Revalidation Progress Report

Transcription

1 APPENDIX 1 Wales Revalidation Delivery Board (WRDB) Revalidation and Appraisal Implementation roup (RAI) Administered by the Revalidation Support Unit, Wales Deanery Revalidation Progress Report 2015 Page 1 of 27 March 2015

2 Revalidation Progress Report: 2015 APPENDIX 1 Revalidation is the process by which doctors in the UK will have their licence to practise renewed. The purpose of revalidation is to assure patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practise. The Revalidation Progress Report is designed to enable designated bodies in Wales to report relevant figures relating to , to carry out a selfassessment of the systems and processes they have in place to support medical revalidation and to provide assurances to their boards and to others that appropriate systems are in place. Completed reports will be analysed by the Wales Deanery on behalf of the Wales Revalidation Delivery Board (WRDB). Data relating to achievements in will be reported to the WRDB. s arising from the self-assessment will be analysed at the All-Wales level. Areas where more than one organisation requires further support will be identified and reported to the Revalidation and Appraisal Implementation roup (RAI). A plan will be developed highlighting areas where action / support at the Wales level may be beneficial. The report is divided into three sections: Section 1: Details of designated body Section 2: Data reporting relating to Section 3: Effective governance to support revalidation: self-assessment The form should be signed off by the responsible officer on behalf of the designated body, though completion of the form may be appropriately delegated. In all cases the responsible officer should confirm that they are happy with the content of the report. The deadline for completion of the report is detailed in the accompanying . Following completion of this self-assessment exercise, it is recommended that designated bodies should produce a more detailed action plan to address the development needs identified within their specific organisation. Liaison with RAI is advised prior to finalising action plans to ensure areas which are already being progressed at an All-Wales level are taken into account. Board-level accountability for the quality and effectiveness of these systems is important and this report, along with the resulting action plan, should be presented to the board, or an equivalent governance or executive group. The self-assessment process will also enable designated bodies to provide assurance to regulators, patients, the public, the profession and other interested bodies, that they are fulfilling their statutory obligations and their systems are sufficiently effective to support the responsible officer s recommendations to the MC Page 2 of 27

3 Section 1: Details of designated body - Please see guidance notes at the end of this document 1.1 Name of designated body: Powys teaching Health Board Name of Responsible Officer: To 28 February 2015: Dr Brendan Lloyd From 1 March 2015: Dr Catherine Woodward Name of person completing this report: Dr Catherine Woodward Job title of person completing this report: Director of Public Health and Acting Medical Director Completed report authorised by Responsible Officer: Dr Catherine Woodward Date: 29 April Type/sector of designated body: (tick one) Local Health Boards Other NHS trust Other NHS organisation Deanery Independent/non-NHS sector (tick one) Independent healthcare provider Locum agency overnment Department or executive agency, armed forces, public bodies Other non-nhs (please enter type) Page 3 of 27

4 NUMBER OF DOCTORS - Please see guidance notes at the end of this document 1.3 Number of doctors with whom the designated body has a prescribed connection as at 31 March 2015 IMPORTANT: ONLY DOCTORS WITH WHOM THE DESINATED BODY HAS A PRESCRIBED CONNECTION SHOULD BE INCLUDED IN THIS SECTION. EACH DOCTOR SHOULD BE INCLUDED IN ONLY ONE CATEORY Consultants (including honorary contract holders) Staff grade, associate specialist, specialty doctor (including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere) eneral practitioners 108 Ps for which we have a prescribed connection. (Also have 60 Ps on MPL who have prescribed connection in England that requires to be on a Welsh MPL for locum/out of hours work) Trainees: doctor on national postgraduate training scheme (for Deaneries only) Doctors with practising privileges (for independent healthcare providers only; all doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade) Temporary or short-term contract holders (including trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts) 0 0 Page 4 of 27

5 1.3.7 Other (including some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc) TOTAL 120 Page 5 of 27

