Revalidation Report to The Trust Board

Size: px
Start display at page:

Download "Revalidation Report to The Trust Board"

Transcription

1 1. Introduction Medical Revalidation was introduced in the UK in December 2012 and has been effected in the Trust since March 2013 (cycle 1). The Medical Director is the Responsible Officer and issues recommendations on revalidation for all doctors with designated connections to the Trust. This recommendation can be positive, deferred or non-engagement. Nationally, in the first year of implementation, nearly 21,000 doctors in England were revalidated, including 409 responsible officers. In the words of Niall Dickson, the GMC's Chief Executive and Registrar: These are very early days but we are pleased with the progress made in the first year. This new system of checks is a world first and over time we believe it will make a significant contribution towards making sure patients in the UK receive safe, effective care. The past 12 months have been dedicated to setting up robust systems to support enhanced appraisal incorporating 360 degree (or multi-source- MSF) feedback and supporting information linked to the General Medical Council s domains for Good Medical Practice, as well as to embedding the concept of revalidation amongst clinicians. Enhanced appraisal furnishes an opportunity for the Trust to raise the bar in terms of expectations and development of its medical staff. The domains of Good Medical Practice (2013) include: Domain 1: Knowledge, skills and performance Domain 2: Safety and quality Domain 3: Communication, partnership and teamwork Domain 4: Maintaining trust This Paper summarises the progress the Trust has made as well as setting out the next steps which are required to ensure that processes within the Trust are robust and nationally compliant. Medical Director s Office January 2014 Page 1

2 2. Context 2.1 Current Revalidation Activity Revalidation activity summary for CUH demonstrates: 59 Decisions issued from amidst 307 doctors with prescribed connection. This equates to 19.2 % of doctors (12.7% recommended). In March 2013, this team informed the Board: by March 2014 it is expected that roughly 1/5 of Consultants will have been put forward for Revalidation. This means that approximately 50 doctors will need to have had an enhanced, revalidation-ready appraisal before March It is expected that all doctors will have been put forward for revalidation by March We remain on trajectory for revalidation. Thirty nine positive recommendations have been made. Twenty deferrals involving fifteen doctors have been issued. Three doctors were deferred twice, one three times. Reasons for deferral: Incomplete documentation: n=12 three times Local investigation: n=5 including 1 doctor deferred twice and 1 doctor deferred External revalidation process: n=1 Maternity leave: n=1 Recent addition to trust insufficient time for valid appraisal: n=1 Current interrogation of e-rms January % Online Appraisal Engagement. 1.1 Tracking appraisal compliance Appraisal at CHS was historically performed using a paper-based system. An electronic appraisal and revalidation management system (e-rms) has now been procured and launched as of August 2013, providing automatic, central, dynamic, electronic tracking of appraisal. Between March and August an interim solution based on an interactive pdf model appraisal form (MAG) with electronic capture of MSF was used to transition appraisal. Paper forms were suspended and a temporary amnesty granted to facilitate the introduction of the electronic system, alignment of appraisal dates with revalidation dates and reassignment of all appraisers. The previous system relied on manual updates of an excel Medical Director s Office January 2014 Page 2

3 spread-sheet to track appraisal compliance. The e-rms allows real time compliance audit. Archived appraisals will need to be uploaded to provide a seamless account of current and historic appraisal status across the trust. 1.2 Auditing complete and missed appraisals The e-rms will be interrogated quarterly to inform reports to the board. Linkage to finance will continue and provide a second check point for auditing missed appraisals. Internal quality assurance by the Medical director s Office continues to address incomplete/inadequate appraisals. Group reminders can be sent through the e-rms to non-compliant medics. 1.3 Escalation process for non-engagement Non-engagement in appraisal is a recognized challenge both nationally and locally. There was no systematic system previously in place to address non-engagement which was identified on a case by case basis. Since March 2013, an augmented process seeks to reduce non-engagement by: 1. Averting non-engagement: Appointment of Associate Medical Director (AMD) and dedicated team with HR input provides focused responsibility, high visibility of appraisal agenda, clear signposting, education and support. Appraisal policy re-written April 2013 to root out poor practice and render explicit expectations and processes. Appraisal policy states Where the practitioner fails to achieve satisfactory progress in appraisal and/or there are concerns raised over practice, Croydon Health Services NHS Trust should facilitate the Responsible Officer to deal with this in line with Handling Concerns about Doctors Performance Policy and/or Remediation for Medical and Dental Staff, and should readily seek external expert advice from their GMC Employer Liaison Adviser or National Clinical Advisory Service (NCAS). Strict adherence to financial consequences Targeted education and engagement of SAS doctors dedicated event. Medical Director s Office January 2014 Page 3

4 Education, support and visibility by regular small group workshops, dedicated training, robust on line support mechanisms (static &interactive help system, video training) high uptake 2. Better recognizing, quantifying and pre-empting non-engagement: Introduction of the e-rms providing real time update on appraisal compliance, issuing appraisal reminders and identifying non-engagers. 3. Communicating awareness and consequences of non-engagement: Written correspondence to doctors for non-engagement, deferral and positive recommendations introduced for revalidation to be utilized for all appraisals. 1.4 Key Achievements Key achievements over the first three quarters of 2013/14 include: Policies New appraisal policy written, agreed and ratified with key stakeholder input including appraisers, LNC. Remediation policy written, agreed and ratified with key stakeholder input including appraisers, LNC Local revalidation team Set up with members including RO, AMD, Business Manager to the MD, Revalidation Support Officer (0.5 WTE) Set up of dedicated contact with significant volume of activity channelled through this. regular meetings to maintain momentum and progress revalidation within the Trust. Support for scanning and upload of MSF Communication Setting up regular workshops providing small group and 1:1 support for revalidation. Sessions are well attended, received and hosted by Medical HR business partner and/or AMD. Medical Director s Office January 2014 Page 4

