ANNUAL BOARD REPORT MEDICAL APPRAISAL AND REVALIDATION

Transcription

1 ANNUAL BOARD REPORT MEDICAL APPRAISAL AND REVALIDATION DR VINCENT KIRCHNER 18 JUNE 2018

2 Purpose of the paper This paper is to provide the Board with information about processes in place in C&I for medical appraisals, revalidation recommendations, remediation and governance. It also reports on current positive achievements and challenges as well as planned future developments over the next year. Introduction Medical appraisal comprises of a summative and formative review of a doctor s clinical practice and professional development. It incorporates important feedback from patients and colleagues. It helps encourage doctors to plan and ensure continued professional development through an agreed personal development plan. GMC Revalidation builds on the appraisal process, reviewing a doctor s performance (and evidence of keeping up to date) over a 5 year period. All non-training doctors (trainee doctors have a separate process under their d training programs) are contractually obliged to participate in this process. It aims to strengthen the way doctors are regulated and consists of Doctors taking part in appraisal, collating portfolio evidence over a five year period to show they meet the standards set by the GMC; it increases public trust and confidence in the medical system. Our Trust medical appraisal and revalidation processes are well developed with clear leadership, policy, quality assurance and governance structures. The General Medical Council allocates all licensed doctors to a Designated Body. Doctors on training will have their Deanery as Designated Body and are therefore not included in this report. Camden and Islington Foundation Trust is the Designated Body for all our non-training doctors. Dr Vincent Kirchner is the Responsible Officer and Dr Koye Odutoye is the Appraisal lead for the Trust. 1. Achievements for Completion of another internal Trust quality assurance audit. This audit was conducted using a much larger sample size of appraisal outputs, assessing 46 of 91 appraisals carried out by 23 appraisers, therefore representing 50% of the total number of appraisals for the year. It therefore provides a very robust and reliable picture of the current state of quality in the process. The results of this audit were very encouraging and demonstrated continuing improvements in target areas identified since the last appraisal cycle. They re-confirm that appraisers are ensuring that appraisees collate sufficient information in their portfolios to support revalidation and broad discussion in the appraisal meeting. Previously improved practice in areas of reflection (well written reflective notes and evidence of reflection in the appraisal discussion) and robust review of the previous personal development plan (PDP) appear well embedded as standard practice. Improvements such as consistent reference to ongoing quality improvement activity and evidence of challenge within the appraisal discussion were also well sustained. Areas requiring further development include ensuring routine reference to mandatory training, probity and health matters as well as ensuring routine review of progress with the last PDP and commentary when limited progress is observed. Summarising the appraisee s work context can also be improved. Finally, a recently introduced form used for declaring external work commitments has been little used so far and needs to be further embedded. New team recruited within HR and re-organised to create a flexible Medical staffing Workforce, consisting of Resourcing team, Medical Education and Medical Appraisal & Revalidation, all based in the same suite of offices to ensure better communication and cross-cover arrangements. Completion of the setting up of a Medical Appraisal & Revalidation page on the intranet, with exemplars of appraiser, appraisee practice outputs and other useful links. This is now up and running and provides a useful information resource for all doctors in the Trust to access. It has received very positive feedback.

3 Improved consistency in gathering information for new starters, i.e. previous appraisal outputs and Medical Practice Information transfer from previous Responsible Officer. This has been further facilitated by the new medical workforce structure and shared workspace, strengthening the links between appraisal administration and medical staffing. We have maintained a 99% rate of engagement with the appraisal for all of our doctors. This level of engagement has consistently remained above the national and London regional average rates for appraisal engagement (90.7% and 98.6% respectively for 2017). Short-term locum doctors are consistently being offered the opportunity of having an NHS appraisal if appropriate. NHSE appraisal/revalidation assessors conducted a detailed assessment and audit of our appraisal and revalidation processes and governance in October 2017 and provided very positive feedback (noted in appendix C), including being impressed with the other place of work form we developed which they intend to recommend to other Trusts. They also commended our well established governance and quality assurance systems and how we ensure that even short-term medical locums are supported to receive an appraisal opportunity. The NHSE review visit also generated some recommendations on how we could further improve our governance (details in appendix C) and an agreed action plan. We have completed approximately 80% of this recommended action plan as detailed below: We have set up a Revalidation Advisory Group with finalised terms of reference, consisting of a lay member (who is a Trust Governor), consultant representative and HR lead. This group will assist the RO with reviewing and making revalidation recommendations with greater transparency. 2. Challenges: We have developed a Job description and person specification for Medical Appraisers which will add clarity to the inherent responsibilities and nature of the role. We have increased the sample size of our quality assurance audit, ensuring a more robust assessment of current practice. Non-completed actions relate to areas where we have set up creative alternative solutions-rather than introduce a new form for Clinical Directors to inform appraisals as suggested by NHSE, we will ask CDs to identify quality/incident themes for their service each year and will upload relevant clinical reports for appraisees to reflect on in their appraisals. Also, rather than the appraisal lead ensuring individual meetings with every appraiser, such meetings will be targeted at new appraisers, those with low quality performance and those who request support. Clinical activity: We still do not have accurate comparative clinical activity and performance data that is sufficiently tailored to individual clinical service settings to facilitate a meaningful discussion on these areas. This is still in part due to poor/unreliable data pulled through by ICT department but we also need to further develop more meaningful comparative data individualised for each clinical division/area. We are currently using screen prints of the clinical dashboard which provide very limited clinical information. This will be prioritised over the next year. We are yet to organise a peer review audit of our systems with another Trust. However, we have ensured other external audits of our processes via KPMG in 2016 and also the recent NHSE visit. Once we have completed all the NHSE action plans we will be looking into setting up a peer review cross-audit process with a neighbouring trust as an additional qualityimprovement process.