6 APPRAISALS - Please see guidance notes at the end of this document Section 2: Appraisal / revalidation data reporting relating to April March Numbers of doctors who had completed appraisal between 1 April 2014 and 31 March 2015 (with whom the designated body has a prescribed connection as at 31 March 2015) IMPORTANT: ONLY DOCTORS WITH WHOM THE DESINATED BODY HAS A PRESCRIBED CONNECTION SHOULD BE INCLUDED IN THIS SECTION. EACH DOCTOR SHOULD BE INCLUDED IN ONLY ONE CATEORY NB TRAINEES ARE NOT TO BE INCLUDED IN THIS SECTION NB: Where the answer is nil, please enter Consultants (including honorary contract holders) Staff grade, associate specialist, specialty doctors (including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere) eneral practitioners Doctors with practising privileges (for independent healthcare providers only; all doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade) Temporary or short-term contract holders (including trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts) Other (including some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc) TOTAL An audit has been performed to determine reasons for all missed or incomplete appraisals A missed or incomplete appraisal is an important occurrence which could indicate a problem with the appraisal system or a potential issue with an individual doctor which needs to be addressed. Missed appraisals are those which were due within the appraisal year but not performed or which were performed outside the 9 to 15 month window for annual appraisal. Incomplete appraisals are those where, for example, the appraisal discussion was not completed or where the personal development plan or appraisal summary have not been signed off within 28 days of the appraisal meeting. For this exercise to be valuable every missed or incomplete appraisal should be included in the audit and in a well-managed system this information should be monitored and tracked on a continuous basis. Page 6 of 27

7 To answer reen : An audit of all missed or incomplete appraisals for the appraisal year 2014/15 has been completed. Recommendations and improvements are enacted. To answer Amber : Information is available relating to some missed or incomplete appraisals but this is not audited in a systematic way To answer Red : No information is available relating to missed or incomplete appraisals Page 7 of 27

8 APPRAISERS - Please see guidance notes at the end of this document 2.3 Number of active medical appraisers as at 31 March 2015: 3 in Secondary Care. 5 P appraisers with capacity to deliver 130 appraisals per year Ratio of active medical appraisers to doctors (appraisers: doctors) Ratio to be calculated as total number of doctors divided by number of appraisers i.e doctors divided by 20 appraisers = 1:50 (appraisers : doctors) 3:12 Secondary Care (1:4) 5:108 Primary Care (1:21) REVALIDATION RECOMMENDATIONS - Please see guidance notes at the end of this document 2.4 Numbers of doctors with whom the designated body has a prescribed connection as at 31 March 2015 who have had a recommendation made to MC between 3 December 2012 and 31 March 2015 Responsible officers should ensure recommendations are made to the MC before the notified due date. This question relates to the number of recommendations completed by the responsible officer between the date revalidation started and the end of the year. Number of recommendations to be split by year (Year 1: December st March Year 2: 1 st April st March Year 3: 1 st April st March 2015) 2012 / / / Positive recommendations Deferral requests Notification of non-engagement TOTAL Recommendations which were due between 3 December 2012 and 31 March 2015 but were not completed on time Page 8 of 27

9 Section 3: Effective governance to support medial revalidation: self-assessment The following checklist is provided as an appendix to Effective governance to support medical revalidation: a handbook for boards and governing bodies. The full document can be accessed at (see overnance handbook") The document states that the checklist provides a list of questions that are relevant in the context of ongoing evaluating, demonst and reporting on governance of local systems and processes supporting patient safety and medical revalidation. These questions draw on well established principles that support quality improvement and medical revalidation objectives. They take account of the clinical governance and appraisal criteria followed in the various assessments of readiness to begin medical revalidation undertaken across the UK, for example the Organisational Readiness Self Assessment. Each designated body should undertake a self assessment against the questions listed, awarding a Red / Amber / reen, outlining the justification for this and summarising key actions to be taken to address any issues identified. Red nothing in place Amber working towards meeting criteria reen criteria met R/A/ 1. There is corporate or organisation-wide commitment to creating an environment that fosters good professional practice How does your organisation: know that the governance of systems supporting the provision of quality patient care and medical revalidation objectives is appropriately supported, managed and assured? A Page 9 of 27 Quality Assurance Framework in place; Metrics reported to Quality & Safety Committee of Board. To implement improved arrangements for Revalidation Panel, including Terms of Reference and regular reporting to Workforce and OD