5 Production and dissemination of clear local guidance including FAQs and SOPS to support revalidation Setting up intranet page signposting local and national guidance on revalidation and appraisal Regular updates on revalidation at Consultants meetings Recommendation decisions communicated via written correspondence with clearly articulated justifications. Copies to HR file. Fitness to practice affidavit document produced and solicited from external sites of practice. In this way the comprehensive scope of practice is reviewed. Appraisal meeting group (AMG) Set up monthly appraisal meeting group providing an active forum for cross pollination of experience and sharing of learning both from successful and less successful appraisals. Represents a form of group mentorship and intrinsic quality assurance. This group has been a key success, well attended and received with active, relevant discussions and a commitment to robust process. IT presence and support has been particularly helpful in navigating local IT issues and informing choice of definitive e-rms. This group reports to the Medical Productivity Steering Group. Systems Procurement of the Allocate MSF software to supplement MAG forms as interim solution for revalidation appraisals March 2013-August 2013 Clear articulation of specifications for electronic revalidation management system (e-rms) Funding, procurement, acquisition and go live of e-rms system from SARD with successful launch 19 th August 2013 Training Further expansion of trained appraisers current total of 42 appraisers. Increase skill base with respect to feedback Mentoring/Coaching training negotiated for appraisers through reputable external firm. Also constructive conversations training to better support them in analysing and providing feedback. Training delivered by Healthcare performance. Medical Director s Office January 2014 Page 5

6 Wider trust subscription to programme of mentorship and coaching. External partners Memorandum of Understanding set up with St. Christopher s Hospice for RO function this involves CUH providing infrastructure for revalidation to the hospice with nominal payment and appraisal provision by the Medical Director of St. Christopher s for equal number of our doctors. Quality Assurance Engagement of MIAD (leaders for appraiser training) for external quality assurance of revalidation process Initial review 27 th September Positive review with excellent elements identified. Onward focus on depth of reflection, enhanced appraisal summary and Personal development plans. Follow up review planned post implementation of the SARD e-rms. Review included the findings of a feedback exercise as below: Twenty-five randomly selected appraisees were asked to complete a feedback exercise on all aspects of the appraisal process. This included the appraisal meeting, their appraiser and the organisation s support of the appraisal process. The questions were asked via an on-line system; Survey Monkey and the results were anonymised. Most appraisal discussions (52%) lasted between 1 and 2 hours with an overwhelming majority (87%) satisfied that there was sufficient protected time for the discussion. Medical Director s Office January 2014 Page 6

7 Category Organisational: Appraisers: Personal & Organisational Impact of Appraisal: Findings Most of the appraisees (92%) felt that, generally, the appraisal process was satisfactory and there was easy access to the forms and materials they needed to complete the process (96%). 96% of appraisees were able to collect the necessary supporting information from the organisation, with the administrative support meeting the needs of 84% of the appraisees. 92% of the appraisees felt that their appraisers were satisfactory or above when it came to establishing rapport with the remaining 8% as borderline. 8% of appraisees felt there appraiser had not prepared sufficiently for the appraisal meeting. 92% felt their appraiser was able to listen to the appraisee during the meeting and gave them adequate time to talk. 8% felt their appraiser did not give constructive or helpful feedback, although the majority felt supported at their appraisal (92%). The majority of appraisees (92%) felt positively challenged by their appraiser, with the same number reporting that their appraiser had reviewed their practice. The majority (92%) of appraisees felt that their appraiser had helped them identify gaps in their portfolio and had also helped them to review progress against their previous personal development plan (PDP).92% of appraisees felt their appraiser had helped them to produce a robust PDP, with the majority (92%) happy to have a further appraisal with the same appraiser. 88% of appraisees felt that appraisal had aided their personal development, with 92% reporting it had helped their professional development. The majority (84%) felt that appraisal had helped promote quality improvements at their place of work, with 80% feeling it had improved patient care. Medical Director s Office January 2014 Page 7

8 SAS engagement: Staff Grade, Specialty and Associate Specialist (SAS) doctors have been identified as a lost tribe for appraisal and revalidation and require concerted efforts for engagement. To this aim, CUH successfully bid for 10,000 from NHS England as part of revalidation resources. The bid was awarded to support SAS engagement and quality assurance of appraisal both internally (IQA) and externally (EQA). Dedicated SAS event successfully delivered 25 th September GMC, BMA, MIAD and SARD contributors. Commitment to and achievement of inclusion of SAS doctors as appraisers and members of the AMG. 1.5 Progress against suggested objectives EQA report progress. MIAD process commissioned in two sections initial pre RMS delivered - realised. SAS engagement progress. Recognition of need for specific SAS engagement realised Inclusion of SAS on appraisers meeting group and as appraisers realised Dedicated SAS event hosted at CUH with contributions from BMA, GMC, MIAD, SARD realised Peer review of anonymised PDPS Not achieved. o Initial suggestions to provide peer review of anonymised PDPs proved operationally challenging without breach of confidentiality as the PDPs were such that they could not be culled sufficiently to anonymise them without compromising the substance of the PDP. Medical Director s Office January 2014 Page 8

9 2.8 National Reporting The Organisational Readiness Self -Assessment (ORSA) reports were utilised to evaluate performance/preparation of Trusts. No issues were identified in the 2013 report for CUH. 2. Next Steps The next focus of the Revalidation Support Team will include: Continued appraiser recruitment and refinement - Time commitments for robust appraisals are considerable restrict number to 7 per appraiser. Continue to increase appraiser recruitment and training to allow for staff flux and ensure 100% appraiser allocation. Investment in the design, rigour and integrity of multi-source feedback questionnaires which are both fit for purpose and GMC compliant. Current systems though basic allow for comparability within and across trusts. Aim to investigate supplementation with leadership and educational supervisor elements. Need to gather, collated and disseminate feedback to appraisers currently generic not specific feedback. Future plans to provide bespoke feedback to individual appraisers. Although audit of incomplete appraisals conforms, need to formalise and report regularly on this system. Private and other practices interrogated via fitness to practice affidavit. Current system is manual and laborious. Plan to integrate and automate such interrogation into routine appraisal process. Established linkages with Trust governance systems. Set up of decision making group to inform remediation decisions. Medical Director s Office January 2014 Page 9