4 3. Objectives for Further explore ways of capturing clinical activity with ICT and clinical directors. This will be a priority focus over the next year. Review of current Medical Appraisal Software. Current license expires in December We are currently meeting with other providers and will shortly make a decision on whether go with a new provider. (This seems likely as we also intend to modernise our job-planning system using electronic software, and the current provider does not provide this option.) Complete NHSE action plan. This will include developing and embedding the new quarterly Revalidation group meeting and fine-tuning the process of ensuring that distilled local clinical service themes are uploaded in doctors appraisal portfolios for reflection. Appraisers to work on areas for improvement identified by Appraisal lead s audit , making use of available resources, i.e. refresher training, appraiser workshops, appraiser peer groups. The main target areas for improvement will be raising the profile and use of the new external work form, reviewing uncompleted PDPs and improving the appraisal summary. 4. Appraisal and Revalidation Performance Data Good engagement with appraisal and revalidation for this year from both appraisers & appraisees. See Appendix C for a more detailed report Appraisals Performed: Overview Data for Appraisers: Leavers: Starters: Revalidations made: Concerns & Remediation One Trust Consultant has recently been the subject of a media investigation into unethical referral payments made for referrals to private clinic settings. We are about to embark on an internal investigation based on maintaining high professional standards (MHPS) principles but the main aspects of this cases are likely to require an external (GMC) investigation. There are no concerns about immediate patient safety or clinical performance and so the doctor has not been suspended from work. The GMC have confirmed that they will also investigate and our own investigation will inform theirs. Our eventual internal action on the matter will partly depend on the outcome of the GMC investigation. (It is likely that the latter process may well extend over the next months or more.) One doctor had his appraisal delayed several times, in part due to a prolonged period of sickness but also secondary to tardy organisation on his part. This matter has been finally resolved (with appraisals completed) without going through a disciplinary process.

5 NHSE Annual Organisational Audit submitted May 2018 Appendix A

6 Internal Audit results Appendix B

7 The results of this audit ( ) on the quality of medical appraisal within the Trust are on the whole very encouraging and demonstrate further significant improvements made since the last appraisal cycle. They re-confirm that appraisers are ensuring sufficient relevant information to support revalidation and that a broad scope of discussion ensues in the appraisal meeting. The audit was based on 46 appraisal outputs from 23 appraisers and 91 appraisals. 7 areas of practice improved: 4 areas of good practice were maintained 4 areas of moderate performance maintained 1 area of a drop in rating to moderate performance NO areas of poor practice Evidence of well written Reflective notes in appraisee portfolios Evidence of reflection (within appraisal portfolio and appraisal conversation or discussion on how to do this Reference to review of previous PDP/Achievements. Reference to patient safety and risk systems PDP has SMART objectives and clear timelines Evident links between the appraisal discussion and later developed PDP Improved end Summary of work scope & context Adequate portfolio documentation Appraisal generates 3-6 PDP items, excluding mandatory training Reference to learning, audit and quality improvement PDP has SMART objectives and clear timelines Documentary evidence of PDP completion in the portfolio Comment on quality & scope of supporting documents (An overall significant improvement was achieved in this domain, now falling in the amber rating range, a significant improvement on the previous red rating) End summary of work scope/context Reference to probity and health declarations Uncompleted previous PDP tasks commented on Making specific comments on whether or not last PDP plan was completed No Areas of poor/unacceptable practice Two such areas from last year (making reference to quality of portfolio and mandatory training) have both moved into the moderate performance range.