10 R/A/ subcommittee of Board. ensure the adequacy of resources to support all doctors in fulfilling their professional responsibilities, eg in relation to staff induction, appraisal, Continuing Professional Development (CPD) and revalidation? In what way: 1.1 does the organisation s governance strategy proactively support the provision of quality patient care and medical revalidation objectives? A Other criteria monitored via Workforce & OD subcommittee of Board. Medical Director personally reviews appraisal documentation prior to revalidation recommendation. Medical Director quarterly meetings with Martin Thomas, Appraisal Coordinator. Regular meetings held with Kate Watkins, MC. Provision of quality patient care through Quality & Safety Committee, reflected in 3 Year Plan and Annual Quality Statement. Quality and safety monitoring based on systems in place is reported via the Board of Directors and assurance provided via the Quality & Safety Committee bi-monthly. The Annual Quality Statement 2013/14 sets out the Health Board s commitment to quality & safety and demonstrates the Regular reporting to Workforce and OD subcommittee of Board. Continue to review case for AMD post in Powys. Page 10 of 27

11 R/A/ systems in place for promoting quality care and protection of patients and supports medical revalidation objectives in respect of safety and quality. The Health Board revalidation panel meets regularly with input from Revalidation Support Unit. 1.2 might reporting around quality patient care and medical revalidation objectives to the board/governing body be improved? A Quality and Safety subcommittee Annual Report to Board Primary Care Quality Assurance Framework Regular reporting to Workforce and OD subcommittee of Board. Continue to review case for AMD post in Powys. Development of Primary Care Quality Assurance Framework, to be reported to Quality and Safety subcommittee. 1.3 How transparent are the board/governing body s governance activities? 1.4 How does the board/governing body regularly review data relating to revalidation and clinical practice? A Transparency monitored through regular reporting of governance activities to Welsh overnment. Board papers available on Powys Health Board Website. Previous Medical Director reports on revalidation. Quality and Safety reports. Continued progress with work already established to address findings of internal and external audit. Page 11 of 27

12 2. Local governance is in place and monitored R/A/ How does your organisation ensure: 2.1 all information systems for monitoring the conduct and performance of doctors working in your organisation are ope effectively? Issues of conduct and performance immediately escalated to Medical Director. Performance reporting system in Localities. 2.2 the performance of locums, doctors in training and temporarily appointed doctors is monitored and reported in a way that contributes constructively to their revalidation? 2.3 pre-employment, and other pre-contract checks undertaken in keeping with statutory and other requirements, are comprehensive and accurate? A No doctors in training. Agency Exit questionnaire completed on performance of locums. Very rarely appoint temporary appointed doctors. All Powys doctors participate in whole practice appraisal. As per the Powys teaching Health Board Recruitment policy Locum doctor policy currently being developed and will encompass this issue. Complete work in hand to confirm supervision arrangements for P trainers in community hospitals. 2.4 quality improvement activities undertaken have been beneficial? Quality and Safety Committee reports. Link to 1000 Lives Programme. Clinical Audit Programme. 2.5 it can and does respond quickly when things go wrong? A Relevant incidents reported directly to Medical Director. Escalation Policy under development. Regular scrutiny of complaints and incidents at Quality and Escalation policy to be approved and implemented. Primary Care Dashboard to be implemented. Page 12 of 27

