Medical Revalidation - Annual Board Report

Transcription

1 Medical Revalidation - Annual Board Report Executive summary During LCHS was responsible as designated body for seven doctors. Six of seven doctors were appraised in their allocated quarter with satisfactory completion of appraisal documentation; the remaining one submitted evidence meeting required standards but outside usual appraisal quarter having missed appraisal in previous year whilst employed by another organisation. Two doctors were reviewed by LCHS revalidation panel and subsequent recommendations were completed. The appraisal resources have been strengthened by addition of a further senior doctor who is contributing to a collaborative arrangement with NHS England GP performer s list appraisers (Lincolnshire and Leicestershire) who provide appraisals of LCHS doctors. The appraisals are subject to quality assurance and LCHS receive regular reports of activity, outputs and quality assurance of appraisals undertaken by LCHS doctors. 2. Purpose of the Paper This paper provides some detailed analysis of the systems and performance of LCHS in meeting the requirements of regulations governing medical appraisal and revalidation and assurance relating to pre-employment checks. The organisation is required to submit an annual statement of compliance and the board is requested to approve statement and declaration based on the content of this annual report. 3. Background Medical Revalidation was launched in 212 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 1 and it is expected that provider boards / executive teams [delete as applicable] 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 is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and Ensuring that appropriate pre-employment background checks (including 1 The Medical Profession (Responsible Officers) Regulations, 21 as amended in 213 and The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 212 1

2 pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed. 4. Governance Arrangements The progress and activity with respect to appraisal and revalidation is monitored by practitioner performance team and reported through Practitioner Performance assurance committee (PPAC) that meets on a monthly basis. PPAC reports to Quality & Risk Committee (Q&R) (formal subcommittee to the board) and the Workforce & Transformation Board Assurance Group (WFTBAG) quarterly to provide assurance to the Trust Board. Process for maintaining accurate list of prescribed connections The trust employs the use of a medical assurance process (MAP) to track all doctors with a relationship to LCHS. All doctors are identified with details surrounding their contractual status, designated body and responsible officer, last appraisal date; recruitment checklists including indemnity and GMC status. The list of doctors with LCHS as designated body is summarised on GMC web site GMC Connect and due to small numbers of doctors with a prescribed connection to LCHS, this is effective. Changes to this list are communicated via automatic NHS Net using a dedicated generic account accessed by practitioner performance team and medical director. Process of internal assurance Regular validation checks on the accuracy of the MAP are undertaken with periodic requests from all doctors to update key documents and records. Policy and Guidance The current Medical Appraisal Policy was developed in 212 and was reviewed and updated in to take into account changes in national policy and guidelines since regulations were first published. No significant changes were required. Next review is scheduled for December 216 and policy update will ensure alignment with NHSE medical appraisal policy and include national templates for communication between NHS organisations and regulator. 5. Medical Appraisal a. Appraisal and Revalidation Performance Data 7 doctors have a prescribed connection with LCHS for revalidation 6 doctors completed appraisal in expected timescales with satisfactory outputs and signed off within 28 days; 1 doctor completed appraisal with satisfactory outputs but appraisal was not within scheduled month due to a missed appraisal in whilst with a different employer. 2 doctors were given a recommendation by the responsible officer to GMC supporting revalidation within planned timescales 2