10 3. Key challenges/risks Recruiting and retaining adequate staffing in the Medical Director s office to support significant administrative burden of revalidation including archiving of previous appraisal documentation. two band 5 posts currently being configured Building and enhancing internal quality assurance systems for revalidation including if possible cross fertilisation with neighbouring trusts around policy. Reduce unnecessary deferrals. Likely to be used as a performance indicator moving forward. This will involve greater prospective planning supported by increased administrative staff. Provide administrative support for patient feedback including electronic capture. This would fully divorce doctors from the process of feedback and would better ensure random sampling two tablets under procurement Linkage with governance systems for automatic extraction of quality data to better inform Quality and Safety domain of GMP liaison with raising the bar group and chief information officer. Defining and ring-fencing where possible funding for remediation. Develop high level reflection as standard in appraisals to better utilise this as a formative tool reflective templates identified, customised and to be included in e- RMS. Guidance on intranet 4. Actions from the Board The Board is asked to note the progress already made, the plans in place for implementation and the challenges to be faced. Specifically, the Board is asked to support in principle the administrative assistance required to support it. Medical Director s Office January 2014 Page 10

11 REPORT TO TRUST BOARD Date: 5 February 2014 Agenda No: 8.6 Title of Document: Report Author: Lead Director: Revalidation Report Progress to-date. Associate Medical Director for Revalidation and Medical Productivity Steve Ebbs, Medical Director Summary: Medical Revalidation was introduced in the UK in December 2012 and has been effected in the Trust since March 2013 (cycle 1). The Medical Director is the Responsible Officer and issues recommendations on Revalidation for all doctors with designated connections to the Trust. This recommendation can be positive, deferred or non-engagement. The past 12 months have been dedicated to setting up robust systems to support enhanced appraisal incorporating 360 degree (or multi-source- MSF) feedback and supporting information linked to the General Medical Council s Domains for Good Medical Practice, as well as to embedding the concept of Revalidation amongst clinicians. Enhanced appraisal furnishes an opportunity for the Trust to raise the bar in terms of expectations and development of its medical staff. In March 2013, this team informed the Board: by March 2014 it is expected that roughly 1/5 of Consultants will have been put forward for Revalidation. This means that approximately 50 doctors will need to have had an enhanced, revalidation-ready appraisal before March It is expected that all doctors will have been put forward for revalidation by March We remain on trajectory for Revalidation. This Paper summarises the progress the Trust has made as well as setting out the next steps which are required to ensure that processes within the Trust are robust and nationally compliant. Key Achievements Development of new Trust-wide policies; Establishment of a local Revalidation Team; Implementation of a robust communication strategy; Establishment of an Appraisal Group consisting of consultants trained in enhanced appraisal methods; Funding, procurement and implementation of an electronic Revalidation Management System; On-going training; and Establishment of external Quality Assurance systems.

12 Challenges Recruiting and retaining adequate staffing in the Medical Director s Office; Reducing unnecessary deferrals; Linkage with governance systems; Defining funding for remediation; and Developing high level reflection as standard in appraisals. Recommendations: The Trust Board is asked to consider this report and approve the arrangements for continued compliance with national and local Revalidation requirements. Corporate Objectives - Corporate Objectives : To deliver high quality, integrated, patient centered care which improves outcomes, patient safety and patient experience. Who has been consulted in the production of this report: The Medical Director; the Associate Medical Director, Chairs of Medical Productivity Working Groups. Has an equality impact assessment (EIA) form been completed? No If not applicable, Please state why an EIA is not applicable. Has legal advice been taken? Does this report have any financial implication? No No If so, has the report been approved by the Finance Directorate? Key Risks: Failure to meet our corporate objectives; and Reputational Risk.

CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Agenda Item 9.3.1 Report of: Paper prepared by: Date of paper: Subject: Professor R C Pearson, Medical Director Miss S Rowlands, Trust Assurance

More information

Improving SAS appraisal: a guide for employers

Improving SAS appraisal: a guide for employers Improving SAS appraisal: a guide for employers June 2013 Improving SAS appraisal: a guide for employers Introduction Effective annual appraisal is the cornerstone of medical revalidation. Doctors need

More information

Good Practice Guidelines for Appraisal

Good Practice Guidelines for Appraisal Good Practice Guidelines for Appraisal Dr Laurence Mynors Wallis Dr David Fearnley February 2010 1 Contents Page Introduction 3 Link between appraisal and revalidation 4 Preparation for the appraisal meeting

More information

Case manager. Person specification and competencies. Version 2 November 2013 www.revalidationsupport.nhs.uk

Case manager. Person specification and competencies. Version 2 November 2013 www.revalidationsupport.nhs.uk Case manager Person specification and competencies www.revalidationsupport.nhs.uk Contents Introduction Purpose and context Primary audience What is a case manager? Person specification Competency framework

More information

QUALITY MANAGEMENT POLICY & PROCEDURES

QUALITY MANAGEMENT POLICY & PROCEDURES QUALITY MANAGEMENT POLICY & PROCEDURES Policy Statement Cotleigh Engineering Co. Limited specialises in the recruitment of engineering & technical personnel in the oil & energy, rail, civil engineering,

More information

THE COLLEGE OF EMERGENCY MEDICINE

THE COLLEGE OF EMERGENCY MEDICINE THE COLLEGE OF EMERGENCY MEDICINE on Supporting Information for Revalidation General Introduction The purpose of revalidation is to assure patients and the public, employers and other healthcare professionals

More information

A Framework of Quality Assurance for Responsible Officers and Revalidation

A Framework of Quality Assurance for Responsible Officers and Revalidation A Framework of Quality Assurance for Responsible Officers and Revalidation Supporting responsible officers and designated bodies in providing assurance that they are discharging their statutory responsibilities.

More information

Medical Appraisal Guide

Medical Appraisal Guide A guide to medical appraisal for revalidation in England March 2013 (reissued with updated hyperlinks September 2014) www.england.nhs.uk/revalidation/ Contents Introduction 3 Purpose and context 4 Primary

More information

Appraisal and Revalidation Policy for Medical Staff

Appraisal and Revalidation Policy for Medical Staff Appraisal and Revalidation Policy for Medical Staff SPONSOR: (Information Asset Owner) Neil Rothnie, Medical Director AUTHOR: (Information Asset Administrator) Lisa Bemister, Appraisal and Revalidation

More information

Quality Assurance of Medical Appraisers

Quality Assurance of Medical Appraisers Quality Assurance of Medical Appraisers Recruitment, training, support and review of medical appraisers in England www.revalidationsupport.nhs.uk Contents 1. Introduction 3 2. Purpose and overview 4 3.

