Doctors Appraisal Policy (Supporting the Revalidation of our Doctors)

Transcription

1 Doctors Appraisal Policy (Supporting the Revalidation of our Doctors) Written By: Signed: Date: Document Author Equality and Diversity Lead Authorised Signature Authorised By: Karen Baker Chief Executive Signed: Date: 16 September 2013 Policy Lead Director: Executive Medical Director Effective Date: September 2013 Review Date: 15 September 2016 Extension Date: 15 March 2017 Approved at: Executive Committee Date Approved: 16 September 2013 Extension Approved: 23 August 2016 Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 1 of 36

2 DOCUMENT HISTOR (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time the initial draft will be version 0.1) Date of Issue Version No. Nov Jun Next Review Date Date Approved Director Responsible for Change Executive Medical Director Executive Medical Director Executive Medical Director Nature of Change First draft Second draft Comments from an Associate Director taken into account. Jul Aug Executive Medical Director Section 4.5 updated to reflect standard setting arrangements within for the NHS Trust. Added new bullet point 4.5 with link to Job Planning Sep Oct Oct Nov Nov Executive Medical Director Executive Medical Director Executive Medical Director Executive Medical Director Executive Medical Director Dec Executive Medical Director Mar Executive Medical Director Section 9 amended Completed Equality Analysis and Impact Analysis Put in to new Trust Policy format and incorporated feedback from appraisers Added reference to Medical Professionals (Responsible Officers) Regulations (page 13). Also completed section 10. Incorporated feedback from LNC. Added GMC link in section 5.2. Section 14, added references to relevant legal documents Review of policy following feedback from Appraisers. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 2 of 36

3 10 Aug Mar Aug 16 Executive Medical Director Extension approved at Corporate Governance & Risk Committee on voting buttons Amendments Introduction Simplified explanation 5.2 Ensure their statutory and mandatory periodic training is up to date deleted. Rationale, it is not a requirement of an appraiser to keep their mandatory training up to date; it is a requirement of their substantive role. 5.5 Deleted sub-heading; to avoid misinterpretation that there is an explicit link between job planning, appraisals and revalidation, this is not the case. Figure 1 Removed phase 5 duplication of section Replace Clinical Director with Lead Appraiser Amended wording to read Appraisers will be expected to attend relevant meetings to ensure they are kept up to date Deleted sentence It is also expected that the appraiser will check their personal indemnity cover. This sentence has been removed following legal advice from the Strategic Health Authority. The Trust s indemnity will cover doctors who undertake appraisals. Appendix 1 Removed names, leaving only job titles Title Change of policy title. Appendix C Key Definitions and Abbreviations added Appendix F EXCELLENCE quality assurance model. Referenced in section New 5.2 Added Alternative Responsible Officer section following new national guidance. All subsequent section renumbered. Section 3 Reference and links to Health Education England (South) Doctors in Training and 14 Revalidation Policy Section 6 Added the four domains set out in the GMC s Good Medical Practice Guide. NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 3 of 36

4 Contents Page 1. Executive Summary 5 2. Introduction 6 3. Scope 6 4. Purpose 6 5. Roles and Responsibilities 7 to Policy detail / course of action 10 to Consultation Training Dissemination Process Equality Analysis Review and Revision arrangements Monitoring Compliance And Effectiveness 16 to Links to Other Organisation Policies/Documents References Disclaimer 18 Appendices A. Appraisal Exemption and Application Form B C D E F G Guidelines for Appraisers and Appraisee s Key Definitions and Abbreviations Checklist for the development and approval of controlled Documentation Impact assessment forms on policy implementation (including checklist) EXCELLENCE quality assurance model Equality Analysis Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 4 of 36

5 1. Executive Summary The purpose of this policy is to outline the Isle of Wight NHS Trust s responsibilities and operational requirements to support the appraisals and revalidation of medical practitioners directly employed by the Trust. This new approach to medical regulation aims to give patients and employers regular assurance that their doctors are up to date and are deemed to be fit to practice. Although Appraisal is not a new concept, the revalidation strengthens the appraisal process. This policy has been based on the Good Medical Practice model produced by the General Medical Council (GMC) and guidance from the Revalidation Support Team. This policy is not exhaustive and does not intended to contain information on all aspects of Appraisal and Revalidation. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 5 of 36