3 Details of exceptions i.e. missed appraisals and reasons, incomplete appraisals etc. (See Appendix A; Audit of all missed or incomplete appraisals audit) b. Appraisers LCHS is supported by NHS England (NHSE) Lincolnshire and Leicestershire Area Team Performers List GP Appraisal team working under a memorandum of understanding (MOU attached as Appendix F) whereby LCHS appraisers undertake appraisals of GPs in return for LCHS doctors appraised by experienced medical appraisers managed by NHSE. During , LCHS contributed two trained appraisers who conducted 9 appraisals in lieu of payment for 7 appraisals conducted in and those planned in LCHS appraisers attend training provided by NHSE and receive feedback and QA reports of appraisals completed in accordance with national guidance. c. Quality Assurance Outline of quality assurance processes: For the appraisal portfolio: During appraisal, the appraiser logs appraisal inputs and comments on structure and relevance to scope of practice; a checklist is used by appraisers to keep a running tally of appraisal inputs and key professional development activities; this tally is maintained to ensure 5 year cycle meets revalidation requirements and supports recommendations for revalidation. Currently, manual systems are supporting this function All appraisers outputs are quality assured to ensure summary of discussion has sufficient detail to support revalidation recommendations; underperformance by appraisers is escalated for consideration of appraiser remediation by the appraiser management team Communication between practitioner performance team and appraiser team is required to highlight any particular items identified by the responsible officer that need to be discussed at appraisal. These issues must be checked off as covered and actions taken or planned described in summary of appraisal discussion. This process is not presently formalised due to small numbers of doctors with prescribed connection and will be enhanced by procurement of an appraisal toolkit in that will support the tracking of mandated appraisal requirements underpinning revalidation recommendation. For the individual appraiser All appraisers have a sample of appraisals quality assured using audit tool and this is provided as feedback to the appraisers with any recommendations; for new appraisers the first 3 appraisals are all quality assured An annual record of all appraisal activity and performance including attendance at training events is supplied to appraisers to include as evidence supporting their own scope of practice at appraisal 3

4 Feedback from appraisers and appraisees is captured after completion of each appraisal to monitor effectiveness of processes and experience; appraisers are provided with a yearly report summarising the feedback provided For the organisation Under the terms of the memorandum of understanding with NHSE, LCHS will be provided with performance data related to appraisal planning, documentation completion and sign off of all appraisals undertaken for LCHS doctors. Timescales include an expectation that appraisal will occur in planned month with sign off and return of feedback and check lists within 28 days A summary of user feedback relating to the experience of LCHS appraisees will be provided by NHSE Further analysis of lessons learned and significant events reflected in the appraisals needs to be undertaken with a view to ensuring capture of highlighted concerns for escalation to responsible officer. Personal review of all appraisal outputs will be undertaken by the responsible officer to respond to this in the interim before a delegated process is considered (See Appendix B; Quality assurance audit of appraisal inputs and outputs) d. Access, security and confidentiality Secure is used to transmit electronic copies of appraisal outputs to the responsible officer for review. Currently, all appraisal outputs are reviewed individually by the responsible officer; appraisers are trained to highlight information governance issues before appraisal and require that appraisal documentation is purged of patient identifiable data prior to appraisal. The guideline that documentation is submitted 2 weeks before appraisal is necessary to allow these checks. The summary of discussion completed by the appraiser is also expected to be completed in anonymised format to allow quality assurance without breach of doctor confidence. No information management breaches were identified in The trust is now using Clarity Appraisal toolkit for all doctors with a connection to LCHS as designated body for revalidation and allow further real time assurance. e. Clinical Governance Outline of Corporate data available for individual doctors to contribute to supporting information. There is a recognised gap in assurance controls for this quality standard and currently the expectation rests between appraisee and line manager to agree and acquire suitable performance metrics that are relevant to the doctor s scope of practice and responsibilities and present these as evidence within the appraisal portfolio. 4

5 Lack of organisational wide prescribing data available at a prescriber lever has delayed inclusion within planned update of the appraisal policy that would include a range of data that should be accessible and included for reflection and drive development needs. Such data could include: Prescribing, with particular regard to: o Antibiotics o PACEF-designated Red-Red drugs o High cost drugs and products o Opiates o Formulary concordance Appointment statistics o Patient waiting times o DNA rates o Next appointment availability o Contact statistics Complaints, Claims & Concerns Incidents Accolades and praise from patients, public and partners Clinical supervision Record-keeping audit The planned policy review and update in December 216 will make specific references to feedback information that can be supplied by informatics team from SystMOne and other information systems. 6. Revalidation Recommendations Two recommendations were made during ; the panel that approves recommendations for revalidation comprises members of the practitioner performance assurance committee. See Appendix C; Audit of revalidation recommendations 7. Recruitment and engagement background checks Formal recruitment to substantive or time-limited employment is determined by trust recruitment policy that makes clear reference to registration and checking of referees that includes previous employer/responsible officer. Locums recruited through agency or partner organisations have contractual agreement to perform these background checks; those individuals directly contracted by LCHS are expected to be subject the same checks as prospective employees. Recruitment records of permanent staff can evidence maintenance of high standards of pre-employment checks to required standards. The current medical assurance process is currently under review and being strengthened in order to report on a real time basis the current status for all doctors undergoing checks and the deployment of locum staff throughout the organisation. See Appendix E; Audit of recruitment and engagement background 5

