title: The relationship between competence and performance: implications for assessing practice performance.
abstract: OBJECTIVE
  This paper aims to describe current views of the relationship between competence and performance and to delineate some of the implications of the distinctions between the two areas for the purpose of assessing doctors in practice.
  
  
  METHODS
  During a 2-day closed session, the authors, using their wide experiences in this domain, defined the problem and the context, discussed the content and set up a new model. This was developed further by e-mail correspondence over a 6-month period.
  
  
  RESULTS
  Competency-based assessments were defined as measures of what doctors do in testing situations, while performance-based assessments were defined as measures of what doctors do in practice. The distinction between competency-based and performance-based methods leads to a three-stage model for assessing doctors in practice. The first component of the model proposed is a screening test that would identify doctors at risk. Practitioners who 'pass' the screen would move on to a continuous quality improvement process aimed at raising the general level of performance. Practitioners deemed to be at risk would undergo a more detailed assessment process focused on rigorous testing, with poor performers targeted for remediation or removal from practice.
  
  
  CONCLUSIONS
  We propose a new model, designated the Cambridge Model, which extends and refines Miller's pyramid. It inverts his pyramid, focuses exclusively on the top two tiers, and identifies performance as a product of competence, the influences of the individual (e.g. health, relationships), and the influences of the system (e.g. facilities, practice time). The model provides a basis for understanding and designing assessments of practice performance.
authors.affiliation: Skillslab, Maastricht University, The Netherlands. j.rethans@sk.unimaas.nl
authors.forename: J-J
authors.initials: JJ
authors.lastname: Rethans
authors.forename: J J
authors.initials: JJ
authors.lastname: Norcini
authors.forename: M
authors.initials: M
authors.lastname: Barón-Maldonado
authors.forename: D
authors.initials: D
authors.lastname: Blackmore
authors.forename: B C
authors.initials: BC
authors.lastname: Jolly
authors.forename: T
authors.initials: T
authors.lastname: LaDuca
authors.forename: S
authors.initials: S
authors.lastname: Lew
authors.forename: G G
authors.initials: GG
authors.lastname: Page
authors.forename: L H
authors.initials: LH
authors.lastname: Southgate
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D004502:Education, Medical, Continuing / Q000592:standards*; D004521:Educational Measurement; D006801:Humans; D010821:Physicians, Family / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards; D015203:Reproducibility of Results