More information

Title. Learning from Incidents, Complaints and Claims. Description of Document

Title. Learning from Incidents, Complaints and Claims. Description of Document Title Description of Document Scope Author and designation Equality Impact Assessment (EIA) Associated Documents Supporting References Learning from Incidents, Complaints and Claims This policy identifies

More information

CHECKLIST OF COMPLIANCE WITH THE CIPFA CODE OF PRACTICE FOR INTERNAL AUDIT

CHECKLIST OF COMPLIANCE WITH THE CIPFA CODE OF PRACTICE FOR INTERNAL AUDIT CHECKLIST OF COMPLIANCE WITH THE CIPFA CODE OF PRACTICE FOR INTERNAL AUDIT 1 Scope of Internal Audit 1.1 Terms of Reference 1.1.1 Do terms of reference: (a) establish the responsibilities and objectives

More information

the role of the head of internal audit in public service organisations 2010

the role of the head of internal audit in public service organisations 2010 the role of the head of internal audit in public service organisations 2010 CIPFA Statement on the role of the Head of Internal Audit in public service organisations The Head of Internal Audit in a public

More information

Job Description. Information Assurance Manager Band 8A TBC Associate Director of Technology Parklands and other sites as required

Job Description. Information Assurance Manager Band 8A TBC Associate Director of Technology Parklands and other sites as required Job Description Job Title: Grade: Accountable to: Base: 1. JOB PURPOSE Information Assurance Manager Band 8A TBC Associate Director of Technology Parklands and other sites as required The purpose of the

More information

The Regulatory Framework for Social Housing in England Governance and Financial Viability standard requirement: Governance Annual Assessment

The Regulatory Framework for Social Housing in England Governance and Financial Viability standard requirement: Governance Annual Assessment East Thames Group The Regulatory Framework for Social Housing in England Governance and Financial Viability standard requirement: Governance Annual Assessment 1 Context 1.1 Under the Regulatory Framework,

More information

SENIOR MANAGEMENT APPRAISAL

SENIOR MANAGEMENT APPRAISAL Report Resources Committee 2 April 21 SENIOR MANAGEMENT APPRAISAL 5-1. Reason for Report To appraise Members of developments since the Best Value and Community Planning Audit highlighted a number of issues

More information

The Compliance Universe

The Compliance Universe The Compliance Universe Principle 6.1 The board should ensure that the company complies with applicable laws and considers adherence to non-binding rules, codes and standards This practice note is intended

More information

4a Revalidation: Guidance on Colleague and Patient Questionnaires Annex A. Revalidation: Guidance on Colleague and Patient Questionnaires

4a Revalidation: Guidance on Colleague and Patient Questionnaires Annex A. Revalidation: Guidance on Colleague and Patient Questionnaires 4a Revalidation: Guidance on Colleague and Patient Questionnaires Annex A Revalidation: Guidance on Colleague and Patient Questionnaires The document is intended to provide guidance for those involved

More information

STAFF AND ASSOCIATE SPECIALIST DOCTORS / SPECIALTY DOCTORS / NON CONSULTANT CAREER GRADE DOCTORS APPRAISAL SCHEME. Date ratified: 27 February 2009

STAFF AND ASSOCIATE SPECIALIST DOCTORS / SPECIALTY DOCTORS / NON CONSULTANT CAREER GRADE DOCTORS APPRAISAL SCHEME. Date ratified: 27 February 2009 STAFF AND ASSOCIATE SPECIALIST DOCTORS / SPECIALTY DOCTORS / NON CONSULTANT CAREER GRADE DOCTORS APPRAISAL SCHEME Version: 1 Ratified by (name of Committee): JLNC Date ratified: 27 February 2009 Date issued:

More information

Supporting information for appraisal and revalidation: guidance for General Practitioners

Supporting information for appraisal and revalidation: guidance for General Practitioners Supporting information for appraisal and revalidation: guidance for General Practitioners Based on the Academy of Medical Royal Colleges and Faculties Core for all doctors 2 Supporting information for

More information

QUALITY AND INTEGRATED GOVERNANCE BUSINESS UNIT. Clinical Effectiveness Strategy (Clinical Audit/Research) 2013-2015

QUALITY AND INTEGRATED GOVERNANCE BUSINESS UNIT. Clinical Effectiveness Strategy (Clinical Audit/Research) 2013-2015 Southport and Ormskirk Hospital NHS Trust QUALITY AND INTEGRATED GOVERNANCE BUSINESS UNIT Clinical Effectiveness Strategy (Clinical Audit/Research) 2013-2015 Any practitioner who is using research-based

More information

PERFORMANCE APPRAISAL AND DEVELOPMENT AND KSF ANNUAL REVIEW

PERFORMANCE APPRAISAL AND DEVELOPMENT AND KSF ANNUAL REVIEW SECTION: HUMAN RESOURCES POLICY AND PROCEDURE No: 10.16 NATURE AND SCOPE: SUBJECT: POLICY AND PROCEDURE TRUST WIDE PERFORMANCE APPRAISAL AND DEVELOPMENT AND KSF ANNUAL REVIEW This policy explains the Performance

More information

ROYAL MASONIC BENEVOLENT INSTITUTION

ROYAL MASONIC BENEVOLENT INSTITUTION ROYAL MASONIC BENEVOLENT INSTITUTION Grade: JOB DESCRIPTION Job Title: HR Business Partner Job Code: HR - HRBP Division: Human Resources Department/Home Location: Regional Accountable To: Director of Human

More information

Commissioning Strategy

Commissioning Strategy Commissioning Strategy This Commissioning Strategy sets out the mechanics of how Orkney Alcohol and Drugs Partnership (ADP) will implement its strategic aims as outlined in the ADP Strategy. Ensuring that

More information

Royal College of Obstetricians and Gynaecologists. Faculty of Sexual and Reproductive Healthcare

Royal College of Obstetricians and Gynaecologists. Faculty of Sexual and Reproductive Healthcare Royal College of Obstetricians and Gynaecologists Faculty of Sexual and Reproductive Healthcare Supporting Information for Appraisal and Revalidation: Guidance for Obstetrics and Gynaecology and / or Sexual

More information

Directors of Public Health in Local Government. Roles, Responsibilities and Context

Directors of Public Health in Local Government. Roles, Responsibilities and Context Directors of Public Health in Local Government Roles, Responsibilities and Context October 2013 You may re-use the text of this document (not including logos) free of charge in any format or medium, under

