians who are experienced in relevant clinical practice and trained in assessment of international medical graduates and other medical trainees and practitioners. 

WBA must have established reliability and validity to ensure that defensible decisions are made. WBA should assess performance across a prescribed range of clinical areas and domains of clinical practice. 

The selection of assessment methods is critical to the success of WBA. The number and nature of the tasks and the total time involved have been shown to be key factors underpinning the reliability and validity of WBA.  

The following should be considered in developing a suitable assessment program: 

• Clinical performance is multifaceted and no single method can assess all the elements that contribute to good medical practice.  

Assessment methods vary in their effectiveness to assess across different elements of performance. It is essential to use a variety of assessment methods that complement each other in the elements they assess. 

• The assessment must be planned to sample across a variety of clinical areas. It is recommended that multiple observations are used in various clinical settings over a period of time. 

• Assessors may vary in their tendency to be harsh or lenient in scoring a candidate. The best method to moderate this tendency is to ensure that the assessment of an individual candidate is based on the opinion of trained multiple assessors. 

Clinical domains for WBA

The focus of WBA should be on the candidate’s application of knowledge and clinical skills in their clinical work. A successful WBA program should assess the following aspects of performance: 

• clinical skills (history taking, physical examination, investigations and diagnosis, prescribing and management, counselling/patient education, clinical procedures) 
• clinical judgment 
• communication skills 
• ability to work as an effective member of the healthcare team 
• ability to apply aspects of public health relevant to clinical settings 
• Indigenous health and cultural competence 
• professionalism 
• patient safety. 

Assessment methods used for WBA

Effective WBA should incorporate several assessment strategies, including both direct observations of in-patient encounters and indirect methods to assess other clinical domains. Strategies that may be used for WBA include: 

• Mini-Clinical Evaluation Exercise (min-CEX) 
• Direct Observation of Procedural Skills (DOPS) 
• Case-based Discussion (CBD) 
• In-Training Assessment (ITA)/Structured Supervision Reports 
• Multi-Source Feedback/360 Degree Assessment 

Choice and design of assessment methods with clearly described criteria and assessor training are essential elements of a successful WBA program. 

References

¹ Miller G. The assessment of clinical skills/competence/performance. Acad Med 1990;65:S63-S67.
² Rethans JJ, Norcini JJ, Baron-Maldonado M, Blackmore D, Jolly BC, LaDuca T, Lew S, Page GC, Southgate LH. The relationship between competence and performance: implications for assessing practice performance. Med Educ 2002;36:901-909.
³ Van der Vleuten CPM. The assessment of professional competence: Developments, research and practical implications. Adv Health Sci Educ 1996;1:41-67.