Board of Directors 26 June 2015

Transcription

1 ITEM NO: 13 PRESENTED BY: PREPARED BY: DATE PREPARED: 15 th May 2015 Board of Directors 26 June 2015 Pamela Chrispin, Medical Director Paul Molyneux, Deputy Medical Director/Pamela Chrispin, Responsible Officer and Medical Director SUBJECT: Responsible Officer Annual Report PURPOSE: To update the Board on the status of medical revalidation and appraisal, and approve the annual Board Statement of Compliance STRATEGIC OBJECTIVE: Ambition 3: Reliable care EXECUTIVE SUMMARY: Since the last Board update on Revalidation (July 2014), there has been further significant progress. This Annual Report outlines the Trust position, updates the Board on recent developments in appraisal and revalidation and asks for confirmation that it is compliant with current regulations. The report highlights areas where progress has been made, and further work that will be required to ensure both timely and appropriate appraisal of all Senior doctors with a prescribed connection to this Trust. The number of doctors with whom the Trust has a prescribed connection during this period was 217, up from 183 9n It should be noted that revalidation for nurses is on the horizon, and a section is included which informs the Board of the potential implications of implementation. Matters resulting from recommendations Present Considered made in this report Financial Implications Yes / No Yes / No Workforce Implications Yes / No Yes / No Impact on Equality and Diversity impact Yes / No Yes / No Legislation, Regulations and other external directives Yes / No Yes / No Internal policy or procedural issues Yes / No Yes / No

2 Risk Implications for West Suffolk Hospital Poor uptake of appraisal risks the responsible Officer being unable to make a recommendation for revalidation to the GMC Mitigating Actions (Controls): Regular monitoring of Appraisal uptake Level of Assurance that can be given to the Board from the report based on the evidence Sufficient Recommendations: The Board are asked to accept the Annual Report, note the contents and approve it for submission to the higher level Responsible Officer The Board are asked to approve the statement of compliance confirming that the West Suffolk NHS FT is compliant with the regulations

3 Background Medical revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care to patients, improving patient safety and increasing public trust and confidence. Provider organisations have a statutory duty to support their Responsible Officer in discharging their duties under the Responsible Officer Regulations and it is expected that provider Boards will oversee compliance by: Monitoring the frequency and quality of medical appraisals in their organisation Checking there are effective systems in place for monitoring the conduct and performance of their doctors Confirming that feedback is sought at suitable intervals from patients so that their views can inform the appraisal and revalidation process for their doctor Ensuring that appropriate pre-employment background checks (including pre-engagement for locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed. Governance Arrangements Individual doctors are responsible for ensuring they undertake annual appraisal and have a prescribed connection with a designated body. The Responsible Officer is responsible for evaluating the doctor s performance based on evidence provided through appraisal and other mechanisms, and making a recommendation to the General Medical Council (GMC) every five years about their fitness to practice. Boards have a responsibility to ensure the RO is provided with adequate resources to fulfil their statutory function. The status of every doctor is continually reviewed and updated and any doctor who is noncompliant with appraisal or revalidation processes is identified early and sent reminders. If this fails to generate a suitable response, the doctor receives an from the Medical Director. Appraisal processes have been well-established for many years. Appraisers are trained and receive top-up training at intervals. The annual appraisal includes: Preparation by the doctor which should include reflection on the full scope of their professional activities, not only their West Suffolk clinical work but private practice, voluntary activities, educational supervisor or appraiser roles and any external professional activities. The doctor must upload a range of suitable supporting evidence. An assessment by the Appraiser of the whole of the doctor s professional activities, which should be supported by evidence. The appraiser will review among other things scope of work, activity, patient outcomes, complaints and incidents, colleague and patient feedback, health and probity. A review of the personal development plan from the previous year, achievements and challenges, and the development of a new PDP to address the learning needs and career development of the doctor. Statements and declarations by the Appraiser and Appraisee that the doctor continues to practice in accordance with obligations of the General Medical Council Good Medical Practice Framework