6 2. INTRODUCTION Revalidation is the process by which licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practise. Licensed doctors have to revalidate, usually every five years, by having regular appraisals that are based on our core guidance for doctors Good Medical Practice produced by the General Medical Council (GMC). Medical appraisal is a process of facilitated self-review supported by information gathered from the full scope of a doctor s work. Medical appraisal can be used for four purposes: 1. To enable doctors to discuss their practice and performance with their appraiser in order to demonstrate that they continue to meet the principles and values set out in Good Medical Practice and thus to inform the responsible officer s revalidation recommendation to the GMC. 2. To enable doctors to enhance the quality of their professional work by planning their professional development. 3. To enable doctors to consider their own needs in planning their professional development. and may also be used 4. To enable doctors to ensure that they are working productively and in line with the priorities and requirements of the organisation they practise in. Revalidation aims: To confirm that licensed doctors practice in accordance with the GMC s generic standards For doctors on the specialist register and GP register, to confirm that they meet the standards appropriate for their specialty It may identify, areas for further investigation and remediation, re-skilling where poor practice is identified where local systems are not robust enough to do this or do not exist. 3. SCOPE This policy applies to all non-training grade medical practitioners, including those with permanent or fixed term contracts where the Isle of Wight NHS Trust is their designated body. Annual appraisal is a requirement, as part of revalidation, for all medical practitioners including: Clinical Fellows, Trust doctors, research fellows with clinical commitments, SAS grades on the old contract, and locums. Doctors in Training are subject to revalidation as all other doctors registered with the GMC. The trust will ensure all doctors in training will be supported through their revalidation in line with the Health Education England (Wessex Deanery) Revalidation of Doctors in Training Policy. A link to this policy can be found in section 14. This policy does not apply to doctors supplied by a locum agency or doctors who are employed by another NHS organisation who provide a service to the Trust under an honorary contract. 4. PURPOSE The purpose of the policy is to ensure that, through an effective appraisal mechanism, all medical practitioners are fit to practise and can provide assurance to the General Medical Council and the Trust that they provide a high standards of safe care to patients. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 6 of 36

7 5. ROLES AND RESPONSIBILITIES There are several key roles required to operate an effective appraisal system. The requirements for Revalidation also have some defined roles as well. The primary role is that of the Responsible Officer. The Isle of Wight NHS Trust this responsibility has been vested in the Executive Medical Director s role, as the senior medical professional within the organisation and is accountable to the Trust Board. 5.1 The Responsible Officer (RO) has overall accountability to the Trust Board for the effective implementation, maintenance and quality assurance of appraisals for all nontraining grade Medical Staff (Consultants, SAS, Trust Doctors and all non-training grade posts) ensuring annual appraisals take place for all doctors for whom they are responsible. The range of the Responsible Officers duties includes: To ensure that all appraisal documentation and feedback is securely stored Makes a recommendation to the GMC on a doctor s fitness for revalidation based on an assessment of their practise through annual appraisals over a five year period. To ensure the Responsible Office can be assured of the quality of appraisals the EXCELLENCE model shown in appendix F will be used To ensure that the systems are in place so that information held by the Trust on each doctors practice within the organisation is made available to the doctor on an annual basis and in a timely manner Ensuring the Trust has the capacity to meet its appraiser and revalidation obligations The recruitment and selection of appraisers and provide to the GMC a description of the selection process for appraisers, together with a Job Description of the required competencies and person specification. There will be a probationary period/early review of skills for all new appraisers. The RO will obtain appraisee feedback on the performance of all its appraisers Arrange training for new appraisers and ensure that existing appraisers are kept update. 5.2 Alternative Responsible Officer Because of Conflict of Interest or Appearance of Bias (CIAB) Where a conflict of interest or appearance of bias exists the 2013 amendment to the Responsible Officer regulations allow for an alternative responsible officer to be nominated. It is envisaged that this will be a rare occurrence and should not be invoked every time a doctor has had a minor disagreement with the RO in the course of their career. There could be conflict of interest or appearance of bias where there is: a personal relationship between the RO and the doctor (e.g. intimate, familial) a financial or business relationship between the RO and the doctor (e.g. private patient income). third party involvement in a personal relationship (e.g. affair, relationship breakdown) known and long standing animosity between the RO and the doctor a role conflict (e.g.ro who is accountable to a medical chief executive Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 7 of 36