More information

BUSINESS CONTINUITY MANAGEMENT POLICY

BUSINESS CONTINUITY MANAGEMENT POLICY BUSINESS CONTINUITY MANAGEMENT POLICY AUTHORISED BY: DATE: Andy Buck Chief Executive March 2011 Ratifying Committee: NHS Rotherham Board Date Agreed: Issue No: NEXT REVIEW DATE: 2013 1 Lead Director John

More information

Revalidation processes for sessional GPs: A feasibility study to pilot current proposals

Revalidation processes for sessional GPs: A feasibility study to pilot current proposals Revalidation processes for sessional GPs: A feasibility study to pilot current proposals Report to the Royal College of General Practitioners April 2010 Di Jelley Gill Morrow Charlotte Kergon Bryan Burford

More information

Communications Strategy and Department Work Plan 2016-2017

Communications Strategy and Department Work Plan 2016-2017 Council, 22 March 2016 Communications Strategy and Department Work Plan 2016-2017 Executive summary and recommendations Introduction The Communications Strategy, which was approved by Council in March

More information

A fresh start for the regulation of independent healthcare. Working together to change how we regulate independent healthcare

A fresh start for the regulation of independent healthcare. Working together to change how we regulate independent healthcare A fresh start for the regulation of independent healthcare Working together to change how we regulate independent healthcare The Care Quality Commission is the independent regulator of health and adult

More information

REVALIDATION GUIDANCE FOR PSYCHIATRISTS

REVALIDATION GUIDANCE FOR PSYCHIATRISTS REVALIDATION GUIDANCE FOR PSYCHIATRISTS Version 2 Dr Laurence Mynors-Wallis Registrar December 2011 1 The Royal College of Psychiatrists is the professional and educational body for psychiatrists in the

More information

The post holder will be guided by general polices and regulations, but will need to establish the way in which these should be interpreted.

The post holder will be guided by general polices and regulations, but will need to establish the way in which these should be interpreted. JOB DESCRIPTION Job Title: Membership and Events Manager Band: 7 Hours: 37.5 Location: Elms, Tatchbury Mount Accountable to: Head of Strategic Relationship Management 1. MAIN PURPOSE OF JOB The post holder

More information

HEALTH SYSTEM. Introduction. The. jurisdictions and we. Health Protection. Health Improvement. Health Services. Academic Public

HEALTH SYSTEM. Introduction. The. jurisdictions and we. Health Protection. Health Improvement. Health Services. Academic Public FUNCTIONS OF THE LOCAL PUBLIC HEALTH SYSTEM Introduction This document sets out the local PH function in England. It was originally drafted by a working group led by Maggie Rae, FPH Local Board Member

More information

UCISA ITIL Case Study on Nottingham Trent University

UCISA ITIL Case Study on Nottingham Trent University UCISA ITIL Case Study on Nottingham Trent University 1. Introduction Nottingham Trent University is a large, diverse and vibrant modern university with approximately 24,000 students. Its mission is to

More information

How To Manage Risk In Ancient Health Trust

How To Manage Risk In Ancient Health Trust SharePoint Location Non-clinical Policies and Guidelines SharePoint Index Directory 3.0 Corporate Sub Area 3.1 Risk and Health & Safety Documents Key words (for search purposes) Risk, Risk Management,

More information

WESTERN HEALTH AND SOCIAL CARE TRUST POLICY ON APPRAISAL FOR DOCTORS and DENTISTS

WESTERN HEALTH AND SOCIAL CARE TRUST POLICY ON APPRAISAL FOR DOCTORS and DENTISTS WESTERN HEALTH AND SOCIAL CARE TRUST POLICY ON APPRAISAL FOR DOCTORS and DENTISTS Consultants/Non Consultant Grades Community Dentists Locum Doctors and Dentists Joint Appointments PROCEDURE AND DOCUMENTATION

More information

Employee Performance Management Policy and Procedure

Employee Performance Management Policy and Procedure Employee Performance Management Policy and Procedure Document Control Document Ref: HREPM001 Date Created: Sept 2007 Version: 1.4 Date Modified: April 2015 Revision due Author: Jane Milone Sign & Date:

More information

Job Description. Team Supervisor

Job Description. Team Supervisor Job Description Title: Call Handler Band: Band 3 Location: Various Reports to: Team Supervisor Job Purpose The post holder will be responsible for the assessment of presenting clinical symptoms, using

More information

Ready for revalidation. Guidance on colleague and patient questionnaires

Ready for revalidation. Guidance on colleague and patient questionnaires 2012 Ready for revalidation Guidance on colleague and patient questionnaires 2 Revalidation is the process by which doctors must demonstrate to the General Medical Council (GMC), normally every five years,

More information

Internal Audit and supervisory expectations building on progress

Internal Audit and supervisory expectations building on progress 1 Internal Audit and supervisory expectations building on progress Speech given by Sasha Mills, Director, Cross Cutting Policy, Bank of England Ernst & Young, London 3 February 2016 2 Introductions Hello,

More information

1.1 Terms of Reference Y P N Comments/Areas for Improvement

1.1 Terms of Reference Y P N Comments/Areas for Improvement 1 Scope of Internal Audit 1.1 Terms of Reference Y P N Comments/Areas for Improvement 1.1.1 Do Terms of Reference: a) Establish the responsibilities and objectives of IA? b) Establish the organisational

More information

JOB DESCRIPTION: DIRECTORATE MANAGER LEVEL 3. Job Description

JOB DESCRIPTION: DIRECTORATE MANAGER LEVEL 3. Job Description JOB DESCRIPTION: DIRECTORATE MANAGER LEVEL 3 Job Description Job Title: Directorate Manager Level 3 Band: Post Type: Location: Managerially Accountable to: Professionally Accountable to: 8C Permanent UHNS

More information

Report to Trust Board 29.11.12. Executive summary

Report to Trust Board 29.11.12. Executive summary Report to Trust Board 29.11.12 Title Sponsoring Executive Director Author(s) Purpose Previously considered by Transforming our Booking and Scheduling Systems Steve Peak - Director of Transformation Steve

More information

A competency framework for all prescribers updated draft for consultation

A competency framework for all prescribers updated draft for consultation A competency framework for all prescribers updated draft for consultation Consultation closes 15 April 2016 Contents 1 Introduction... 3 2 Uses of the framework... 4 3 Scope of the competency framework...

