1 Effective governance to spport medical revalidation A handbook for boards and governing bodies
2 This docment sets ot a view of the core elements of effective local governance of the systems that spport revalidation. It has been prodced collaboratively by the following organisations, in recognition of the important potential role of medical revalidation in driving improvement in healthcare qality and safety across the United Kingdom: the Care Qality Commission the General Medical Concil the Government Procrement Service Healthcare Improvement Scotland Healthcare Inspectorate Wales Monitor the Reglation and Qality Improvement Athority.
3 1 Foreword There is an ever growing focs on the qality of healthcare services across the United Kingdom and throghot the world. Increasing demand, changes in pblic expectations and developing technology are leading all healthcare systems to look closely at how to ensre safety and qality for patients, in the face of significant pressre on available resorces. Qality in healthcare embraces many factors that need to mesh together to deliver safe and effective patient care. In any setting, the integration of the responsibilities of organisations providing healthcare with those of individal professionals working within them is fndamental to achieving qality and safety objectives. It follows that effective local governance and qality assrance of the systems spporting medical revalidation make an essential contribtion to the improvement of qality and safety for patients. It also follows that there is a paramont need for close co-operation between the agencies that set and monitor standards for those systems. The introdction of medical revalidation in the United Kingdom (UK) from 3 December 2012 provides a frther lever for healthcare improvement. Medical revalidation reinforces the dty of healthcare organisations to create an environment where doctors can meet their professional obligations. It also reqires doctors to take part in organisational processes sch as annal appraisal and clinical governance. Althogh as reglatory athorities we each operate within different legal and methodological frameworks, we share similar objectives and vales. These centre on the prime importance of paying continos attention to the isses that nderpin qality and safety for patients. Medical revalidation can be expected to featre in or ftre reglatory programmes, and we will each se the handbook to spport or stattory roles, acknowledging that these are not identical across the UK. In collaborating over recent months to prodce this short handbook, we recognise the importance of medical revalidation as a tool for improvement. The handbook is particlarly intended to help boards and governing bodies in the initial phase of medical revalidation. Its contents will be kept nder review as medical revalidation and systems reglation policies develop.
4 2 It follows that effective local governance and qality assrance of the systems spporting medical revalidation make an essential contribtion to the improvement of qality and safety for patients.
5 3 Prpose and se of this handbook The core elements of effective governance* set ot in this handbook aim to help healthcare provider organisations (via their boards, governing bodies and responsible officers) evalate the robstness and effectiveness of local systems spporting qality patient care and medical revalidation. These elements are not new, and so are not additional to existing governance processes. The handbook is intended to serve as a reminder, and to help strctre local evalation. All boards and governing bodies overseeing medical care and treatment of patients shold take accont of the contents of the handbook when evalating their own organisation s arrangements, however there is no specific reqirement to report against it. In preparing for ftre inspection, assessment or adit work, boards or governing bodies may find it sefl to record how this docment, alongside other relevant gidance issed by reglators and qality improvement bodies, has been sed in practice. Appendix 2 smmarises or respective roles and responsibilities. Appendix 1 provides a list of qestions that yo may wish to se on an ongoing basis at ftre board/governing body meetings in order to demonstrate sond governance, governance reporting and systems evalation within yor organisation. These shold be read alongside the core elements. A separate version of appendix 1, which can be sed as a checklist, is available on the General Medical Concil (GMC) website. * Incorporating clinical governance and medical appraisal
6 4 Or giding principles These giding principles will nderpin the reglatory and qality improvement activities of or organisations. They are consistent with the objective of clarifying roles and responsibilities in the delivery of high qality services: responsibility for the qality and safety of services rests first and foremost with healthcare provider organisations and the individal professionals working within them; healthcare provider organisations shold pt in place governance systems that consistently promote and protect the interests of patients and service sers inclding creating an environment in which healthcare professionals can meet their professional obligations; qality improvement, government procrement and reglatory agencies prpose is to help improve the qality of care. They do this throgh a range of activities which inclde: monitoring and, where relevant, enforcing compliance with standards or contracts; sharing information and intelligence; driving improvement throgh bilding capacity and promoting learning; acting decisively to protect the pblic where evidence of risks to health or wellbeing emerge. in flfilling their professional obligations, healthcare professionals shold comply with the vales and principles expected of their profession and participate flly in the systems and processes pt in place by their organisations to improve qality and protect patients;