8 Figure 1 Process for Dealing with Conflicts of Interest or Appearance of Bias Doctor, RO or other identifies CIAB Process for CIAB Discussed with neutral person Doctor or Level 1 RO may still raise Discussed with Level 2 RO Formal correspondence Decision is final Key Next step agreed Alternative RO nominated Formal submission to RO Formal confirmation Not agreed The Trust has an agreement with another organisation to provide RO services the process to be followed should be confirmed in the agreement The doctor, the RO or another concerned individual should have the opportunity to raise CIAB with a senior neutral person e.g. clinical governance lead, HR Lead within the designated body If the doctor, RO and neutral person agree, this should be discussed with the NHS England (South) RO. If they agree, then an alternative RO should be nominated or appointed. This will usually be a trained and experienced RO from another designated body, usually within the same region. A formal communication should be made using the form in appendix H by the Trust to the NHS England (South) RO setting out: The grounds for CIAB The alternative arrangements proposed. The NHS England (South) RO will confirm agreement in writing If the agreement is not reached in discussion with the NHS England (South) RO, the neutral representative should write formally setting out the case for CIAB. The decision is final. The NHS England (South) RO will be responsible for keeping a record of all decisions If the doctor, Trust RO and neutral representative of the designated body cannot reach agreement, the doctor, Level 1 RO or neutral person may approach the NHS England (South) RO independently to discuss the issues. The NHS England (South) RO will take a view after discussion with the other parties concerned and then the process in 2 or 3 outlined in Figure 1 should be followed, as appropriate If an alternative RO designated the Trust RO will confirm in writing the responsibilities of the various parties in the new arrangement. This includes the responsibility of the Trust to arrange appraisals, provide data/feedback and to exchange that information with the alternative RO annually. The doctor is responsible for informing their designated body when they have been revalidated or if any issues will delay their revalidation. The doctor s appraiser has a responsibility to inform BOTH ROs if there is a perceived cause for concern or patient safety issue. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 8 of 36

9 5.3 Appraisers will be appointed by the RO. An appraisal meeting should be a supportive and developmental two-way conversation between the appraisers and appraisee. At an appraisal the appraiser will review with the doctor various sources of information (details can be found from the GMC web site and in section 6 of this policy, to gain a rounded impression of that doctor s entire scope of practice which will be used to inform a mutually agreed Personal Development Plan (PDP). An appraiser will be expected to: Assist and cooperate with the Revalidation Support Officer to organise their appraisals within the appraisal timeframe. Support all allocated appraisee s in gathering their supporting information in readiness for their appraisal. Assist all allocated appraisee s to identify their own development needs. Review appraisal documentation and evidence two weeks before the appraisal interview takes place, identifying key areas for discussion. Ensure all paperwork is processed as required on completion of the appraisal interview, including the signing off of the PDP by both parties. Report on the outcome of their appraisals to the Responsible Officer. Maintain appraisal skills and undertake appraisal training and attend periodic updates. Take part in a performance review, including feedback on performance in their role. Organising their own appraisal in a timely manner. Use the organisations approved appraisal toolkit and 360⁰ feedback system. Appraisers must declare any conflicts of interest between themselves and the appraisee. This could be: A personal or family relationship Paired appraisals where two doctors appraisee each other An appraiser receiving direct payment from an appraisee for performing the appraisal. 5.4 Individual doctors are responsible for ensuring they meet the requirements Revalidation having an annual appraisal covering their whole practice. In preparing for their appraisal all doctors will need to: Make arrangements to share information from each of their employers, including private practice, on an annual basis. Maintain a professional portfolio including feedback from each of their employers (whole practice review) including the independent sector, records of their training, reflective practice and additional documentation as specified by the GMC. This evidence must be available to their Appraiser two weeks before the date of the appraisal Ensure their mandatory training must be at least 80% compliant or provide evidence that demonstrates they have tried to complete all mandatory training requirements. 5.5 The Revalidation Support Officer will provide support to the Responsible Officer by coordinating the appraisal and revalidation process. This will also include: Maintaining the records/electronic data system and ensure that the systems in place are held securely. Undertaking regular quality control checks to ensure the appraisal documentation submitted meets the agreed standards. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 9 of 36

10 Maintain a database of trained Appraisers to ensure that there are sufficient numbers to meet the needs of the medical workforce and allocate a trained Appraiser to the appropriate level of doctor to be appraised. Provide monthly performance reports to Clinical Directorates and the Revalidation Support Team of appraisal activity within the Trust. Ensure that the information on each doctor s practice within the organisation is made available to them in a timely manner see section Those who undertake job planning at a Directorate level will be responsible for ensuring the Supporting Professional Activities (SPA) principles set out in appendix B will be adhered too. 5.7 The table below shows how other functions within the organisation will support doctors to prepare for their appraisal by providing some of the multi-source information. Function Patient Safety and Experience or Directorate Quality Lead Performance Information Individual services and departments Colleagues of a doctor Patient Safety and Experience Governance Evidence will be provided by Report of complaints and concerns received relating to a named doctor. Performance monitor information against corporate and speciality specific indicators and standards. Compliments they have received involving the doctor May be asked to participate in giving 360 feedback to a named doctor. This will form part of multisource feedback. Clinical Audit 6. POLIC DETAIL / COURSE OF ACTION An appraisal is a two-way conversation between an appraiser (person undertaking the appraisal) and the appraisee (the doctor who s standards of care are being reviewed). Above all, an appraisal is a supportive and developmental mechanism. Appraisals are expected to happen on an annual basis within each appraisal year. It is an opportunity to review feedback from patients and colleagues. Medical appraisal differs fundamentally from appraisal in other settings due to its elemental link with external professional regulation and revalidation. Medical appraisals are based on a doctor s performance as described in the GMC s Good Medical Practice. It is recommended that, to ensure fairness, equity and to mitigate against conflicts of interest, an appraisee will not be appraised by the same appraiser for more than three times in any 5-year appraisal cycle. Areas covered by the appraisal: Knowledge, skills and performance o Develop and maintaining professional performance o Applying knowledge and experience in practice o Recording work clearly, accurately and legibly Safety and Quality o Contribute to and comply with systems to protect patients o Responds to risks to safety o Protects patients and colleagues from any risk posed by the doctors health Communication, partnership and team working o Communicates effectively Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 10 of 36