6 8. Monitoring Performance Process by which the performance of all doctors is monitored All incidents, concerns, complaints and claims involving medical staff are subject to initial fact find (IFF) and discussion between service managers, practitioner performance team and Medical Director. Where underperformance is suspected then a full investigation is commissioned and a decision regarding restrictions placed on the doctors practice made having taken into account advice from HR team and NCAS. Further work is required to look at proactive collection and analysis of individual performance data as part of supervision, clinical leadership and effective line management of medical staff. This data is also required to contribute to appraisal and reflection by the doctor. 9. Responding to Concerns and Remediation Resources and policy reference All staff, including medical staff are subject to the trust s disciplinary policy which in conjunction with medical appraisal policy states the expectations of staff and organisation in managing concerns regarding underperformance related to any combination of conduct, capability and well-being with clear reference to MHPS in respect of those concerns regarding medical staff. LCHS has a good track record of incident reporting with escalation of concerns related to individuals to practitioner performance team after completion of IFF. Remediation programmes numbers and types No doctors required management through capability process or remediation plans in Risk and Issues As identified earlier in document there are recognised gaps in controls relating to: Collection and analysis of individual performance data to support doctor at appraisal and monitor performance within the organisation requires a systematic review of practitioner level performance data collection and reporting; linked to service level reporting and management plans Functionality for reporting on recruitment to and exit from organisation to support liaison with RO s from other organisations regional and national programs have developed an information transfer form (Medical Practitioner Information Transfer Form) to standardise sharing of information when doctors move from one organisation to another. This tool is now being used to good effect and has improved the cooperation and communication between organisations resulting in better quality assurance of preemployment checks and monitoring non-permanent staff. Maintaining register of doctors relationships with other healthcare providers continues to challenge healthcare systems. Refinement of medical assurance process has assisted this. 6

7 11. Board Reflections The organisation has continued to make progress towards more robust management of medical appraisal for all doctors with a prescribed relationship with LCHS but more work is needed to secure a greater degree of confidence in the medical assurance process supporting recruitment and monitoring key controls for medical practitioners. Regional and national partnership working with providers and regulators has been supportive of these developments. 12. Corrective Actions, Improvement Plan and Next Steps Corrective Actions and Improvement Plan Further update to Medical Appraisal Policy to close identified gaps in assurance controls regarding sharing performance metrics with doctors is scheduled for December 216 Action plan presented to WFTBAG in January 216; outstanding actions relating to automated suite of metrics to serve as performance feedback 13. Recommendations The board is requested to approve the report (noting it will be shared, along with the annual audit, with the higher level responsible officer) and to support the recommendations and commitment of resources to achieve compliance. The board is requested to approve the statement of compliance confirming that the organisation, as a designated body, is in compliance with the regulations acknowledging the declared comments detailing gaps in controls. 7

8 Medical Revalidation Annual Report Appendix A Audit of all missed or incomplete appraisals audit Doctor factors (total) Maternity leave during the majority of the appraisal due window Sickness absence during the majority of the appraisal due window Prolonged leave during the majority of the appraisal due window Suspension during the majority of the appraisal due window New starter within 3 month of appraisal due date New starter more than 3 months from appraisal due date Postponed due to incomplete portfolio/insufficient supporting information Appraisal outputs not signed off by doctor within 28 days Lack of time of doctor Lack of engagement of doctor Other doctor factors (Incomplete appraisal due to specialist training completion) Appraiser factors Unplanned absence of appraiser Appraisal outputs not signed off by appraiser within 28 days Lack of time of appraiser Other appraiser factors (describe) (describe) Organisational factors Administration or management factors Failure of electronic information systems Insufficient numbers of trained appraisers Other organisational factors (describe) 8