13 R/A/ Safety Committee. 3. Equality and diversity considerations are integrated into all of the organisation s medical revalidation policies and practices How does your organisation: 3.1 ensure its policies and practices supporting medical revalidation are fair and non-discriminatory, and comply with legal requirements? 3.2 keep up to date with equality and diversity issues and policies? All policies, reports to the Board and relevant activities including service change and planning are impact assessed and analysed in accordance with the Specific Equality Duty Wales 2011 and the Public Sector eneral Equality Duty. During 2015 the revised Policy on Policies was updated and reinforces this requirement which will be monitored by the Corporate overnance and Equality Teams. Through a combination of statutory and targeted training, presentations to Board members, organisational leaders and key groups of staff. The Equality Manager is a member of the thb s Workforce Directorate and the All Wales NHS Equality Leads, Sensory Loss and Welsh Language roups. 3.3 approach training in equality and diversity matters? Page 13 of 27 There is a two pronged approach. Firstly, imparting knowledge of legislation and the terminology

14 R/A/ specific to this field. Secondly, and in our view more importantly, the dignity and respect, human rights and core empathetic values are emphasised and explored. During 2015 a Powys teaching Health Board Values and Behaviours Framework has been developed. This was informed by a comprehensive staff engagement exercise. Equality features prominently within the Values and Behaviours Framework. 3.4 How do your organisation s policies and practices supporting quality patient care and medical revalidation promote equality and diversity, eg for people with protected characteristics? All policies and reports to the Board are impact assessed and analysed in accordance with the Specific Equality Duty Wales 2011 and the Public Sector eneral Equality Duty. This process has been strengthened during 2015 with the revised Policy for Policies and will be monitored by both the Corporate overnance and the Equality Teams. 3.5 How does your organisation s board/governance hierarchy engage with equality and diversity issues, and what benefits does this bring? The Board has a designated Champion for Equalities and Welsh Language. The Director of Workforce & OD is the lead for Equality and Diversity. The Page 14 of 27

15 R/A/ Assistant Director of Workforce & OD HR Operations is the operational lead to whom the equality manger reports. This arrangement gives the Equality Advisor access to the workforce team as well as to Board members and senior managers. Reporting arrangements to the Board are through the Workforce & OD sub committee of the Board. Equality features as a regular agenda item to the WOD subcommittee. The WOD structure operates in partnership with the localities which also gives direct access to the localities and frontline staff and managers for the purposes of engaging regarding equality and diversity. 4. Ongoing compliance with regulatory requirements and standards creates an environment where professionals can flourish In what ways does your organization: 4.1 ensure ongoing familiarity with the organisational and professional responsibilities set down in regulations and guidance? A Regular Protected Learning Time sessions for Primary and Secondary Care Doctors in partnership with Institute of Rural Health. Changes in professional Institute for Rural Health has now ceased to function; temporary arrangements have been established in Powys teaching Health Board, in advance of formal review and Page 15 of 27

16 4.2 take patient and public views, complaints and compliments into account to support governance and quality improvement? R/A/ responsibilities discussed at Local Medical Advisory roup. Change managed at locality level. Improving Patient Involvement & Experience roup. Complaints and compliments dealt with through the Quality & Safety Unit and also reported at Locality level. Members of Locality Management Team attend Focus groups. National Service User Framework questionnaire issued and analysed. Range of local feedback methods including surveys. option appraisal for new delivery model. 4.3 know that relevant data are collected and distributed to doctors, including for doctors working in a range of, or remote, practice settings, in a way that supports their revalidation? We have a small number of secondary care doctors and therefore communication is very good. This is usually done by but all doctors have good links and communication with the Medical Director, Locality eneral Managers and Workforce &OD. Primary Care Department disseminate relevant Page 16 of 27

17 R/A/ information to primary care doctors by an established P network. Director of Workforce & OD is now also lead Director for communications in Powys teaching Health Board. 4.4 monitor the quality of data supporting your RO in their role, including making revalidation recommendations to the MC? All relevant data discussed at Revalidation Panel. Any clinical or performance data issues are reported through Workforce & OD or Locality eneral Manager. Medical Director personally reviews appraisal information, prior to revalidation recommendation. 4.5 What was the outcome of your last review of data needs to support quality improvement and monitoring? A Quality performance indicators developed and reported bimonthly. Trend analysis developing alongside narrative to evidence quality improvement. Work is in development with regards to gathering and monitoring data and information on commissioned services to support quality improvement. To use the English provided quality and safety data to inform the commissioning process. To develop a quality review model for commissioned services in Wales with one Health Board. Following successful development of a quality review model, replicate it across all commissioned Page 17 of 27