11 o o o o Works collaboratively with colleagues to maintain or improve patient care Teaching, training, supporting and assessing Continuity and coordination of care Establish and maintain partnership with patients Maintaining Trust o Show respect for patients o Treat patients and colleagues fairly and without discrimination o Act with honesty and integrity At least once every five years, each doctor is responsible for obtaining and then reflecting on a range of supporting information and discussing it at their appraisal. Supporting information should include: Continuing professional development Quality improvement activity Significant events Feedback from colleagues Feedback from patients Review of complaints and compliments. 6.1 The Appraisal Cycle see figure 1 Annual appraisal for consultants and those on the new Associate Specialist and Specialty doctor contracts is already a contractual requirement. An appraisal is not considered to have been completed without timely sign off of a mutually agreed PDP (within 28 days of the appraisal meeting). The Annual Appraisal Cycle shown in Figure 1 is carried out between 1 st April and 31 st March each year and should comprise of five phases: Phase 1: Preparation work and information gathering by both appraiser and appraise. Appraisals for revalidation need to take into account the doctor s whole practice; therefore the appraisee must provide information from all organisations that employ them. If any part of the essential documentation is not identified in a portfolio (unless a satisfactory explanation can be offered by the appraisee) the appraiser must bring this to the attention of the appraisee prior to the appraisal meeting. Phase 2: Appraisal discussion including a review of the previous year s PDP Phase 3: Completion of post appraisal documents and agreement of a new PDP going forward Phase 4: Appraiser statements completed and appraisal signed off (electronically) by both parties within 28 days of the appraisal. Phase 5: Annual appraisal completed. 6.2 Appraisal Process & Revalidation Administration Details of the appraisal process, relevant documentation and any linked processes and supporting information will be agreed with the Responsible Officer and Appraisers before it is made available to all staff involved in appraisals and the requirements of revalidation. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 11 of 36

12 It is a mandatory requirement that all appraisals are undertaken using the Trust approved appraisal toolkit via this web link to e-appraisal found in web based systems on the intranet by following this link then selecting Zircadian. From April 2013 Appraisals held on any other platform will not be acceptable. Appraisals will be coordinated by the Clinical Directors and Lead Clinicians with the support of the Revalidation Support Officer, to ensure standard procedures are met and enable full compliance across the Isle of Wight NHS Trust. Figure 2. Phase 1 Preparation Phase 5 Appraisal completed Phase 2 The Appraisal Discussion Phase 4 Appraiser statements completed and appraisal signed off within 28 days Phase 3 Completion of post appraisal documents and PDP 6.3 Appraisal Exemption/Deferment For details of the Appraisal Exemption/Deferment process, please see Appendix A. 6.4 Appraisal Outcome and Addressing Concerns In the majority of instances, the outcome of an appraisal is a positive one. However, it is possible that the appraiser or appraisee may have concerns such as: Where there is disagreement on wording of the appraisal outcomes, i.e. summary of discussion or PDP, which cannot be resolved between appraiser and appraisee, then this should be recorded and advice sought from the Lead Appraiser in the first instance. If the Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 12 of 36