More information

Honours Degree (top-up) Business Abbreviated Programme Specification Containing Both Core + Supplementary Information

Honours Degree (top-up) Business Abbreviated Programme Specification Containing Both Core + Supplementary Information Honours Degree (top-up) Business Abbreviated Programme Specification Containing Both Core + Supplementary Information 1 Awarding Institution / body: Lancaster University 2a Teaching institution: University

More information

Aintree Library and Information Resource Centre (LIRC) Strategy 2011-14. Introduction

Aintree Library and Information Resource Centre (LIRC) Strategy 2011-14. Introduction Aintree Library and Information Resource Centre (LIRC) Strategy 2011-14 Introduction The Aintree Library and Information Resource Centre (LIRC) is a multidisciplinary library facility based within the

More information

Job description Customer Care Team Leader (Engagement)

Job description Customer Care Team Leader (Engagement) Job description Customer Care Team Leader (Engagement) Main purpose of job The Customer Care Team Leader will manage the day to day running of the internal Customer Care engagement team, ensuring it provides

More information

Guide for Clinical Audit Leads

Guide for Clinical Audit Leads Guide for Clinical Audit Leads Nancy Dixon and Mary Pearce Healthcare Quality Quest March 2011 Clinical audit tool to promote quality for better health services Contents 1 Introduction 1 1.1 Who this

More information

UoD IT Job Description

UoD IT Job Description UoD IT Job Description Role: Projects Portfolio Manager HERA Grade: 8 Responsible to: Director of IT Accountable for: Day to day leadership of team members and assigned workload Key Relationships: Management

More information

Evidence of English language skills: Guidance for European doctors applying for a licence to practise

Evidence of English language skills: Guidance for European doctors applying for a licence to practise Evidence of English language skills: Guidance for European doctors applying for a licence to practise 1 The GMC (Licence to Practise and Revalidation) Regulations Order of Council Consolidated (the Regulations)

More information

DOCUMENT CONTROL PAGE

DOCUMENT CONTROL PAGE DOCUMENT CONTROL PAGE Title: Preceptorship Policy Title Version: Reference Number: Supersedes Supersedes: All previous preceptorship prior to this date Significant Changes: Originator or modifier Ratification

More information

Supporting information for appraisal and revalidation: guidance for paediatrics and child health

Supporting information for appraisal and revalidation: guidance for paediatrics and child health Supporting information for appraisal and revalidation: guidance for paediatrics and child health Based on the Academy of Medical Royal Colleges and Faculties Core Guidance for all doctors. General Introduction

More information

Information Governance Management Framework

Information Governance Management Framework Information Governance Management Framework Responsible Officer Author Business Planning & Resources Director Governance Manager Date effective from October 2015 Date last amended October 2015 Review date

More information

A simple yet advanced toolkit enabling you to communicate in new ways with patients and the public.

A simple yet advanced toolkit enabling you to communicate in new ways with patients and the public. Full with Mobile Apps Integrated Customer Relationship Management System A simple yet advanced toolkit enabling you to communicate in new ways with patients and the public. Branded for your organisation,

More information

National Disability Authority Resource Allocation Feasibility Study Final Report January 2013

National Disability Authority Resource Allocation Feasibility Study Final Report January 2013 National Disability Authority Resource Allocation Feasibility Study January 2013 The National Disability Authority (NDA) has commissioned and funded this evaluation. Responsibility for the evaluation (including

More information

NHS e-referral Service

NHS e-referral Service NHS e-referral Service Vision and Key messages Making paperless referrals a reality Version 1.0 June 2013 Contents Foreword... 4 Background... 5 Document Purpose... 5 Vision Principles... 5 Strategic drivers...

More information

1. Executive Summary...1. 2. Introduction...2. 3. Commitment...2. 4. The Legal Context...3

1. Executive Summary...1. 2. Introduction...2. 3. Commitment...2. 4. The Legal Context...3 Mainstreaming Report and Equality Outcomes April 2013 to March 2017 Contents 1. Executive Summary...1 2. Introduction...2 3. Commitment...2 4. The Legal Context...3 5. An Overview of the Mainstreaming

More information

Delivering Excellence in Insurance Claims Handling

Delivering Excellence in Insurance Claims Handling Delivering Excellence in Insurance Claims Handling Guide to Best Practice Delivering Excellence in Insurance Claims Handling Contents Page 1. Introduction 1 2. Executive Summary 2 3. Components of Best

More information

Government Communication Professional Competency Framework

Government Communication Professional Competency Framework Government Communication Professional Competency Framework April 2013 Introduction Every day, government communicators deliver great work which supports communities and helps citizens understand their

More information

Honours Degree (top-up) Computing Abbreviated Programme Specification Containing Both Core + Supplementary Information

Honours Degree (top-up) Computing Abbreviated Programme Specification Containing Both Core + Supplementary Information Honours Degree (top-up) Computing Abbreviated Programme Specification Containing Both Core + Supplementary Information 1 Awarding Institution / body: Lancaster University 2a Teaching institution: University

More information

Appendix G: Organizational Change Management Plan. DRAFT (Pending approval) April 2007

Appendix G: Organizational Change Management Plan. DRAFT (Pending approval) April 2007 Appendix G: Organizational Change Management Plan DRAFT (Pending approval) April 2007 Table of Contents TABLE OF CONTENTS... 1 INTRODUCTION:... 2 ABT ORGANIZATIONAL CHANGE MANAGEMENT SCOPE... 2 PEOPLESOFT

More information

Achieve. Performance objectives

Achieve. Performance objectives Achieve Performance objectives Performance objectives are benchmarks of effective performance that describe the types of work activities students and affiliates will be involved in as trainee accountants.

