Sunday, December 17, 2006

RANZCO Setting the Standard - Developing Ophthalmic Competencies

Note to Readers: This case study was prepared by Dario Tomat (left) February 2004 and released following review by Dennis Sligar (right - Director, Education and Training, RANZCO).

In 1999 the Royal Australian and New Zealand College of Ophthalmologists first introduced the concept of defined standards that could be used to assess competency.

The decision by the Victorian Government to allow optometrists to prescribe S4 pharmaceuticals meant that non-medically trained practitioners were given access to a range of controlled substances.

RANZCO proposed to the Government that optometrists should demonstrate a level of competency before they were registered to prescribe S4 drugs.

This approach saw RANZCO engage Whetstone, a management and training consulting firm that is part of the Ndarala Group, to assist with the facilitation of the development of standards. The work of establishing the Optometric Therapeutic Standards was carried out through workshops involving number of professional ophthalmologists facilitated by Whetstone's Dario Tomat.

Following the successful implementation of these standards, RANZCO chose to use a similar approach to defining standards for ophthalmic training when the need arose to develop and document the new five year training program the College was going to move to and would accredit through the Australian Medical Council.

Dario Tomat of Whetstone was again engaged to facilitate the process.

Overview of Selection and Training Approach

Before the introduction of the five-year program potential applicants were required to complete a Part 1 examination as a pre-requisite for entry to the course. Trainees later sat a Part 2 examination towards the completion of the training program.

Training was undertaken on the job with registrars being assigned to various training posts under supervision of Fellows of the College. Supervisors provided periodic reports on the progress of the registrars. While there was an expectation that during the rotation process registrars would be provided with experience in all sub-specialties, detailed monitoring of the scope of training for each trainee was not undertaken centrally by the College.

As part of the move to a five-year program, the Part 1 examination for entry was abolished and the hospital-based selection process was augmented by the assessment of applicants' behavioural capabilities.

The College also decided that summative assessment during the training program would be desirable to ensure that the scientific basics were well understood early in the course.

Registrars need to have passed assessment in the basics by the eighteenth month of the course. The Part 2 clinical examination was to be conducted during the fourth year of the course.

Standard Setting Process

The Curriculum Committee of RANZCO facilitated by Dario Tomat coordinated the development of the approach to standard setting.

The Committee identified two potential approaches. One possibility was to divide the subject area into a number of bands of knowledge that increased on an annual basis. The other possibility was to use a sub-specialisation approach.

The Committee decided to set up a pilot of the two approaches. A "Fundamentals" slice covering the knowledge and skills required in the first two years was to be developed, while glaucoma as a sub-specialty unit was also piloted.

Two sub-committees comprising 6-8 volunteer Fellows were established to handle the task.

To minimise development costs, membership of sub-committees was generally confined to a region. A blend of sub-specialists and generalists was sought the committees to ensure that the requirements in the standards were reflective of a general level of ophthalmic practice rather than becoming too deeply slanted to the sub-specialty.

A series of three workshops a week apart were scheduled for each pilot.

As part of the facilitation Whetstone developed a template for presentation of the standards and prepared drafts of the workshop outputs after each session. These drafts were circulated to the group electronically for comment and correction.

Once completed, drafts were circulated to the Curriculum Committee for review and were then placed on the RANZCO web site seeking further review and comment from the College membership.

The drafts were then critically reviewed by a College education workshop.ᅠ The workshop resolved that a hybrid approach to standard setting should be adopted.

The fundamentals draft standard comprising basic ophthalmic clinical and surgical procedures should be retained.ᅠ This should be augmented by standards covering each of the basic sciences.

These standards combined would form the basis for the first two years. Registrars would be required to demonstrate competence in the basic sciences by the eighteenth month and to achieve all of the fundamental standards by the end of the second year in order to proceed to the final three years of study.

Standards for the clinical content of the course were to be developed around the concept of ophthalmic sub-specialities. ᅠThe registrars could cover these in any order based on the experience available within their rotations. ᅠBecause registrars must achieve the standards in all areas, the Director of Training in each training scheme would work with trainees to develop a program of rotation covering all areas.

Because the basic science standards had largely been defined in the previous four year course, their further development was undertaken in one full-day workshop for each of the basic standards. Whetstone or members of the College training staff facilitated each workshop.

Membership of working groups was drawn from ophthalmologists in a region, and included subject experts from the Part 1 Board of Examiners.

A similar process of peer review was undertaken to that adopted for the standards.

The ophthalmic specialty standards were developed over a series of three evening workshops (requested by members) spaced one week apart. Normally the workshops were conducted in private residences, or at College facilities. A light meal without alcohol provided by RANZCO was served each evening.

RANZCO staff sought expressions of interest for standards development from amongst the College Fellows, normally on a regional basis. As a consequence, workshops were undertaken in Brisbane, Sydney, Melbourne, Adelaide and Auckland NZ. The use of regional groups meant that the concept of standards could be more widely understood and better ownership of the new process achieved amongst the College members.

These workshops were also facilitated mainly by Whetstone with some undertaken by College staff.

Development of the standards occurred over approximately an eighteen-month period.

Lessons learnt

Use of interested ophthalmologists worked very well, although the nature of ophthalmic practice meant that some working group members were unable to attend all workshops. Having groups of four to six meant that the absence of one or two members did not impede progress at the workshop.

The spacing of evening workshops one week apart meant that members had only three days to review draft outputs. This tight time frame meant that some members did not have the opportunity to provide input. Scheduling the evening workshops two or three weeks apart would assist members to more carefully review each week's output.

Evening workshops that ran for more than 3 hours (excluding meal time) resulted in fatigue among participants.

Planning for workshops, ensuring that members brought suitable references and that they were reminded to attend on each day of the workshop was required.

The further process of peer review was coordinated by College staff, leading to sign-off from the Curriculum Committee on each standard.

The next stage - training clinical tutors, examiners and trainers in the use of the standards - will be coordinated through College educational networks.

Note on authorship:

This case study was prepared by Dario Tomat February 2004 and released following review by Dennis Sligar (Director, Education and Training, RANZCO). The material is copyright Whetstone but can be copied and quoted with appropriate acknowedgement.

Further Information:

The standards developed by the College through the full curriculum review process are in the public domain and can be found at

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