13 matter cannot resolved then advice should be sought from the Executive Medical Director who will then consult with the appraiser, appraisee and any other individual that they think appropriate (e.g. previous appraiser, Clinical Director) before reaching a decision on the most appropriate way forward. Where the doctor continues to disagree with the content of the appraisal, and/or the process that has been followed, and/or satisfactory completion of appraisal documentation such that satisfactory completion of appraisal cannot be confirmed then they will be advised of their right to raise their concern formally in accordance with Isle of Wight NHS Trust s Grievance Procedure Failure to address issues that have previously been raised about clinical performance or personal behaviour. The appraiser will need to escalate any concerns about performance that arise during the appraisal discussion, in line with the Isle of Wight NHS Trust relevant policies and guidelines The appraiser s judges that there is inadequate evidence in any section of the appraisal Toolkit see phase 1 of the Appraisal Cycle There has been a failure to comply with previous year s PDP without adequate explanation. It is only when there has been a clear failure to respond to actions outlined in previous appraisal summaries that the appraisal could be considered as being unsatisfactory. If the issues cannot be resolved with the doctor then the matter should be referred to the Responsible Officer. 6.5 Failure to participate in appraisal If a doctor refuses to participate in the appraisal process, the Clinical Director/Lead Clinician will be asked by the Responsible Officer to carry out an investigation as to the reasons why the individual doctor has not completed an appraisal. A report on the investigation will be submitted to the Responsible Officer and appropriate action will be taken. Doctors who have not completed an annual appraisal will not be eligible for routine pay progression or local clinical excellence awards unless a deferment on exceptional grounds has been agreed. 6.6 Recording and Confidentiality The detail of discussions during the appraisal interview would generally be considered to be confidential to the appraisee and appraiser. However within the context of appraisal for revalidation, the appraiser will be reporting to the Responsible Officer on the general outcomes of their appraisals. The Isle of Wight NHS Trust will retain copies of the appraisal documentation over a five year period. The appraisee should retain and add to their supporting documentation in an appraisal folder. Further information on the principles of good appraisals and guidance on conducting them and what to expect can be found in Appendix B Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 13 of 36

14 6.7 Doctors in difficulty The Trust expects that any issues or performance concerns are dealt with as they arise, and should not wait until the appraisal. It may be appropriate to delay an appraisal under such circumstances, but a doctor s appraisal for revalidation has to take place annually within the financial year. Arrangements should be made as quickly as possible for the appraisal to be rescheduled. Where this is not possible records must be kept and timescales clearly documented. In the event that the appraisal process indicates that a doctor is in difficulty, the appraiser must escalate this to the relevant Clinical Director/Responsible Officer without delay, who will deal with the issues in accordance with the Isle of Wight NHS Trust Procedure for dealing with the conduct, capability and performance of medical and dental staff. 6.8 Appraiser selection, training, retention and review The Responsible Officer should scope the number of appraisals that will be needed and ensure there is a sufficient pool of trained appraisers within the organisation to carry out these appraisals. The selection and training of new appraisers will be carried out as and when required. There will be a database of appraisers which will be maintained by the Revalidation Support Officer National guidelines (GMC, Revalidation Support Team, etc) will be followed regarding curriculum and approved training Medical staff with appraiser responsibilities will have this included in their own appraisal to ensure their competence and performance is satisfactory. The team of appraisers will have periodic meetings to ensure consistent standards are maintained Doctors wishing to become formal appraisers for the Isle of Wight NHS Trust will need to formally apply Appraisers will be appointed following a formal interview involving the Responsible Officer and Clinical Director and any other panel member deemed necessary by the RO Newly appointed appraisers will be expected to attend an approved appraiser training course. This course will contain the necessary approved core content defined by the national Revalidation Support Team (RST) Following appointment, a probationary period of 12 months will follow during which the new appraiser will undertake a minimum of six appraisals. After the first three of these appraisals, a formal review will be undertaken with the Responsible Officer or Clinical Director to assess progress, deal with any new learning needs identified and confirm whether the appraiser is competent to continue Established appraisers will have access to ongoing support through their Clinical Director and Appraisal Lead. Regular appraiser meetings will be held through the year to provide refresher skills training, group feedback and updates on the Isle of Wight NHS Trust s appraisal policy changes. Appraisers will be expected to attend relevant meetings to ensure they are kept up to date. Appraisers will also be expected to include relevant learning objectives for developing their appraisal skills in their PDPs as a result of their own annual appraisal. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 14 of 36

15 6.9 Responsible Officer s appraisal Responsible Officers also need to undergo appraisal themselves, and to be revalidated every five years. Recommendations for revalidation will then be made by the RO of NHS England (South) Indemnity It is appropriate for appraisers who are not acting negligently to be indemnified for their actions by the organisation. The organisation will provide explicit assurance of indemnity for the appraiser. 7. CONSULTATION Consultation of this new policy opened on the 26 th September Consultation closed on the 25 th October. 25 th September 2012 Quality and Clinical Standards Directorate and Performance Information Department (PIDs) 26 September 2012 Appraisers and Partnership Forum 27 September 2012 Joint Consultative and Negotiation Committee 2 October 2012 All Consultants, SAS and Specialist Doctors February 2013 Appraisers meeting 8. TRAINING This Revalidation and Appraisal Policy does not have a mandatory training requirement but the following non mandatory training is recommended:- Training for Appraisers as and when required and based on organisational need to ensure the Trust has adequate capacity to undertake appraisals for revalidation purposes. 9. DISSEMINATION 9.1 When approved this document will be available on the Intranet and will be subject to document control procedures. Approved documents will be placed on the Intranet within 5 working days of date of approval once received by the Corporate Governance Team. 9.2 When submitted to the Corporate Governance Team for inclusion on the Intranet this document will have fully completed document details including version control with the actual hard copy signed by the relevant Lead Director. 9.3 Notification of new and revised documentation will be issued on the Front page of the Intranet, through e-bulletin, and on staff notice boards where appropriate. Any controlled documents noted at the Trust Executive Committee / Corporate Governance & Risk Management will be notified through the e-bulletin. 9.4 Staff using the Trust s intranet can access all procedural documents. It is the responsibility of managers to ensure that all staff are aware of where, and how, documents can be accessed within their areas of work. 9.5 It is the responsibility of each individual who prints a hard copy of any document to ensure that the printed hardcopy is the current version. Current versions are maintained on the Intranet. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 15 of 36

