Clinician's own experiences in direct patient care
•“Blind spots”	Formal approaches to quality management and risk assessment	Non-clinical activities
• Clinically generated unknowns	• Audit	• Academic activities
• Competence standards	• Morbidity patterns	• Conferences
• Diaries	• Patient adverse events	• International visits
• Difficulties arising in practice	• Patient satisfaction surveys	• Journal articles
• Innovations in practice	• Risk assessment	• Medicolegal cases
• Knowledgeable patients	Specific activities directed at needs assessment	• Press and media
• Mistakes	• Clinical incident surveys	• Professional conversations
• Other disciplines	• Gap analysis	• Research
• Patients' complaints and feedback	• Objective tests of knowledge and skill	• Teaching
• Necropsies and the clinico-pathological conference	• Observation
• PUNs (patient unmet needs) and DENs (doctor's educational needs)13	• Revalidation systems
• Reflection on practical experience	• Self assessment
Interactions within the clinical team and department	• Video assessment of performance
•Clinical meetings—department and grand rounds	Peer review
• Department business plan	• External
• Department educational meetings	• Informal—of the individual doctor
• External recruitment	• Internal
• Junior staff	• Multidisciplinary
• Management roles	• Physician assessment
• Mentoring