9 Medical Revalidation Annual Report Appendix B Quality assurance audit of appraisal inputs and outputs Total number of appraisals completed Number of appraisal portfolios sampled (to demonstrate adequate sample size) Appraisal inputs 7 7 Scope of work: Has a full scope of practice been described? Continuing Professional Development (CPD): Is CPD compliant with GMC requirements? Quality improvement activity: Is quality improvement activity compliant with GMC requirements? Patient feedback exercise: Has a patient feedback exercise been completed? Colleague feedback exercise: Has a colleague feedback exercise been completed? Yes 7 2 Review of complaints: Have all complaints been included? 7 7 Review of significant events/clinical incidents/suis: Have all significant events/clinical incidents/suis been included? Is there sufficient supporting information from all the doctor s roles and places of work? Is the portfolio sufficiently complete for the stage of the revalidation cycle (year 1 to year 4)? Explanatory note: For example Has a patient and colleague feedback exercise been completed by year 3? Is the portfolio complete after the appraisal which precedes the revalidation recommendation (year 5)? Have all types of supporting information been included? Appraisal Outputs Appraisal Summary 7 7 Appraiser Statements 7 7 PDP 7 7 Number Number of the sampled appraisal portfolios deemed to be acceptable against standards 9

10 Audit of revalidation recommendations Medical Revalidation Annual Report Appendix C Revalidation recommendations between 1 April 215 to 31 March 216 Recommendations completed on time (within the GMC recommendation window) Late recommendations (completed, but after the GMC recommendation window closed) 2 Missed recommendations (not completed) TOTAL 2 Primary reason for all late/missed recommendations For any late or missed recommendations only one primary reason must be identified No responsible officer in post New starter/new prescribed connection established within 2 weeks of revalidation due date New starter/new prescribed connection established more than 2 weeks from revalidation due date Unaware the doctor had a prescribed connection Unaware of the doctor s revalidation due date Administrative error Responsible officer error Inadequate resources or support for the responsible officer role Other Describe other TOTAL [sum of (late) + (missed)] 1

11 Audit of concerns about a doctor s practice Medical Revalidation Annual Report Appendix D Concerns about a doctor s practice High level Medium level Low level Total Number of doctors with concerns about their practice in the last 12 months Explanatory note: Enter the total number of doctors with concerns in the last 12 months. It is recognised that there may be several types of concern but please record the primary concern Capability concerns (as the primary category) in the last 12 months Conduct concerns (as the primary category) in the last 12 months Health concerns (as the primary category) in the last 12 months Remediation/Reskilling/Retraining/Rehabilitation Numbers of doctors with whom the designated body has a prescribed connection as at 31 March 216 who have undergone formal remediation between 1 April 215 and 31 March 216 Formal remediation is a planned and managed programme of interventions or a single intervention e.g. coaching, retraining which is implemented as a consequence of a concern about a doctor s practice A doctor should be included here if they were undergoing remediation at any point during the year Consultants (permanent employed staff including honorary contract holders, NHS and other government /public body staff) Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS and other government /public body staff) General practitioner (for NHS England area teams only; doctors on a medical performers list, Armed Forces) Trainee: doctor on national postgraduate training scheme (for local education and training boards only; doctors on national training programmes) Doctors with practising privileges (this is usually for independent healthcare providers, however practising privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade) Temporary or short-term contract holders (temporary employed staff including locums who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixedterm employment contracts, etc) All DBs 11