16 10. EQUALIT ANALSIS This policy outlines the local mechanisms the Isle of Wight NHS Trust will put into place to protect patients and provide assurance to the Trust Board so that the Responsible Officer can carry out the duties set out in the Medical Officer (Responsible Officer) Regulations In particular the R O has a duty to ensure that doctors have sufficient language competency so they can communicate with patients and other health professionals safely. In doing so the Trust will enhance public confidence in our ability to bridge any gaps in language competence. The Trust employs 249 doctors of which 44% ethnic origin is white British. In the future, checking language competence will be addressed at the recruitment stage. Any existing employee who has difficulties with language will be supported by the Trust and offered training and development. Through this policy, the Isle of Wight NHS Trust expects all doctors to have an appraisal annually and every five years their appraisal will be used for Revalidation purposes. We accept our responsibility to support all doctors through this process irrespective of their gender, whether they work full time or part-time, if they that a disability; adjustments will be made. This procedure has undergone an equality analysis see Appendix D. 11. REVIEW AND REVISION ARRANGEMENTS A review of this policy will be initiated by the Responsible Officer by November 2015 unless national guidance issued before this renewal date by the Department of Health or the General Medical Council 12. MONITORING COMPLIANCE AND EFFECTIVENESS The effectiveness of the Revalidation process and the application of this policy will be monitored through the following mechanisms. The Revalidation Support Officer will support the Revalidation Officer to monitor this policy. Reports provided to Assurance Frequency Trust Board and Directorate Number of appraisals undertaken Monthly Boards NHS England (South) Trust Board NHS Revalidation Support Team General Medical Council NHS Revalidation Support Team Number of doctors revalidated Summary of performance including quality of appraisal feedback Organisational Readiness Self Assessment (ORSA) overall performance External Peer Review Monthly Annual Annual 3-yearly This policy has indirect links with NHSLA standards: Standard 2 Learning from Experience 2.1 Clinical Audit doctors are required to provide evidence of audits undertaken at appraisal. 2.3 Concerns and Complaints are also required as evidence at appraisal 2.5 Investigations doctors may be involved or have to provide evidence to an investigation relating to their own clinical practice. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 16 of 36

17 2.9 Doctors would be expected to practice in accordance with NICE Guidelines Being Open this entire policy seeks to ensure there is a non-punitive approach to mistakes and learning from experiences. 6.7 Duty of Candour 13. LINKS TO OTHER ORGANISATION POLICIES/DOCUMENTS Conduct, Capability, Ill Health and Appeals Policy and Procedure for Medical and Dental Practitioners under review Equality and Diversity Policy Grievance Policy and Procedure Conduct, Performance and Ill-Health Procedures for Medical and Dental Staff (draft at the time of writing this policy). Mandatory Training Policy 14. REFERENCES AND LINKS TO EXTERNAL DOCUMENTS AND POLICIES The Medical Act 1983 which requires the General Medical Council to keep a register of all medical practitioners and the General Medical Councils (License to Practice) Regulations The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council Assuring the Quality of Medical Appraisal. Strengthening NHS Medical Appraisal to Support Revalidation in England A proposal paper for piloting from the NHS Revalidation Support Team pport%20revalidation%20in%20england.pdf Assuring the Quality of Training for Medical Appraisers. Consultant Appraisal: A Brief Guide. Assuring the Quality of Medical Appraisals for Revalidation. on.pdf Health Education England (South) Revalidation Policy for Doctors in Training (2012) %20Wessex%20Deanery1%20-%20January% pdf Organisational Readiness Self Assessment tool (Synapse - issued February 2011) Medical Professional (Responsible Officers) Regulations 2010 and Equality Impact Assessment. Revalidation Support Team March 2012 Supporting Doctors to Provide Safer Healthcare: Responding to Concerns about a doctors practice Responsible Officer Regulations 2010 (amended in April Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 17 of 36