18 How does your organisation: 4.6 ensure the identity, qualifications, references and experience of your doctors? R/A/ Powys participates in clinical quality review forums with English providers; work with Welsh providers planned. All of these pre-employment checks are undertaken as per the Recruitment policy. services for Powys residents in Wales. 4.7 monitor the conduct and performance of doctors, including temporarily appointed doctors, locums and doctors in training, and ensure any issues arising are addressed? A This is managed through job planning and appraisal as well as regular manager review. For locum and agency staff a competency questionnaire/proforma is completed and any issues addressed. Locum policy under development. 4.8 manage admission to the performers list, if relevant? Medical Director signs off following communication with Shared Services Partnership. 4.9 know that the arrangements to grant and monitor practising privileges for medical practitioners are robust? High level of awareness of performance of each doctor as so few employed directly by Health Board. 5. Medical appraisal takes place in accordance with MC guidance and organisational requirements 5.1 What is the practical effect of the integration of your organisation s appraisal policy with other governance arrangements? All doctors in Powys participate in an annual appraisal process following the All Wales Medical Page 18 of 27

19 R/A/ Appraisal Policy v0.6. How does your organisation: 5.2 know that all doctors requiring annual appraisal have participated? Board Report Workforce metrics 5.3 manage the situation where doctors requiring appraisal have not been appraised? Primary care doctors are not an issue as appraisal is required for continuation on Medical Performers List. Secondary doctors all participate in process. Medical Director takes direct action where non engagement of appraisal occurs. 5.4 know all doctors are familiar with your organisation s appraisal policy and system? The All Wales Medical Appraisal Policy has been distributed to all doctors and is also accessible via the PtHB website. This policy was due for review in April 2014 and is in the process of being revised by an All Wales Task and Finish roup. Information is also supplied by the Wales Deanery to all doctors. Page 19 of 27

20 How does your organisation ensure: 5.5 the focus of appraisal is on the MC s ood Medical Practice and other relevant guidance? R/A/ Powys teaching Health Board uses MARS appraisal system. 5.6 appraisers are appropriately trained to conduct appraisals? P appraisers have to attend a two-day residential training programme covering all aspects of the appraisal process led and facilitated by experienced Appraisal Coordinators. During the probationary process the quality of the appraisal summaries produced by the newly appointed P appraisers are monitored by an Appraisal Coordinator in order to ensure that they meet the RSU's standards with respect to the process of appraisal and revalidation. Powys teaching Health Board appraisers have received training and update reminders. 5.7 medical appraisers are supported in the role through leadership and peer support? Each P appraiser has a designated Appraisal Coordinator who is their line manager. The Appraisal Coordinator is responsible Page 20 of 27

21 R/A/ for supporting the P appraiser in question with respect to their practice as a P appraiser. P appraisers are expected to attend regional team meetings with their peers on a quarterly basis for training and peer support with respect to the appraisal process. Training requirements of Powys teaching Health Board appraisers are supported by organisation. Clinical Director provides leadership and peer support. 5.8 adequate resources are available to support doctors appraisal, revalidation and CPD? There are currently 5 P appraisers offering 130- appraisal slots for Ps who are based in the Health Board. They provide doctors with support and guidance relating to appraisal and revalidation during the appraisal meeting. The appraisers are led by a designated Appraisal Coordinator who is responsible for supporting the appraisers, and monitoring the quality of their work with respect to Page 21 of 27

22 R/A/ appraisal and revalidation as discussed above. Ratio of Powys teaching Health Board doctors to appraisers is adequate. Concerns would be discussed with Medical Director or through Job Planning process. 5.9 the quality and completeness of information supporting appraisal? How does your organisation: 5.10 manage and monitor the performance of its appraisers in their role? For eneral Practitioners: see responses to 5.10 and All Powys teaching Health Board doctors are appraised through MARS and comply with necessary standards. Page 22 of 27 The regional Appraisal Coordinator reviews appraisal summaries produced by P appraisers who are members of the regional appraisal team on a regular basis using a standard template, which specifies the relevant standards with respect to the appraisal process in Wales. Each P appraiser has an annual performance review meeting with their designated Appraisal Coordinator, which reviews the