More information

Summary of the role and operation of NHS Research Management Offices in England

Summary of the role and operation of NHS Research Management Offices in England Summary of the role and operation of NHS Research Management Offices in England The purpose of this document is to clearly explain, at the operational level, the activities undertaken by NHS R&D Offices

More information

UKCPA - A Review of the Current Pharmaceutical Facility

UKCPA - A Review of the Current Pharmaceutical Facility Modernising Pharmacy Careers Review of Post-Registration Career Development Discussion Paper PRO FORMA FOR CAPTURING RESPONSES TO STAKEHOLDER QUESTIONS Please complete and return to: MPCProgramme@dh.gsi.gov.uk

More information

7 Directorate Performance Managers. 7 Performance Reporting and Data Quality Officer. 8 Responsible Officers

7 Directorate Performance Managers. 7 Performance Reporting and Data Quality Officer. 8 Responsible Officers Contents Page 1 Introduction 2 2 Objectives of the Strategy 2 3 Data Quality Standards 3 4 The National Indicator Set 3 5 Structure of this Strategy 3 5.1 Awareness 4 5.2 Definitions 4 5.3 Recording 4

More information

MANAGEMENT OF POLICIES, PROCEDURES AND OTHER WRITTEN CONTROL DOCUMENTS

MANAGEMENT OF POLICIES, PROCEDURES AND OTHER WRITTEN CONTROL DOCUMENTS MANAGEMENT OF POLICIES, PROCEDURES AND OTHER WRITTEN CONTROL DOCUMENTS Document Reference No: Version No: 6 PtHB / CP 012 Issue Date: April 2015 Review Date: January 2018 Expiry Date: April 2018 Author:

More information

Supporting information for appraisal and revalidation: guidance for clinical oncology and clinical radiology, Second edition

Supporting information for appraisal and revalidation: guidance for clinical oncology and clinical radiology, Second edition www.rcr.ac.uk Supporting information for appraisal and revalidation: guidance for clinical oncology and clinical radiology, Second edition Based on the Academy of Medical Royal Colleges and Faculties Core

More information

How To Manage The Council

How To Manage The Council Mole Valley District Council Corporate Communications Strategy 2002-2005 CONTENTS Content Section 1: Introduction Section 2: Stakeholders Section 3: Objectives Section 4: Targets Section 5: Principles

More information

Healthcare Governance Alert and Guidance Review Procedure

Healthcare Governance Alert and Guidance Review Procedure Healthcare Governance Alert and Guidance Review Procedure Healthcare Governance Alert and Guidance Review Procedure Page: Page 1 of 20 Recommended by Approved by Quality Directorate/Medical Directorate

More information

SUMMARY OF 2016/17 GMS CONTRACT NEGOTIATIONS

SUMMARY OF 2016/17 GMS CONTRACT NEGOTIATIONS SUMMARY OF 2016/17 GMS CONTRACT NEGOTIATIONS This note sets out a summary of the key changes to the General Medical Service (GMS) contract in England for 2016/17. These changes have been agreed between

More information

JOB DESCRIPTION & PERSON SPECIFICATION. Based in Harold s Cross. Advanced Nurse Practitioner (candidate) Indefinite Duration 1.

JOB DESCRIPTION & PERSON SPECIFICATION. Based in Harold s Cross. Advanced Nurse Practitioner (candidate) Indefinite Duration 1. JOB DESCRIPTION & PERSON SPECIFICATION Based in Harold s Cross Advanced Nurse Practitioner (candidate) Indefinite Duration 1.0WTE JOB DESCRIPTION TITLE: REPORTING TO: RESPONSIBLE TO: SALARY SCALE: HOLIDAYS:

More information

JOB DESCRIPTION. Hours: 37.5 hours per week, worked Monday to Friday

JOB DESCRIPTION. Hours: 37.5 hours per week, worked Monday to Friday JOB DESCRIPTION Job Title: Head of Business Continuity & Risk Band: Indicative Band 8b Hours: 37.5 hours per week, worked Monday to Friday Location: Accountable to: Tatchbury Mount, Calmore, Southampton

More information

Risk Management & Business Continuity Manual 2011-2014

Risk Management & Business Continuity Manual 2011-2014 ANNEX C Risk Management & Business Continuity Manual 2011-2014 Produced by the Risk Produced and by the Business Risk and Business Continuity Continuity Team Team February 2011 April 2011 Draft V.10 Page

More information

POSTGRADUATE PROGRAMME SPECIFICATION

POSTGRADUATE PROGRAMME SPECIFICATION POSTGRADUATE PROGRAMME SPECIFICATION Programme Title: Awarding Body: Teaching Institution: Final Awards: MSc International Accounting and Financial Management Staffordshire University Staffordshire University

More information

Internal Audit Quality Assessment Framework

Internal Audit Quality Assessment Framework Internal Audit Quality Assessment Framework May 2013 Internal Audit Quality Assessment Framework May 2013 Crown copyright 2013 You may re-use this information (excluding logos) free of charge in any format

More information

Internal Audit Division

Internal Audit Division Internal Audit Division at the Financial Conduct Authority Information Pack April 2013 Contents of Information Pack A. Introduction B. Internal Audit Terms of Reference C. Organisation D. Skills and Competencies

More information

Digital Inclusion Programme Started. BL2a

Digital Inclusion Programme Started. BL2a PROJECT BRIEF Project Name Digital Inclusion Programme Status: Started Release 18.05.2011 Reference Number: BL2a Purpose This document provides a firm foundation for a project and defines all major aspects

More information

Office of the Police and Crime Commissioner for Avon and Somerset and Avon and Somerset Constabulary

Office of the Police and Crime Commissioner for Avon and Somerset and Avon and Somerset Constabulary Office of the Police and Crime Commissioner for Avon and Somerset and Avon and Somerset Constabulary Internal Audit Report () FINAL Risk Management: Follow Up of Previous Internal Audit Recommendations

More information

Genito-urinary Medicine

Genito-urinary Medicine Specialty specific guidance on documents to be supplied in evidence for an application for entry onto the Specialist Register with a Certificate of Eligibility for Specialist Registration (CESR) Genito-urinary

More information

INFORMATION MANAGEMENT AND TECHNOLOGY (IM&T) STRATEGY

INFORMATION MANAGEMENT AND TECHNOLOGY (IM&T) STRATEGY INFORMATION MANAGEMENT AND TECHNOLOGY (IM&T) STRATEGY 1 INTRODUCTION 1.1 This Somerset Information Management and Technology (IM&T) Strategy outlines the strategic vision and direction for the development

More information

SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CHAIRMAN S APPRAISAL FOR 2014/15 AND OBJECTIVES FOR 2015/16

SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CHAIRMAN S APPRAISAL FOR 2014/15 AND OBJECTIVES FOR 2015/16 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CHAIRMAN S APPRAISAL FOR 2014/15 AND OBJECTIVES FOR 2015/16 1. PURPOSE 1.1 To provide the Council of Governors with feedback on the 2014/15 Chairman s appraisal