8 Appendix C NHSE report examples of good practice & areas for development

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10 Appraisal & Revalidation Performance data 2017/18 Appendix D Designated Body at 31st March 2018 Designated body during 1st April 2017 to 31st March 2018 Consultants SAS LAS Locs 9 2 Subs Consultants SAS LAS Subs Loc New Starter Appraisal Data Valid appraisal 12 No valid appraisal 3* One doctor was appraised by C&I & two doctors were new to the UK and they were asked to book an early appraisal in the next cycle Revalidation data Revalidation due for the year 4 Deferral for the year 1 * (Deferred for 4 months) Positive recommendations for the year 4 (Inc. the above deferred doctor) *Deferral was to allow more time for preparation only.

11 Governance Arrangements Current overarching governance structure summarised as follows: Appendix E Structure Arrangements Responsible officer (RO): Set up processes for appraisal, revalidation, remediation of C&I DB. Review appraisal outputs, performance, conduct and behaviour against national standards prior to making recommendation. Board report is submitted anually POLICIES: Appraisal & Revalidation policy, Conduct & Capability and Rehabilitation & Remediation policy are available on the intranet. REVALIDATION MANAGEMENT SYSTEM (RMS) software: Records individual Appraisal process, monitors, generates reports for RO. Collates appraisee feedback on appraisers Statement of compliance is submitted annually to NHSE Appraisal Lead: Day to day running of the appraisal and revalidation process. Quality assurance NHS ENGLAND AUDITS: Audits are submitted quarterly and annually NHSE have produced a Framework of QA checklist of core standards, C&I consistently meet those requirements. See Appendix A (Audit 16-17) Clinical Governance The medical appraisal system currently ensures that general clinical governance and performance measures across the clinical divisions in the Trust also inform the process. The inputs are tabled below. Serious incident investigation outcomes and clinical performance activity are automatically uploaded to each doctor s portfolio. Audits Doctors to perform one audit or quality improvement project each revalidation cycle (5 yearly) and upload in appraisal portfolio Supporting Documents for clinical governance Complaints & Compliments Serious Investigations & Datix Clinical activity Other place of work form Collected, anonymised and uploaded to appraisal portfolios. Collected, anonymised and uploaded to appraisal portfolio with emphasis on learning potential and areas for improvement within the doctor s individual practice or clinical service. Gathered by IT dept, reported on to show average markers for each consultant in each division. Uploaded in appraisal portfolio. Helps identify any issue at other place of work beyond the trust during the appraisal year; it is to be signed by the other RO or manager. There is a self-declaration option as well for private practice.

12 Quality Assurance Structures Appendix F A range of quality review processes are all well embedded and are tabulated below. We have now conducted two internal audits led by the appraisal lead. We anticipate that once areas for improvement are further fine-tuned we can then cut down the internal audit frequency to a biennial arrangement. All other interventions and NHSE audits will continue in a yearly cycle to ensure continued maintenance of knowledge and practice amongst appraisers. Measures Appraisal & Revalidation Software (RMS) Appraiser workshops Appraiser Training Peer group mailing list Documentation NHSE Audits Internal Audit QA of output samples Generates reports for Responsible officer & appraisal lead. Generates appraiser feedback; which in turn is used to further develop of our medical appraisal process and for yearly audits. Appraisal lead chairs three workshops yearly to share experiences, discuss quality assurance reviews, set standards and prepare for the next appraisal cycle All appraisers receive initial training and refresher training every 3 years through an approved trainer recommended by the NHSE revalidation team. Appraisers to communicate and share ideas during the cycle. Doctors are sent a list of recommended documentation covering the 6 domains** required by the GMC, to include in their portfolios. This is also available on the intranet. (**Feedback from patients and colleagues; significant events; continuous professional development activity; audit and quality improvement work and complaints/incidents over the appraisal year) Quarterly audits are sent to NHSE. Annual Organisational audits are done yearly, was completed on 08/05/17 (see extract in appendix A) In keeping with NHSE and GMC directives, there is an internal system in place for quality assurance of an appropriate sample of the outputs of the medical appraisal process to ensure that they comply with GMC requirements and other national guidance. The Appraisal lead prepares a yearly audit based on feedback generated from the software RMS; these findings are individualised and uploaded to each appraiser s portfolio for discussion in their own appraisal. This is also presented and discussed on our Quality Assurance workshop. (See appendix B for audit results )

13 Pre-employment checks Appendix G The following routine employment checks and requirements were performed on all doctors joining C&I in by the Medical Staffing Team: DBS Clearance Proof of GMC registration Fitness to Practice form to declare criminal convictions Self-declaration of health and probity Occupational Health Clearance. Relevant qualifications Photographic identification Most recent NHS payslip if applicable Right to work in the UK Two proofs of address Proof of Section 12/Approved Clinician status. 1 reference from current employer if working for the NHS with no gaps in service. Otherwise 3 references covering the last 3 years and 3 references for Consultants. RO to RO information transfer All new Doctors are asked to upload their last appraisal outputs to RMS including previous PDP. (Appraisal revalidation software)