23 R/A/ performance of the P appraiser in a number of areas using relevant data generated by the appraisal website. A Personal Development Plan is produced during this meeting in order to guide the P appraisers' development in these roles during the coming year. Secondary care doctors able to provide feedback on their appraisals monitor the quality and robustness of appraisals and appraisal outputs? The quality assurance of P appraisal summaries is undertaken in the RSU's annual Internal Quality Assurance event. A team of appraisers and external stakeholders participates in this exercise producing data regarding the quality and robustness of appraisals and appraisal outputs for future action planning review the annual appraisal process and put consequential learning into effect? A Any identified learning is fed into the Clinical Director who would raise this with the Medical Director. Relates to work to be taken forward under 4.1. Page 23 of 27

24 R/A/ Requires further work to implement consequential learning monitor the outcomes of doctors participation in CPD? All appraisals consider the previous year s CPD activity and outcomes How does your governance hierarchy oversee appraisal, and consider whether it is delivering anticipated benefits? Medical Director quarterly meetings with Martin Thomas, Appraisal Coordinator. Page 24 of 27

25 UIDANCE NOTES NUMBER OF DOCTORS 1.3 Number of doctors with whom the designated body has a prescribed connection as at 31 March 2015 The responsible officer should keep an accurate record of all doctors with whom the designated body has a prescribed connection. The prescribed connection is defined in detail in the RO regulations and the responsible officer must be satisfied that the doctor has correctly identified their designated body. To do this the responsible officer will need to understand this section of the regulations and will need to know the other roles the doctor performs. A number of doctors, including locums, other employed or contracted doctors and doctors in wholly independent practice may not be included in these categories and should be entered under other. All general practitioners (Ps) including principals, salaried and locum Ps on the medical performers list should be entered under general practitioner. Trainees on national training schemes, including P trainees, have a prescribed connection to the Deanery; trainees on independent schemes may have a prescribed connection to the employing trust. Academics with honorary clinical contracts will usually have their responsible officer in the Health Board or Trust where they perform their clinical work. Depending on their contractual status, secondary care locums may have a prescribed connection to a locum agency or an employer. Doctors with practising privileges may have a prescribed connection with the independent sector hospital depending on their other roles. The categories relate to current roles and job titles rather than qualifications or previous roles. The number of individual doctors in each category should be entered. APPRAISALS Section 2: Appraisal / revalidation data reporting relating to April March 2015 The appraisal system is one of the cornerstones of revalidation and good quality appraisal is essential for the responsible officer to be assured that each medical practitioner is up to date and fit to practise. Appraisal must also provide a safe environment for personal development needs to be discussed and agreed. A good appraisal system is dependent on effective leadership and management, the quality of the supporting information and the quality and professionalism of the appraisers. For revalidation to fulfil its primary objectives it is essential that information from all the doctor s roles is available at appraisal. The appraisal system must be set up to deliver annual appraisal for all the doctors who have a prescribed connection with the designated body. In order to ensure all doctors have an annual appraisal, it is necessary for the responsible officers to establish the reasons for missed or incomplete appraisals, to satisfy themselves that the appraisal system is functioning effectively and also that doctors are fulfilling their professional and contractual obligations. The responsible officer is responsible for the quality and effectiveness of the appraisal system even if Page 25 of 27