12 Other (including all responsible officers, and doctors registered with a locum agency, members of faculties/professional bodies, some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc) All DBs TOTALS Other Actions/Interventions Local Actions: Number of doctors who were suspended/excluded from practice between 1 April and 31 March: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included Duration of suspension: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included Less than 1 week 1 week to 1 month 1 3 months 3-6 months 6-12 months Number of doctors who have had local restrictions placed on their practice in the last 12 months? GMC Actions: Number of doctors who: Were referred to the GMC between 1 April and 31 March Underwent or are currently undergoing GMC Fitness to Practice procedures between 1 April and 31 March Had conditions placed on their practice by the GMC or undertakings agreed with the GMC between 1 April and 31 March Had their registration/licence suspended by the GMC between 1 April and 31 March Were erased from the GMC register between 1 April and 31 March National Clinical Assessment Service actions: Number of doctors about whom NCAS has been contacted between 1 April and 31 March: For advice For investigation For assessment Number of NCAS investigations performed Number of NCAS assessments performed 12

13 Medical Revalidation Annual Report Appendix E Audit of recruitment and engagement background checks Number of new doctors (including all new prescribed connections) who have commenced in last 12 months (including where appropriate locum doctors) Permanent employed doctors 4 Temporary employed doctors 1 Locums brought in to the designated body through a locum agency 4 Locums brought in to the designated body through Staff Bank arrangements Doctors on Performers Lists Other Explanatory note: This includes independent contractors, doctors with practising privileges, etc. For membership organisations this includes new members, for locum agencies this includes doctors who have registered with the agency, etc TOTAL 16 For how many of these doctors was the following information available within 1 month of the doctor s starting date (numbers) 7 Total Identity check Past GMC issues GMC conditions or undertakings On-going GMC/NCAS investigations DBS 2 recent references Name of last responsible officer Reference from last responsible officer Language competency Local conditions or undertakings Qualification check Revalidation due date Appraisal due date Appraisal outputs Unresolved performance concerns Permanent employed doctors Temporary employed doctors Locums brought in to the designated body through

14 a locum agency Locums brought in to the designated body through Staff Bank arrangements Doctors on Performers Lists Other (independent contractors, practising privileges, members, registrants, etc) Total (these cells will sum automatically) For Providers use of locum doctors: Explanatory note: Number of locum sessions used (days) as a proportion of total medical establishment (days) NB: this section may change as a result of the SCL Project The total WTE headcount is included to show the proportion of the posts in each specialty that are covered by locum doctors Locum use by specialty: Surgery Total establishment in specialty (current approved WTE headcount) n/a Consultant: Overall number of locum days used SAS doctors: Overall number of locum days used Trainees (all grades): Overall number of locum days used Total Overall number of locum days used Medicine 4.51 Psychiatry Obstetrics/Gynaecology n/a n/a 14

15 Accident and Emergency (UCC) 2. Anaesthetics Radiology Pathology n/a n/a n/a Other 1. Not available Not available Total in designated body (This includes all doctors not just those with a prescribed connection) Number of individual locum attachments by duration of attachment (each contract is a separate attachment even if the same doctor fills more than one contract) Total 2 days or less 3 days to one week 1 week to 1 month 1-3 months 3-6 months 6-12 months More than 12 months Figures not available due mixed economy of contracts within trust Total Figures not available Preemployment checks completed (number) Induction or orientation completed (number) Exit reports completed (number) Concerns reported to agency or responsible officer (number) 15