18 15. DISCLAIMER It is the responsibility of all staff to check the organisation intranet to ensure that the most recent version/issue of this document is being referenced Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 18 of 36

19 Appendix A APPRAISAL EXEMPTION PROCESS AND APPLICATION FORM Introduction 1.1 It is a contractual requirement for all Consultant, SAS and non-training grade doctors to undergo an appraisal annually. It is expected that this will also be a requirement for successful revalidation and recertification. There are however exceptional circumstances when a doctor may request that an appraisal is deferred such that no appraisal takes place during one appraisal year (April to March). This will be deemed an exemption. Instances when doctors may request an exemption or deferment include breaks in practice due to sickness or maternity leave, absence abroad or sabbaticals. 1.2 Doctors who have a break from practice may find it harder to collect evidence to support their appraisal, particularly if being appraised soon after their return to clinical practice. However an appraisal can often be useful when timed to coincide with a doctor s reinduction to clinical work. The Appraisal Team will use their discretion when guiding doctors as to the best timing for their appraisal, and when deciding the minimum evidence acceptable for these exceptional appraisals. 1.3 Doctors should have one appraisal in each twelve month period which begins in April each year and ends the following March (appraisal year). A deferral will be accepted provided that the appraisal is no less than nine months, or more than 15 months since the last appraisal in that appraisal year. If this is not feasible then an application for exemption should be made. Each case will be dealt with on its merits and the Trust is mindful that no doctor must be disadvantaged or unfairly penalised as a result of pregnancy, sickness or disability. 1.4 The Trust has the right to initiate disciplinary procedures if doctors do not undergo an annual appraisal without having good reason. This process aims to ensure that these circumstances are dealt with in an appropriate, timely and consistent manner, minimising bureaucracy and ensuring that all doctors benefit from appraisal at a time which meets their professional needs. 1.5 Doctors who think they may need to defer their appraisal should complete the exemption application form and submit it to the Revalidation Support Officer. The decision will be made by the Responsible Officer, where necessary in consultation with the Clinical Leads. The decision can be appealed and appeals will be dealt with by the Director of Human Resources or their deputy. 1.6 Exemption applications should be submitted at the earliest possible opportunity and no later than 3 months before the doctor s appraisal date would be due. 1.7 The decision to allow an exemption will depend on a number of factors. These include how many appraisals have been, or will be, missed in a 5 year period; whether there is anticipated to be further breaks from practice in the near future; if there have been problems with evidence in previous appraisals; if the doctor is undergoing any investigation about his/her performance. This list is not exhaustive. 1.8 Informal advice on the likelihood of an exemption being agreed can be obtained from the Responsible Officer or Revalidation Support Officer. 1.9 A formal response to the application will either be an exemption certificate or a letter advising against a deferment of an appraisal and a warning that if an appraisal is not undertaken, this may result in the start of disciplinary procedures. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 19 of 36

20 Appendix A Application for Exemption from Appraisal This application is for doctors who wish to postpone their appraisal in such a way that they will not have an appraisal during one Appraisal ear (1 st April to 31 st March) Name Address Telephone Numbers: Mobile Work Home Address: Work Home GMC Number Date of Birth Please complete the details of your last 3 appraisals: Name of Appraiser Date of Appraisal Please submit copies of the Form 4/Appraisal summary for the last 3 appraisals carried out. Please answer the following questions: Please indicate WH you wish to request a deferment of your appraisal and WHEN you would next like to be appraised Do you anticipate having any breaks in practice Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 20 of 36

21 Appendix A in the next 2 years If you have missed any appraisals in the last 4 years please indicate the reasons why Are you currently under investigation by your employer or GMC for any issue regarding your clinical performance? Any further comments Name: Signature: Date: Please return this form either electronically or by post to: Revalidation Support Officer Human Resources St Mary s Hospital Parkhurst Road Newport Isle of Wight PO30 5TG workforcerevalidation@iow.nhs.uk Tel ext 6120 or 6727 Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 21 of 36

