Presentation Title
36pt Arial Bold
Sub heading 24pt Arial
A Framework of Quality Assurance for
Responsible Officers and Revalidation
Annual Board Report,
Surrey and Sussex Healthcare NHS Trust
August 31st 2017
Mr Adam Stacey-Clear
Responsible Officer for Revalidation
Executive Summary
• This report Follows the NHS England template as outlined in the
Framework for Quality Assurance and is an annual requirement for all
designated bodies.
• The annual Organisation Audit findings for Surrey and Sussex
Healthcare NHS Trust will be presented
• 353 doctors with a GMC connection to The Trust were included in the
audit, April 1st 2016-March 31st 2017
• A statement of compliance confirming compliance with The Medical
Profession (Responsible Officers) regulations 2010 needs to be signed
by either the CEO or Chairman following this report.
Governance Arrangements
• Surrey and Sussex Healthcare NHS Trust (SASH) has a Medical
Appraisal Policy on the Trust website which is available for all doctors
to read
• The Responsible Officer is Adam Stacey-Clear who regularly attends
network RO meetings on a regular basis throughout the year. The RO
and Medical director Des Holden also attend quarterly meetings with
the GMC Liaison Officer, Michael Cotton.
• The human resources dept. maintains a list of employed doctors at the
Trust.
• All completed appraisal forms are read by AS-C.
Access, Security and Confidentiality
• All appraisals are stored in a secure folder on the G drive
• No patient identifiable data is stored in any appraisal folders
• No information management breaches.
• The GMC have provided ASC with a secure link which lists all doctors
with a prescribed connection to the Trust (designated body).
• The list is regularly updated.
• Transfer of information between designated bodies.
Slide 4
Conduct and Performance
• All Trust doctors are subject to the organizational policies e.g. capability
and disciplinary in line with Maintaining High Professional Standards
best practice. The Trust recognizes the BMA code of conduct.
• The Trust reviews doctors performance in the yearly job plan,
supported by the annual appraisal process for all medical and dental
staff. Linking job planning with appraisal is currently being developed
as part of a new Trust strategy.
• The clinical effectiveness strategy supports Medical and Dental staff in
their practice by ensuring evidence is practice based and clinically
effective.
• The complaints procedure is Trust policy. This is part of doctor’s
feedback and concerns are raised at job planning stage to enable
improvement in doctor’s practice and patient care.
Slide 5
Pre-employment background checks
• Medical staffing check qualifications against persons specifications for
the post. DBS (formerly a CRB)
• Photographic ID
• Visa or Biometric card as proof of the right to work in the UK
• 2 proofs of address
• GMC registration check
• Must be on specialist register- substantive consultants
• 2 references
• Occupational health check
Locums employed through medacs
Slide 6
Responding to Concerns
• The Trust responds to concerns in respect of a doctor’s practice by
supporting them with regular and ongoing development opportunities.
• Fitness to practice concerns from The GMC about a doctor are dealt
with following the GMC guidelines.
• The Trust has an active whistleblowing (raising concerns) policy
Slide 7
Risks and Issues
• Medical Practice Information Transfer Form for new/visiting doctors
whose current designated body is not SASH.
• Appraisals in March- cohort of doctors have now been moved to earlier
in the year to offset the March crush.
• Appraisal policy changes to incorporate sanctions imposed for late
appraisals.
• All doctors will be sent a link to the new appraisal policy when
reminders are sent out
• The RO regulations are adhered to as strictly as possible, and the
annual appraiser update meetings enhance this.
Slide 8
Appraisals – Why?
• Revalidation demonstrates that a Doctor is up to date and fit to
practice through Appraisal and Clinical Governance
• This leads to improved Safety and Quality in Healthcare
• Fit for Practice – minimum standards as per GMC guidelines
• Fit for Purpose – above and beyond requirement for GMC –
able to undertake the roles for which they are employed
Hawk
Dove
Pen
Sword
Example
Precept
Horses Courses
Less
More
Moss
Rolling Stone
Appraisal Objectives
•Covering total scope of practice in terms of evidence seen •Documenting review of last year's personal development plans & recording origin of newly identified PDP items •Objective exploration of quality improvement activity •Recording that reflection has occurred & learning shared •Stage of revalidation and any outstanding requirement
•Speciality guidance followed & mandatory training recorded
Appraisers
• 44 trained appraisers in faculty of appraisers.