26 this has been commissioned from an external provider organisation. In these circumstances, it is advisable for a service agreement to be drawn up defining the required quality standards and key indicators. For the purposes of this guidance the organisational appraisal year runs from 1 April to 31 March. The appraisal year is defined in this way to assist the management and monitoring of the appraisal system and to allow comparison and benchmarking between organisations and sectors. A completed annual appraisal is one where the appraisal meeting has taken place between 9 and 15 months of the date of the last appraisal and the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting. It is not suggested that these definitions, required for managing an effective organisational appraisal system, should be applied to revalidation recommendations for individual doctors. The audit will give a detailed understanding of what has happened in all missed or incomplete appraisals and the responsible officer will exercise judgement on a case by case basis if an appraisal falls outside the appraisal year for acceptable reasons. For doctors in training it has been agreed that revalidation recommendations will be based on the process of annual review of competence progression and therefore Deaneries do not need to complete this section. The role of medical appraiser is an important professional role and effective selection processes and structured initial training programmes are needed. Ongoing performance review, development and support of appraisers will also be necessary to maintain the skills of the appraiser and to assure the quality and consistency of appraisal. It has been agreed by the Wales Revalidation Delivery Board that, in order to further support revalidation, all NHS doctors will be required to access their appraisal via MARS from 1 April Therefore it is anticipated that NHS designated bodies will be taking steps to ensure this happens. 2.1 Numbers of doctors who had completed appraisal between 1 April 2014 and 31 March 2015 (with whom the designated body has a prescribed connection as at 31 March 2015) For the purposes of this guidance, a completed annual appraisal is one where the appraisal meeting has taken place between 9 and 15 months of the date of the last appraisal and the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting. In most circumstances the final sign-off of the appraisal should occur within a few days of the appraisal meeting. Some organisations may require additional sign-off from a medical manager, clinical director or medical director. These additional processes should be described in the organisation s appraisal policy with any necessary deadlines but the principle that should apply in all situations is that the appraiser and doctor should sign the agreed outputs within 28 days. The 28-day period is to allow for holidays and other absences and should be sufficient for agreement and sign-off in almost all circumstances. For example, an appraisal meeting taking place on 31 March would need to be signed off on 27 April for it to be included in the year. An appraisal that has not been signed-off within this period should be regarded as incomplete and included in the audit of missed/incomplete appraisals so the reason for the delay can be explored. Page 26 of 27

27 In completing this self-assessment it is important to distinguish between the responsible officer s responsibility to manage the quality and effectiveness of the appraisal system and their responsibility to make revalidation recommendations on individual doctors. To manage the system the responsible officer needs to know that every doctor has had an appraisal meeting and the sign-off has been completed. In making recommendations on individual doctors the responsible officer can use their judgement to allow flexibility for appraisals delayed by holidays, sickness absence, study leave, etc. There is no suggestion that an individual appraisal will be invalidated by delays, but in managing the appraisal system the organisation needs to set a reasonable expectation, track what s happening and understand the reasons for delays. It would be unusual for a designated body to complete appraisals on all the doctors for whom it has responsibility within the appraisal year. There are many potential reasons for this and the main purpose of this section is to help the designated body establish the reasons for missed or incomplete appraisals so that the management of the appraisal system can be optimised. The same categories of doctors in section 1.3 are used in this section to identify those doctors who have had a completed appraisal in the year 2014/15. Comparing the numbers in sections 1.3 and will give an indication of the additional organisational capacity and training required. APPRAISERS Number of active medical appraisers as at 31 March 2015: Active appraisers are those who have performed at least one appraisal in the appraisal year and undertaken revalidation ready training, as described in the Appraisal Policy and Ope Standards, should include: Understanding of the purpose of appraisal and revalidation and the links between these processes and other systems for improving the quality of medical practice in the organisation and the wider healthcare system Competency in assessing supporting information that informs the appraisal and revalidation process, speciality aspects of appraisal Skills to conduct an effective appraisal discussion, including all the elements needed for revalidation Ability to produce consistently high quality appraisal documentation, sufficient to inform the revalidation recommendation as well as inform personal development Wales Medical Appraisal Policy in particular ethos of appraisal in Wales, integration with other quality improvement and patient safety processes, principles of delivery Wales Whole Practice Appraisal policy Wales Quality Indicators of Supporting Information policy Concept of agreement at appraisal and processes for resolving disputes Quality criteria for appraisal summary and PDP For those using MARS, managing the above through MARS Page 27 of 27