7 Medical revalidation and governance 5 Medical revalidation bears on all organisations in which doctors work *, on clinical leaders and on doctors themselves. Its introdction from 3 December 2012 reinforces the interdependent responsibilities of healthcare organisations and individal professionals. Medical revalidation places new stattory dties on all of these organisations and individals, and will over time provide additional assrance that doctors in the UK are fit to practise. This additional assrance for patients and the pblic derives from doctors practising in well strctred, managed and governed systems. Medical revalidation also provides a powerfl lever on organisations to drive improvements in the qality of patient care and treatment, and frther nderscores the paramont importance of robst systems for clinical governance, inclding appraisal and local qality assrance. The majority of systems, processes and responsibilities that nderpin medical revalidation are essential reqirements of high qality health services for patients - they are not new or additional for medical reglation. It is important that people can be confident that the arrangements pt in place can be relied pon. Within this new system: organisations appoint a senior doctor (a responsible officer RO) to oversee systems for governance and appraisal for doctors, for dealing with practice concerns abot doctors and for advising the GMC abot doctors fitness to practise; organisations are also responsible for providing resorces to spport ROs in their role. Their local governance arrangements shold incorporate constrctive challenge arond the way services are delivered and monitored; ROs mst assre themselves that the qality of their systems spports the evalation of doctors fitness to practise in a fair and consistent way; individal doctors mst demonstrate they contine to meet the vales and principles expected of the profession set ot in the GMC s core gidance Good medical practice. This is achieved by doctors reflecting on a portfolio of information and evidence at annal appraisal of the doctor s whole practice. * Incldes locm agencies and Government Procrement Services
8 6 All boards and governing bodies overseeing medical care and treatment of patients shold take accont of the contents of the handbook.
9 The core elements of effective governance 7 These core elements are intended to apply in respect of all organisations where doctors with a licence to practise work, inclding where those doctors do not ndertake any direct clinical activity or they are employed by another body. Boards and governing bodies shold embed these core elements in local systems, and se them to monitor governance in the key areas where organisations deliver care and treatment of patients. 1. There is corporate or organisationwide commitment to creating an environment that fosters good professional practice Well led and committed governing bodies will place high qality patient care and workforce qality at the centre of their bsiness. Their organisations will provide sfficient, well planned and managed resorces to spport that objective. Risks to the systems spporting the provision of safe and effective patient care will be identified and managed. These systems in trn spport medical revalidation, inclding appraisal and development of spporting information for appraisal. 2. Local governance is in place and monitored Local governance shold ensre that healthcare and other reglatory reqirements and standards are met, and stattory and other relevant gidance is followed. There shold be internal and/or external qality assrance to assre the robstness of governance. Organisational cltre will focs on high standards of patient care and safety and be actively promoted, managed and monitored to foster patient relationships fonded in partnership and trst. Qality improvement programmes will deliver activities that reslt in improvement actions and derived learning that is pt in place and adited. 3. Eqality and diversity considerations are integrated into all of the organisation s medical revalidation policies and practices Fair and non-discriminatory policies and practices shold be in place to spport qality patient care and medical revalidation. These shold be actively monitored and reglarly reviewed. Eqality and diversity isses which may impact on medical revalidation shold be identified and addressed in accordance with good practice. 4. Ongoing compliance with reglatory reqirements and standards creates an environment where professionals can florish Organisations and ROs mst act in accordance with their responsibilities, eg nder the Medical Profession (Responsible Officer) Reglations 2010, * as read with the General Medical Concil (Licence to Practise and Revalidation) Reglations Order of Concil 2012 or as set down in gidance or their job descriptions. * The Medical Profession (Responsible Officers) Reglations 2010 ( (as amended). The corresponding legislation in Northern Ireland is The Medical Profession (Responsible Officers) Reglations (Northern Ireland) 2010 (