4 The West Suffolk Hospital has a system in place which ensures that all doctors have suitable preemployment checks. The Trust submits quarterly information to NHS England about appraisal activity including whether the Responsible Officer has sufficient resources to undertake the role. Progress against last year s development plan a) Continue to monitor appraisal uptake/rates of completion appraisal rates have risen from mid-70s to 82%. A doctor who is 1 day overdue will count as non-compliant, as will all doctors who are delayed for an accepted reason e.g. sickness or maternity leave. At the beginning of April, of the 24 doctors showing as non-compliant 2 were new consultants, 3 had an accepted reason for delay, 17 were less than three months overdue (of which 7 were less than one month overdue). In line with other Trusts and GMC guidance, we have introduced a rule that more than three months overdue now counts as a missed appraisal and will have consequences for pay progression, clinical excellence awards and potentially revalidation. Doctors in this category providing the West Suffolk have made every effort to remind and support them are sent a formal letter which forms part of their revalidation evidence and must be discussed with their appraiser. Doctors have now been allocated an appraisal month in which their appraisal falls every year. This fits with GMC guidance which counts a missed appraisal as one that occurs more than 89 days after the last day of the month in which the appraisal was due. b) Quality Assure on an appropriate proportion of appraisals in a more objective manner, with appropriate identification of relevant clinical incidents and outcome measures and a more tailored approach for appraisal for each Directorate this was discussed at the medical appraisers update meeting, and agreed that all revalidation-ready appraisals are now reviewed by the Medical Director and Deputy Medical Director using a standard checklist, with feedback to the appraise and appraiser. This is gradually raising expectations of what appraisees should provide and appraisers expect to see. c) Collect detail on why appraisals were delayed there is now a much more pro-active system of chasing consultants and identifying reasons for delay. d) Train cohort of new appraisers completed. A total of 9 new appraisers were recruited and trained. e) Provide appraisers with enhanced training on writing objectives and appraisal outputs undertaken through the Appraiser Training Workshops f) Undertake evaluation of individual appraiser performance using SARD feedback mechanisms still in development as insufficient appraisals undertaken on SARD by each appraiser to date Other significant developments between April 2014 and March 2015 include the following: 1. SARD on-line appraisal system embedded This system is used by all doctors to undertake their annual appraisal and is also the management system for revalidation. The Responsible Officer is supported by a 0.8 WTE administrative assistant who oversees and updates the list of doctors and ensures they receive notice about appraisals. The system was introduced in February 2014 so most doctors have had at least one appraisal using the SARD system. Patient and colleague feedback is now being undertaken using their system. 2. Ability to obtain information from previous employers

5 Towards the end of the GMC have provided details of a doctor s former designated body and this has allowed us to put in place a system to obtain information from previous employers, including fitness to practise concerns and appraisal documentation. 3. Review by Internal Audit summary of internal audit was that there were only a small number of areas requiring review, and actions have been taken to implement all the recommendations 4. Remediation framework approved by TNC 13 th December 2014 Medical Appraisal Activity 173/222 doctors were appraised during this period. Delayed appraisals are detailed in the table below. 21/28 over 3 months overdue were agreed by the RO sick, maternity leave, understanding of SARD system or appraiser not available in time (sick or A/L) Consultants Completed in due month 39 One month overdue 29 Two months overdue 25 Three months overdue 14 Over three months over due SARD form not submitted - not recorded 14 New - appraisal not due in this period Staff Grades Completed in due month 9 One month overdue 3 Two months overdue 2 14 SARD form not submitted not recorded 2 16 Fix term & Locum Completed in due month 9 One month overdue 2 Two months overdue 1 Over 3 months overdue 2 14 SARD form not submitted 3 New - appraisal not due in this period 9 26 Clinical Fellows & Trust Doctors Completed in due month 9 One month overdue 1 Two months overdue 2 Over 3 months overdue 4 16 SARD form not submitted 3 New - appraisal not due in this period 8 27 Total The total number of trained appraisers at 31 st March 2015 was 37. At present we have a sufficient number of appraisers.

6 Revalidation Activity The number of recommendations made between April 2014 and March 2015 was 82 Positive recommendations 72 Deferrals 10 Non-engagements 0 Late recommendations 0 Development Plan / Issues for Implementation of the internal audit recommendations. 2. Recruiting and training appraisers is becoming increasingly onerous and needs to be structured in line with GMC requirements. Whilst the Trust has the capability to undertake top-up training it no longer feels it has the ability to undertake the recommended initial appraiser training (two days). In addition, appraisers are becoming increasingly concerned about the responsibility placed on them in terms of assurance regarding fitness to practice. There is no budget allocated to appraisal for either appraiser training or undertaking appraisals, in comparison to medical educational activities, for instance. 3. On-going improvement to quality assurance process we will continue to strengthen the processes by which we share information with previous and future employers, and continue to feed back to appraisees regarding their portfolio completion and quality of supporting evidence and to appraisers regarding their appraisal summaries. 4. The SARD job planning module has been refined with input from the West Suffolk operational team, and this will be trialled in It should be noted that Revalidation for Registered Nurses is also being developed. The details of this are currently being confirmed nationally. The Chief Nurse will ensure that the Board is apprised of requirements to deliver and monitor this locally as this becomes clear. For approval The Board are asked to accept the Annual Report, note the contents and that it will be submitted to the higher level RO The Board are asked to approve the statement of compliance confirming that the West Suffolk NHS FT is in compliance with the regulations