16 Appendix F: MEMORANDUM OF UNDERSTANDING BETWEEN NHS ENGLAND CENTRAL MIDLANDS AND LINCOLNSHIRE COMMUNITY HEALTH SERVICES NHS TRUST Introduction This memorandum sets out the framework for a collaborative working relationship between NHS England Central Midlands and Lincolnshire Community Health Services NHS Trust in order to achieve their joint and separate objectives. This memorandum is not legally binding nor is it intended to be comprehensive in detail. It sets out principles which both sides agree to follow in the course of a day-to-day working relationship. Framework The establishment of a reciprocal arrangement for doctor appraisal between NHS England Central Midlands and Lincolnshire Community Health Services NHS Trust. Individual responsibilities NHS England Central Midlands: NHS England Central Midlands will undertake the appraisal of doctors employed by Lincolnshire Community Health Services NHS Trust who require annual clinical appraisal as identified by Lincolnshire Community Health Services NHS Trust. There will be no direct charge to Lincolnshire Community Health Services NHS Trust for undertaking these appraisals. NHS England Central Midlands will identify suitable appraisers to perform appraisals for Lincolnshire Community Health Services NHS Trust. These appraisals will be administered as part of the NHS England Central Midlands annual appraisal system but allowance will be made concerning any particular issues required by Lincolnshire Community Health Services NHS Trust around timing of such appraisals to facilitate the Lincolnshire Community Health Services NHS Trust s Responsible Officer recommendations to the GMC for revalidation. Appraisals performed on behalf of Lincolnshire Community Health Services NHS Trust will be in line with the Revalidation Support Team Medical Appraisal Guide system and meet quality assurance systems developed by NHS England. Appraisal Output documentation (summary of discussion, signoff statements and PDP) produced by appraisers will be quality assured to provide assurance to the Lincolnshire Community Health Services NHS Trust Responsible Officer of the quality of the appraisal. NHS England Central Midlands will flag any issues identified by the appraiser or Appraisal Output documentation to the Responsible Officer of Lincolnshire Community Health Services NHS Trust. 16 P a g e

17 Lincolnshire Community Health Services NHS Trust: Lincolnshire Community Health Services NHS Trust will fund any backfill required for to cover the absence of their doctors undertaking Appraiser training or duties. Identified Appraisers within LCCHS who provide reciprocal appraisals for NHS England will be fully trained to the nationally required standard based on the Revalidation Support Team and GMC training standards. Identified Appraisers within LCCHS will join the team of GP Appraisers for NHS England Central Midlands. Identified Appraisers within LCCHS will sign an NHS England Contract for the provision of services to NHS England Central Midlands in the delivery of Medical Appraiser services. In any Appraisal year the identified Appraisers within LCCHS will undertake a reciprocal number of doctors on the NHS England Central Midlands performers list without charge to NHS England Central Midlands. Should the Identified Appraisers within LCCHS request to do additional appraisals, they will be paid in accordance with the National Appraisal Policy and Contracting terms and conditions set out by NHS England. As this memorandum of understanding is with LCCHS and not individual doctors, LCCHS will provide NHS England with an annual invoice which details any additional appraisals completed. The payment will be paid directly to LCCHS. The invoice will be submitted in late January to ensure prompt payment. Identified Appraisers within LCCHS will take part in the required attendances at appraiser specific CPD events to ensure they remain fit for purpose and to meet their own appraisal and revalidation requirements Identified Appraisers within LCCHS will take part in the appraisal quality assurance process. Documentation for presenting evidence to the Appraisers of Lincolnshire Community Health Services NHS Trust doctors will be provided using the Medical Appraisal Guide Form (MAF) and copies of this, when signed off and completed, will be made available to the Lincolnshire Community Health Services NHS Trust Responsible Officer. Electronic tool kits do not allow duel access. Lincolnshire Community Health Services NHS Trust will provide contact details and Revalidation date information for those requiring an appraisal in a timely manner to ensure suitable alignment to appraiser. Appraisee s within Lincolnshire Community Health Services NHS Trust will be expected to follow the required preparation timelines for appraisal as detailed within the NHS England National Appraisal Policy in order to meet Revalidation standards. Review of the Memorandum 17 P a g e

18 The Memorandum of Understanding may be amended at any time by agreement between NHS England Central Midlands and Lincolnshire Community Health Services NHS Trust. In addition, this memorandum will be updated as necessary to take account of any changes in statutory responsibilities or framework. Signed:... (For NHS England Central Midlands Date:. Signed: Dr Philip Mitchell, Medical Director, For LCHS NHS Trust) Date: 4/6/15 18 P a g e