10 8 ROs shold be appropriately trained to ndertake their responsibilities, and shold reglarly participate in local RO network activities that provide shared learning opportnities and aid consistency of approach. Information systems and records (eg for complaints and compliments and to access staff, patient and pblic feedback) will provide accrate, valid, timely, reliable and relevant information to spport workers in delivering high qality patient care and to spport doctors in their revalidation. Information shold be considered and acted pon where appropriate. All records shold be accrately maintained. The organisation shold have in place mechanisms to assre that the medical workforce (whether employed, contracted, doctors in training, working with practising privileges, hired or volnteer) is planned, recrited and sitably skilled, competent and knowledgeable to ndertake their dties professionally. 5. Medical appraisal takes place in accordance with GMC gidance and organisational reqirements ROs shold ensre that all doctors are familiar with appraisal arrangements and that all doctors participate in annal appraisal. Appraisal mst cover a doctor s whole practice, and take accont of all relevant information relating to the doctor s fitness to practise. The Good Medical Practice Framework for appraisal and revalidation and Spporting Information for Revalidation gidance set ot the approach to medical appraisal, as well as the information to be considered. ROs fitness to practise advice (revalidation recommendations) to the GMC is based on this process and on information from governance systems. Organisations shold ensre they are making reasonable arrangements to spport doctors in collecting spporting information for appraisal and revalidation, and to share with them information gathered to spport service qality and delivery. Any areas for development in a doctor s practice shold be identified and addressed in a targeted way, and concerns abot a doctor s fitness to practise referred to the GMC where appropriate. Specialty or other central or local (regional) advice shold be taken where appropriate. Examples of sch advice inclde that on training and appraisal provided by the Medical Royal Colleges and Faclties, and on fitness to practise provided via the GMC s Employer Liaison Service. The appraisal system for doctors shold be sbject to appropriate qality assrance measres. Appraisers shold be appropriately trained and their performance as appraisers monitored and evalated. Medical appraisal shold be focsed on the GMC s Good medical practice. Patient incldes the pblic/clients/cstomers as appropriate For example, qality data, performance data, adits, compliments, complaints and significant events
11 9 Well led and committed governing bodies will place high qality patient care and workforce qality at the centre of their bsiness.
12 Appendix 1 10 List of governance qestions This appendix provides list of qestions that are relevant in the context of ongoing evalating, demonstrating and reporting on governance of local systems and processes spporting patient safety and medical revalidation. These qestions draw on well established principles that spport qality improvement and medical revalidation objectives. They take accont of the clinical governance and appraisal criteria followed in the varios assessments of readiness to begin medical revalidation ndertaken across the UK, for example the Organisational Readiness Self Assessment sed in England, however there is no specific reqirement to report against them. A separate version of this appendix, which can be sed as a checklist, is available on the GMC website ( 1. There is corporate or organisationwide commitment to creating an environment that fosters good professional practice How does yor organisation: know that the governance of systems spporting the provision of qality patient care and medical revalidation objectives is appropriately spported, managed and assred? ensre the adeqacy of resorces to spport all healthcare workers in flfilling their professional responsibilities, eg in relation to staff indction, appraisal, Contining Professional Development (CPD) and revalidation of doctors? In what way: does the organisation s governance strategy proactively spport the provision of qality patient care and medical revalidation objectives? might reporting arond qality patient care and medical revalidation objectives to the board/governing body be improved? How transparent are the board/governing body s governance activities? How does the board/governing body regarly review data relating to revalidation and clinical practice? 2. Local governance is in place and monitored How does yor organisation ensre: all information systems for monitoring the condct and performance of doctors working in yor organisation are operating effectively? the performance of locms, doctors in training and temporarily appointed doctors is monitored and reported in a way that contribtes constrctively to their revalidation?
13 11 pre-employment, and other pre-contract checks ndertaken in keeping with stattory and other reqirements, are comprehensive and accrate? 4. Ongoing compliance with reglatory reqirements and standards creates an environment where professionals can florish qality improvement activities ndertaken have been beneficial? it can and does respond qickly when things go wrong? 3. Eqality and diversity considerations are integrated into all of the organisation s medical revalidation policies and practices In what ways does yor organisation: ensre ongoing familiarity with the organisational and professional responsibilities set down in reglations and gidance? take patient and pblic views, complaints and compliments into accont to spport governance and qality improvement? How does yor organisation: ensre its policies and practices spporting medical revalidation are fair and non-discriminatory, and comply with legal reqirements? keep p to date with eqality and diversity isses and policies? approach training in eqality and diversity matters? How do yor organisation s policies and practices spporting qality patient care and medical revalidation promote eqality and diversity, eg for people with protected characteristics? How does yor organisation s board/ governance hierarchy engage with eqality and diversity isses, and what benefits does this bring? know that relevant data are collected and distribted to doctors, inclding for doctors working in a range of, or remote, practice settings, in a way that spports their revalidation? monitor the qality of data spporting yor RO in their role, inclding making revalidation recommendations to the GMC? What was the otcome of yor last review of data needs to spport qality improvement and monitoring? How does yor organisation: ensre the identity, qalifications, references and experience of yor doctors?