More information

THE UNIVERSITY OF MANCHESTER PARTICULARS OF APPOINTMENT

THE UNIVERSITY OF MANCHESTER PARTICULARS OF APPOINTMENT THE UNIVERSITY OF MANCHESTER PARTICULARS OF APPOINTMENT FACULTY OF MEDICAL & HUMAN SCIENCES MANCHESTER PHARMACY SCHOOL CENTRE FOR PHARMACY POSTGRADUATE EDUCATION Lead Pharmacy Technician, Learning Development

More information

Research and Innovation Strategy: delivering a flexible workforce receptive to research and innovation

Research and Innovation Strategy: delivering a flexible workforce receptive to research and innovation Research and Innovation Strategy: delivering a flexible workforce receptive to research and innovation Contents List of Abbreviations 3 Executive Summary 4 Introduction 5 Aims of the Strategy 8 Objectives

More information

Tri-borough Adult Social Care. Supervision Policy

Tri-borough Adult Social Care. Supervision Policy Tri-borough Adult Social Care Supervision Policy April 2014 Supervision Policy Title: Supervision Policy Version: 1 Approved by: Policies sub committee Name of originator/author: Helena Cava Date approved:

More information

Introduction to Clinical Examination and Procedural Skills Assessment (Integrated DOPS)

Introduction to Clinical Examination and Procedural Skills Assessment (Integrated DOPS) Introduction to Clinical Examination and Procedural Skills Assessment (Integrated DOPS) October 2014 RCGP WPBA core group Contents Introduction 3 Summary of the key changes 4 Step-by-step guide for Trainees

More information

Quality Governance Strategy 2011-2013

Quality Governance Strategy 2011-2013 Quality Governance Strategy 2011-2013 - 1 - Index Content Page Number Key Messages and context of the Strategy 3 Introduction What is Quality governance? What do we want to achieve? Trust Objectives Key

More information

An effective working relationship is required with the WP Group Board of Directors, Leadership Team members and the Operations team.

An effective working relationship is required with the WP Group Board of Directors, Leadership Team members and the Operations team. Key Account Manager Role reports to: Group Commercial Director WP Group Overview WP Group is an integrated fuels and lubricants company focused on providing bespoke service solutions to its growing customer

More information

Supporting appraisals: a simpler KSF

Supporting appraisals: a simpler KSF November 2010 Briefing 77 Effective appraisals are an essential part of NHS employment practice, leading to improved staff performance, higher staff satisfaction and better patient outcomes. The NHS Constitution

More information

CHIEF NURSE / DIRECTOR OF CLINICAL GOVERNANCE

CHIEF NURSE / DIRECTOR OF CLINICAL GOVERNANCE www.gov.gg/jobs JOB POSTING CHIEF NURSE / DIRECTOR OF CLINICAL GOVERNANCE JOB TITLE Chief Nurse / Director of Clinical Governance SALARY Attractive Remuneration Package available with post TYPE Full Time

More information

Quality Assurance. Policy P7

Quality Assurance. Policy P7 Quality Assurance Policy P7 Table of Content Quality assurance... 3 IIA Australia quality assurance and professional standards... 3 Quality assurance and professional qualifications... 4 Quality assurance

More information

QUALITY MANAGEMENT SYSTEM MANUAL

QUALITY MANAGEMENT SYSTEM MANUAL The online version of this document is controlled. Therefore, all printed versions of this document are unofficial copies. QUALITY MANAGEMENT SYSTEM MANUAL 6901 Charles Street Towson, Maryland 21204 Manual

More information

Nurse Practitioner Mentor Guideline NPAC-NZ

Nurse Practitioner Mentor Guideline NPAC-NZ Nurse Practitioner Mentor Guideline NPAC-NZ Purpose To provide a framework for the mentorship of registered nurses to prepare for Nurse Practitioner (NP) registration from the Nursing Council of New Zealand.

More information

Context and aims of the workshops

Context and aims of the workshops Themes from the Quality Assurance Review Workshops June 2012 Context and aims of the workshops 1. The General Medical Council (GMC) has legal responsibility for setting standards for undergraduate and

More information

Corporate Governance Report

Corporate Governance Report Corporate Governance Report Chairman s introduction From 1 January 2015 until 31 December 2015, the company applied the 2014 edition of the UK Corporate Governance Code (the Code ). 1. BOARD COMPOSITION

More information

Project organisation and establishing a programme management office

Project organisation and establishing a programme management office PROJECT ADVISORY Project organisation and establishing a programme office Leadership Series 1 kpmg.com/nz About the Leadership Series KPMG s Leadership Series is targeted towards owners of major capital

More information

The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process

The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process [This is the final draft of the NHS KSF Handbook that will be used for national roll-out if implementation of Agenda

More information

Supplier & Contract Management System (SCMS)

Supplier & Contract Management System (SCMS) Meeting of the Executive Member for Corporate Services and Advisory Panel 30 October 2007 Report of the Assistant Director Audit and Risk Management Supplier & Contract Management System (SCMS) Summary

More information

A Review of the NHSLA Incident Reporting and Management and Learning from Experience Standards. Assessment Outcomes. April 2003 - March 2004

A Review of the NHSLA Incident Reporting and Management and Learning from Experience Standards. Assessment Outcomes. April 2003 - March 2004 A Review of the NHSLA Incident Reporting and Management and Learning from Experience Standards Assessment Outcomes April 2003 - March 2004 September 2004 1 Background The NHS Litigation Authority (NHSLA)

More information

The Robert Darbishire Practice JOB DESCRIPTION. Nursing Team Leader

The Robert Darbishire Practice JOB DESCRIPTION. Nursing Team Leader The Robert Darbishire Practice JOB DESCRIPTION Nursing Team Leader JOB SUMMARY To provide a practice nursing service to patients, including in chronic disease management and other specialist areas. To

More information

Health and Safety Policy and Procedures

Health and Safety Policy and Procedures Health and Safety Policy and Procedures Health & Safety Policy & Procedures Contents s REVISION AND AMENDMENT RECORD : Summary of Change Whole Policy 4.0 05 Nov 08 Complete re-issue Whole Policy 4.1 10

More information