A Framework of Quality Assurance for Responsible Officers and Revalidation

Transcription

1 A Framework of Quality Assurance for Responsible Officers and Revalidation Annex D - Annual Board Report Template

2 NHS England INFORMATION READER BOX Directorate Medical Commissioning Operations Patients and Information Nursing Trans. & Corp. Ops. Commissioning Strategy Finance Publications Gateway Reference: Document Purpose Document Name Author Publication Date Target Audience Additional Circulation List Description Cross Reference Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information Guidance A Framework of Quality Assurance for Responsible Officers and Revalidation, Annex D - Annual Board Report Template Gary Cooper, Project Manager Quality and Assurance, Professional Standards Team 16 June 2015 All Responsible Officers in England Foundation Trust CEs, NHS Trust Board Chairs, Medical Appraisal Leads, CEs of Designated Bodies in England, NHS England Regional Directors, NHS England Directors of Commissioning Operations, All NHS England Employees, Directors of HR, NHS Trust CEs A template board report for use by designated bodies to monitor their organisation s progress in implementing the Responsible Officer Regulations. The Medical Profession (Responsible Officers) Regulations, 2010 (as amended 2013) and the GMC (Licence to Practise and Revalidation) Regulations 2012 A Framework of Quality Assurance for Responsible Officers and Revalidation, Annex D - Annual Board Report Template, version 4 April Designated Bodies to receive annual board reports on the implementation of revalidation and submit an annual statement of compliance to their higher level responsible officers. From June 2015 england.revalidation-pmo@nhs.net 0 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. NB: The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the National Health Service Commissioning Board has used the name NHS England for operational purposes.

3 1. Executive summary We currently employ 42 doctors with a prescribed connection to Humber NHS Foundation Trust as on 31 March All the doctors with a prescribed connection completed their appraisals within the appraisal year. Therefore we achieved an appraisal completion rate of 100%. We have continued to use MYL2P and the Res 360 tool to record appraisals of consultants and complete multi-source feedback. 2. Purpose of the Paper Medical Revalidation is the process by which the General Medical Council (GMC) confirms the continuation of a doctor s license to practice in the United Kingdom. All doctors who wish to retain their License to Practice need to participate in revalidation. The purpose of revalidation is to provide greater assurance to patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practice. It is a key component of a range of measures designed to improve the quality of care for patients. The purpose of this report is to demonstrate the adherence to the appraisal and revalidation process within Humber NHS Foundation Trust. Revalidation is based on a local evaluation of doctors practice through appraisal. Through a formal link within an organisation (prescribed connection) determined usually by employment or contracting arrangements each doctor relates to a senior doctor in the organisation, the Responsible Officer. The Responsible Officer makes a recommendation about the doctor s fitness to practice to the GMC. The recommendation will be based on the outcome of the doctor s annual appraisal over the course of five years combined with information drawn from the organisational clinical governance systems. Following the Responsible Officer s recommendation the GMC decides whether to renew the doctor s license. 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 provided to patients, improving patient safety and increasing public trust and confidence in the medical system. Provider organisations have a statutory duty to support their Responsible Officers 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 organisations; checking there are effective systems in place for monitoring the conduct and performance of their doctors; confirming that feedback from patients and colleagues is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and

4 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. An Annual Organisational Audit is submitted along with this report duly completed with a statement of compliance to the Board for approval. 4. Governance Arrangements The governance structure within the organisation was reviewed and is currently embedded with the care groups and monitored centrally by the Nursing Director and the Medical Director. The SI policy and process has been developed in line with the Department of Health guidance. A completed structure with functions and responsibilities has been shared with the board. The MYL2P system has been in use across the organisation and clinicians have been reporting positive experience. The system is now fully operational and doctors are signed up to it. Prior to the Annual Organisational Audit last year we had undertaken an internal audit of the quality of appraisals and have shared the findings and actions from the audit with all the appraisers in order to ensure uniformity and maintenance of high standards across all the appraisers. A further audit is to be repeated next year. a. Policy and Guidance The existing Revalidation policy has been revised in view of the more recent guidance. It has been approved at LNC and EMT and is now on the intranet. 5. Medical Appraisal a. Appraisal and Revalidation Performance Data None Number of doctors: Number of completed appraisals: Number of doctors in remediation and disciplinary processes: There is one doctor who did not complete their appraisal in the 9 to 15 month window due to long term absence. The doctor has since returned to work and a date for appraisal has been set..

5 b. Appraisers Over the past year we have had three new appraisers join the cohort of appraisers within the organisation. The new appraiser is due to receive new appraiser training and the other appraisers have either attended the new appraiser training or the refresher training or are scheduled to attend. c. Quality Assurance An audit of the quality of appraisals undertaken by appraisers was completed two years ago. These findings were shared with the appraisers. The learning outcomes and good practice was shared among the group and this was received positively by the appraisers. All Doctors prior to their appraisal are provided information from the Risk Management department regarding SI and Complaints over the year. d. Access, Security and Confidentiality Doctors are aware that all patient identifiable information is to be redacted when storing such information as part of their appraisal documentation. A reminder to this effect has also been sent recently. e. Clinical governance Doctors are provided information regarding complaints and SIs in which they have been named and a reflection is included in the appraisal.

6 6. Revalidation Recommendations Number of recommendations between April March - 10 Recommendations completed on time; - 10 not on time - 0 Positive recommendations - 10 Deferrals requests - 0 Non engagement notifications - Nil Reasons for all missed or late recommendations - None See Annual Report Template Appendix C; Audit of revalidation recommendations 7. Recruitment and engagement background checks All Consultant appointments pre-employment include a sharing of their portfolio from their previous Responsible Officer and the completion of a transfer of appraisal information form (MPIT form). Feedback is also given to the ROs of Locum Doctors once their employment with Humber NHS Foundation Trust has ended. 8. Monitoring Performance The performance of all doctors is monitored via the annual Job Planning process. With the Trust restructure and reorganisation a further strengthening of this process is envisaged. The possibility of acquiring a bespoke system for job planning is being considered. 9. Responding to Concerns and Remediation The Medical Disciplinary Policy has been updated. There are currently no doctors undergoing a remediation programme under NCAS. 10. Risks and Issues Robust support to the appraisal and revalidation systems within the organisation will need to be maintained with support from the Human Resources Department. 11. Board Reflections The Board are supportive of the current appraisal arrangements for Doctors within the Organisation.

7 12. Corrective Actions, Improvement Plan and Next Steps Future developments will include support to Clinical Leads and Consultants to train as appraisers, refresher training for all doctors around appraisal and revalidation and support to the Director of Nursing in the nurse revalidation process. 13. Recommendations Board to accept the report. Board to approve the statement of compliance confirming that the organisation as a designated body is in compliance with the regulations.