22 Appendix B Guidelines for Appraisers and Appraisees Introduction The GMC s current proposals call for a five-yearly demonstration of all doctors fitness to practise, to be based on information and evidence that should already be available in the Trust as it forms part of good clinical governance. What is the difference between Appraisal and Revalidation? While there is a clear connection between revalidation and appraisal, there are also differences. Revalidation concerns itself with a standard measured against the framework of the GMC s guidance Good Medical Practice, while NHS appraisal takes, in addition to this, a broader look at a doctor s work and service delivery. This distinction may change as a result of revalidation. Appraisal documentation and evidence The revised documentation will form part of the overall process but while completing the documents is an important facet of appraisal, as it provides a written agreement and encourages consistency, dialogue between individuals and the exchange of views is now equally important. Every doctor being appraised should prepare an appraisal folder of all the documents (information, evidence and data) which will help inform the appraisal process, and this can and should be updated as necessary. our portfolio should represent your whole practice and include information from each of their employers. our documentation should continue to allow access to the original documents in the folder in a structured way, record what the appraisal process concluded from them and, finally what action was agreed as the outcome following discussion (PDP). What goes into the folder will, for the most part, be available from clinical governance activity, and other existing sources. Consultants and SAS grades on the new contract will also use information from the job planning process. Doctors need to consider which documents they need to collect for the appraisal process. Preparing for your appraisal It is essential that adequate time is allocated for preparation, both for the appraiser and appraisee. Preparation time and time for carrying out the appraisal should take place during usual working hours; proper time should be included in the job plan of the appraiser for this purpose from 1 st April A successful appraisal depends on both the parties giving their contribution some thought beforehand. Both parties should give themselves enough time to produce exchange and consider any documents necessary for the appraisal a few weeks rather than a few days in advance is best. Where, for whatever reason, a third party needs to contribute to an appraisal this should also be discussed and agreed well in advance. It is very important that the discussion, a vital component of appraisal, is planned in diaries well ahead and protected. Appraisal for revalidation requires that annual appraisals are carried out and signed off in year, in line with the organisation s own appraisal cycle. Therefore, the timing, location and people involved in the appraisal need to be discussed and confirmed at least six weeks beforehand. Selecting your appraiser Consultant appraisal is currently carried out on a peer-review basis, although all appraisers should be trained. For revalidation the Trust has appointed a formal pool of trained appraisers, appropriate to the numbers of appraisals needed within the organisation, whose job plans would recognise an annualised commitment to carry out a fixed number of appraisals, and who would be assigned to appraisee a set number of doctors each year. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 22 of 36

23 Appendix B Appraisers Time Commitment This pool will be full training and will be assigned dedicated time in their annual job plans to carry out the work required. As this work is already being carried out, the Trust does not expect that additional PAs will be required; it should be possible to recycle existing SPA time through proper, robust departmental job planning. The following assumptions have been made: Time required per appraisal (including preparation) 4.2 hours Number of appraisals per appraiser per year: 10 (suggested maximum number) Total amount of time per appraiser: 42 hours per year SPA requirement per appraiser per year: 10.5 SPAs (0.25 per week) Training time per appraiser (on appointment): 8 hours/1 day It is anticipated that new appraisers will need to be added to the pool on an annual basis either to replace those who leave, or as numbers of appraisee s change. Any new appraisers will be trained and subject to an early review of their skills, including appraisee s feedback. Each doctor will need to agree an appraiser with the Revalidation Support Officer. It is recommended that over the course of five years, each individual should be appraised by at least two different appraisers, to ensure objectivity, avoidance of conflicts of interest and a diversity of viewpoints. It would be the responsibility of the Clinical Director to ensure that all doctors have been appraised and their PDP signed off during the current year. 360 degree appraisal The revalidation process will require practitioners to receive formal feedback from both patients and colleagues at least once every five years. Should concerns arise during the appraisal? Both the appraiser and the appraisee need to recognise that as registered medical practitioners they must protect patients if they believe that a colleague s health, conduct or performance is a potential risk to patient safety. If, as a result of the appraisal process, the appraiser believes that the activities of the appraisee are such as to put patients at risk, then the appraisal should be stopped and the matter referred to the Responsible Officer/Clinical Director in line with the organisation s policies immediately. It is understood that this would happen only on the rarest of occasions. However a doctor s appraisal for revalidation has to take place annually within the financial year. Arrangements should therefore be made as quickly as possible for the appraisal to be re-scheduled. Development needs Any other concerns or development needs which are highlighted by the appraisal would need to be presented to the Clinical Director so that these can be discussed and the appraisee can (with the relevant support) take appropriate steps to address these. Where appropriate the completed appraisal form should be taken by the appraisee into his / her job planning meeting, which should follow reasonably closely after the appraisal meeting. After the appraisal A copy of the completed appraisal, with a PDP signed by both parties within 28 days of the appraisal interview, should be submitted to the Revalidation Support Officer on behalf of the Responsible Officer as part of the ongoing portfolio of evidence for revalidation. Although it is the responsibility of the Responsible Officer to recommend to the GMC for revalidation the appraiser must make known to the Responsible Officer any concerns arising from the appraisal which might delay a recommendation for revalidation, within each appraisal year, so that action can be taken to resolve these issues in a timely manner. Doctors Appraisal policy (Supporting the Revalidation of our Doctors) Page 23 of 36