14 12 monitor the condct and performance of doctors, inclding temporarily appointed doctors, locms and doctors in training, and ensre any isses arising are addressed? manage admission to the performers list, if relevant? adeqate resorces are available to spport doctors appraisal, revalidation and CPD? the qality and completeness of information spporting appraisal? How does yor organisation: know that the arrangements to grant and monitor practising privileges for medical practitioners are robst? 5. Medical appraisal takes place in accordance with GMC gidance and organisational reqirements What is the practical effect of the integration of yor organisation s appraisal policy with other governance arrangements? manage and monitor the performance of its appraisers in their role? monitor the qality and robstness of appraisals and appraisal otpts? review the annal appraisal process and pt conseqential learning into effect? monitor the otcomes of doctors participation in CPD? How does yor organisation: know that all doctors reqiring annal appraisal have participated? How does yor governance hierarchy oversee appraisal, and consider whether it is delivering anticipated benefits? manage the sitation where doctors reqiring appraisal have not been appraised? know all doctors are familiar with yor organisation s appraisal policy and system? How does yor organisation ensre: the focs of appraisal is on the GMC s Good medical practice and other relevant gidance? appraisers are appropriately trained to condct appraisals?
15 Appendix 2 13 Roles of the organisations prodcing this handbook Care Qality Commission, England ( The Care Qality Commission (CQC) is the independent reglator of healthcare and adlt social care services in England. CQC also protects the interests of people whose rights are restricted nder the Mental Health Act. Whether services are provided by the NHS, local athorities or by private or volntary organisations, CQC focses on: identifying risks to the qality and safety of people s care; acting swiftly to help eliminate poor qality care; making sre care is centred on people s needs and protects their rights. By law, all providers of care services in England are responsible for making sre that their services meet national standards of qality and safety set by Government. CQC registers providers and can se a range of powers to take action to drive improvement when a service is not meeting the standards. CQC ses inspections and information from other organisations to monitor whether care services are meeting the standards, as well as the views and experiences of people who se services, which are at the centre of CQC s work. General Medical Concil, UK ( The General Medical Concil (GMC) is the independent reglator for doctors in the UK. Its role is to protect, promote and maintain the health and safety of the pblic by ensring proper standards in the practice of medicine. GMC has for main fnctions nder the Medical Act 1983: keeping p-to-date registers of qalified doctors; fostering good medical practice; promoting high standards of medical edcation and training; dealing firmly and fairly with doctors whose fitness to practise is in dobt. Revalidation provides a frther lever to drive improvements in medical practice. GMC controls entry to the medical register and sets the standards for medical schools and postgradate edcation and training. GMC also determines the principles and vales that nderpin good medical practice and takes firm bt fair action where those standards have not been met.
16 14 GMC has strong and effective legal powers designed to maintain the standards the pblic have a right to expect of doctors. Where any doctor fails to meet those standards, GMC acts to protect patients from harm - if necessary, by removing the doctor from the register and removing their right to practise medicine. The introdction of medical revalidation across the UK in early December 2012 provides a new way of reglating licensed doctors that will give extra confidence to patients that their doctors are p to date and fit to practise. Only licensed doctors have to revalidate, sally every five years, by having annal appraisals based on the GMC s core gidance for doctors, Good medical practice. The majority of licensed doctors are expected to be revalidated for the first time by the end of March Government Procrement Service, UK ( Government Procrement Service (GPS) is an exective agency of the Cabinet Office with the overall priority of providing procrement savings across central government and the UK pblic sector inclding local government, health, edcation, devolved administrations, emergency services, defence and not for profit organisations. The GPS centralisation programme drives vale in the prchase of services via a system of framework agreements. One sch agreement negotiated by the GPS is for spply of hospital medical locm doctors for short drations. This aims to deliver savings in the NHS while enhancing the safety and qality of services for sers and patients. The agreement provides NHS bodies with a reglated means of providing continity of patient care and core hospital services in a wide range of sitations eg while permanent doctors are on annal leave, sick, or are attending interviews or training, or to provide additional resorce at peak periods or cover nfilled vacancies. Operation of the agreement is monitored and adited by GPS via its Health Assrance Team whose objective is to ensre that all workers spplied to the NHS nder the framework are of high qality and do not present a risk to patient safety. Healthcare Improvement Scotland ( Healthcare Improvement Scotland (HIS) is a health body with the vision to deliver excellence in improving the qality of the care and experience of every person in Scotland every time they access healthcare. The focs and key responsibility of HIS is to: help NHS Scotland and independent healthcare providers deliver high qality, evidence-based, safe, effective and personcentred care; scrtinise services to provide pblic assrance abot the qality and safety of that care. HIS activities are organised with patient focs and pblic involvement at their heart. They encompass all three areas of an integrated cycle of improvement, involving:
17 15 developing evidence-based advice, gidance and standards for effective clinical practice; driving and spporting improvement of healthcare practice; providing assrance abot the qality and safety of healthcare throgh scrtiny and reporting on performance. Healthcare Inspectorate Wales ( Healthcare Inspectorate Wales (HIW) is the independent inspectorate and reglator of all healthcare in Wales, and has a primary focs on: making a significant contribtion to improving the safety and qality of healthcare services in Wales; improving citizens experience of healthcare in Wales whether as a patient, service ser, carer, relative or employee; strengthening the voice of patients and the pblic in the way health services are reviewed; ensring that timely, sefl, accessible and relevant information abot the safety and qality of healthcare in Wales is made available to all. HIW s core role is to review and inspect NHS and independent healthcare organisations and to provide independent assrance for patients, the pblic, the Welsh Government and healthcare providers that services are safe and of good qality. Services are reviewed against pblished standards, policies, gidance and reglations. HIW seeks to identify and spport both the improvement of services and the actions needed to achieve this. If necessary, HIW will ndertake special reviews and investigations where there appears to be systematic failres in delivering healthcare services, to ensre that rapid improvement and learning takes place. In addition, HIW is the reglator of independent healthcare providers in Wales and is the Local Spervising Athority for the stattory spervision of midwives. Monitor, England ( Under the Health and Social Care Act 2012 Monitor becomes the sector reglator for health, with a main dty to protect and promote the interests of people who se healthcare services by promoting provision of healthcare services which are economic, efficient and effective, and which maintain or improve the qality of those services. In carrying ot its sector reglator role, Monitor will licence providers of NHS services in England and exercise fnctions in three areas: pblishing the national tariff, inclding setting the prices and/or setting the rles for determining prices for NHS fnded care; enabling integrated care and preventing anti-competitive behavior where this is in the best interests of people who se healthcare;
18 16 spporting the continity of essential services. Monitor contines to assess NHS trsts for fondation trst stats, and to ensre that they are finacially viable and well led, so they can deliver sstainable qality care. Monitor will also, sbject to consltation, contine to oversee the governance of NHS fondation trsts. If an NHS fondation trst s governance is sch that it will fail to meet the conditions of its licence, Monitor will be able to intervene to address the governance failings. Reglation and Qality Improvement Athority, Northern Ireland ( The Reglation and Qality Improvement Athority, Northern Ireland (RQIA) is the independent body responsible for monitoring and inspecting the availability and qality of health and social care services in Northern Ireland, and encoraging improvements in the qality of those services. RQIA s main fnctions are to: inspect the qality of services provided by Health and Social Care Services (HSC) bodies in Northern Ireland throgh reviews of clinical and social care governance arrangements within these bodies; reglate (register and inspect) a wide range of services delivered by HSC bodies and by the independent sector. The reglation of services is based on minimm care standards to ensre that service sers know the qality of services they can expect to receive, and service providers have a benchmark against which to measre their qality; ndertake a range of responsibilities for people with a mental illness and those with a learning disability. These inclde preventing ill treatment, remedying any deficiency in care or treatment, terminating improper detention in a hospital or gardianship and preventing or redressing loss or damage to a patient s property.
20 Care Qality Commission Finsbry Tower , Bnhill Row London EC1Y 8TG Tel: General Medical Concil 3 Hardman Street Manchester M3 3AW Tel: Government Procrement Service Floor 9 The Capital Bilding Old Hall Street Liverpool L3 9PP Cstomer contact: Spplier contact: Healthcare Improvement Scotland Gyle Sqare 1 Soth Gyle Crescent Edinbrgh EH12 9EB Tel: Healthcare Inspectorate Wales Bevan Hose Caerphilly Bsiness Park Van Road Caerphilly CF83 3ED Tel: Monitor 4 Matthew Parker Street London SW1H 9NP Tel: Reglation and Qality Improvement Athority 9th Floor Riverside Tower 5 Lanyon Place Belfast BT1 3BT Tel: This information can be made available in alternative formats or langages. To reqest an alternative format, please call s on or s at Pblished March 2013 The text of this docment may be reprodced free of charge in any format or medim, providing it is reprodced accrately and not in a misleading context. Code: GMC/GH/0313