• Rather unequal distribution of appraisals from those who responded to request for
number of appraisals carried out.
• Appraisal year runs from April 1st to March 31st.
• Recent guidelines from NHS England recommend new appraisal categories:
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Number
Number
Number of appraisals carried out by Dr – April 2016: March 2017
NHS England appraisal guidelines
Medical Appraisal
• 353 doctors were included in this audit, 178 consultants and 175
associate specialists/Trust doctors/staff grade.
• 166 consultants completed an annual appraisal between 1/4/2016 and
31/3/2017.
• 7 late consultant appraisals were approved, 5 were not
• 165 associate specialists/Trust doctors completed an appraisal.
• 8 late SAS appraisals were approved, 2 were not.
• Audit sheet for late appraisals is maintained.
• Late appraisals default to the original due date the next year
Slide 15
Slide 16
2016/17 AOA indicator
SECTION 2: Appraisal
Your
organisation’s
response
Same sector:
DBs in sector: 54
All sectors:
Total DBs: 821
No. of doctors
(in organisation)
Total no. of doctors
(in SAME sector)
Total no. of doctors
(across ALL sectors)
Consultants 178 15381 50102
Staff grade, associate
specialist, specialty doctor
175 4084 11974
Slide 17
Completed appraisals (Measure 1a & 1b)
Your
organisation’s
response and (%)
calculated
appraisal rate
Same sector
appraisal rate
ALL sectors
appraisal rate
166 (93.3%) 93.6% 91.7%
165 (94.3%) 87.5% 87.0%
Slide 18
Approved incomplete or missed appraisal (Measure 2)
Your
organisation’s response
and (%) calculated
appraisal rate
Same sector
appraisal rate
ALL sectors
appraisal rate
7 (3.9%) 3.5% 4.7%
8 (4.6%) 6.6% 7.4%
Slide 19
Unapproved incomplete or missed appraisal (Measure 3)
Your organisation’s
response and (%)
calculated appraisal
rate
Same sector
appraisal rate
ALL sectors
appraisal rate
5 (2.8%) 2.9% 3.5%
2 (1.1%) 5.9% 5.6%
Recommendations submitted to GMC
• 22 revalidation recommendations made.
• 4 deferrals
• 18 positive recommendations
• Deferrals mainly due to lack of supporting information
• 108 doctors left the Trust
• 45 doctors were correctly connected to the Trust.
• 6 doctors were in training posts (and therefore not AS-C’s
responsibility) but had told the GMC that we were their DB.
• 7 doctors were found to be GPs
• 1 doctor died
• 49 doctors told GMC they were here but we could not get information
from them
Slide 20
Slide 21
Late appraisals without prior permission
Dr Michael Wilde Dr Matthew Cowan Dr Helena Wright Dr Rahi Yallapragada Dr Usha Limbu Miss Jean Arikosamy Dr Domo Kiss
WHAT’S GONE WELL
• New form for Locums with scope for feedback
• Attachment of Achievement Reviews to Appraisals
• Embedding Trust Values and Behaviours into Appraisal
• Reasonable good appraisal rates obtained
• Majority of doctors respond to e-mails confirming dates of booked-
in appraisals
• Updated e-mails in relation to reminders / new doctors / 360◦s
• New doctors acceptance letter includes requests to give Jenny
Cawthorne details of current RO and DB
• Good relations with St Catherine’s Hospice
Slide 23
WHAT’S NOT GONE WELL
• Doctors do not always respond to their SaSH e.mails so now including a “read
receipt” on their reminders
• Uneven response rate to feedback survey following an appraisal
• Doctors seem unaware that they have to update their own GMC details
• Some doctors not happy that appraisals moved from March to earlier date
• Public / Patient Involvement
• Repeat offenders
• Appraisal date drift
• Mood of reduced engagement and constant chasing required
• Some summaries not adequate
• Uneven distribution of appraisals
• Date of appraisal
Slide 24
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