Revalidation in Obstetrics and Gynaecology

Revalidation in Obstetrics and Gynaecology Criteria, Standards and Evidence Guidance from the RCOG Professional Standards Committee July 2002

This guidance was produced on behalf of the Professional Standards Committee of the Royal College of Obstetricians and Gynaecologists by Professor Robert Shaw FRCOG, Chairman of the Professional Standards Committee and Mrs Charnjit Dhillon, Head of Clinical Governance and Standards. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the Publisher (Royal College of Obstetricians and Gynaecologists). Registered Charity No. 213280 Published by the RCOG Press Royal College of Obstetricians and Gynaecologists 2002 ISBN 1 900364 79 4 Further copies of this report can be obtained from: RCOG Bookshop 27 Sussex Place Regent s Park London NW1 4RG Tel: +44 (0) 20 7772 6275 Fax: +44 (0) 20 7724 5991 Email: bookshop@rcog.org.uk Website: www.rcog.org.uk Printed by Manor Press, Unit 1, Priors Way, Maidenhead, Berks. SL6 2EL

CONTENTS Page 1. Introduction 1 2. The route to revalidation 2 3. The GMC revalidation folder 2 4. The RCOG guidance 3 5. To whom does this guidance apply? 3 6. Definitions used in this guidance 4 7. Summation of documentation 5 Section 1: Your personal and registration details 5 Section 2: What you do 6 Section 3: Information about your practice: 7 3.1: Good professional practice 7 3.2: Maintaining good medical practice 11 3.3: Relationships with patients 12 3.4: Working with colleagues 16 3.5: Teaching and training 19 3.6: Probity 20 3.7: Health 23 Section 4: Appraisal 24 4.1: Management activity 24 4.2: Research 24 8. General declaration 26 References 27 Appendix 1: Suggested audit topics 29 Appendix 2: Patient satisfaction audit 31 Appendix 3: Third-party questionnaire 32

1. INTRODUCTION The General Medical Council (GMC) is developing proposals that will require all doctors to demonstrate their fitness to practise on a regular basis. This is to be termed Revalidation a licence to practise. Doctors will be required to collect information about their performance based on the GMC s Good Medical Practice. 1 This information will need to be submitted as evidence to support doctors applications for revalidation on a five-yearly basis. Revalidation, like registration, will be generic. It will be flexible enough to allow individuals to change their field of practice or to undertake new procedures or activities throughout the revalidation cycle. Doctors who take a break from their usual field of medical practice to undertake activities such as teaching and research, or have taken career breaks for other reasons, will be able to return to their usual practice at any time, provided they do so in a responsible and professional manner. Doctors will be expected to provide evidence for revalidation that demonstrates that they have done this and are able to reaffirm their competence to practise. Individuals should bear in mind the requirement to ensure that they work only within the limits of their professional competence, and that revalidation will require them to demonstrate that they are continually fit to practise in all areas they undertake. Revalidation in obstetrics and gynaecology Doctors who have only completed their training during the preceding five years would need to gather evidence as part of their training. 2. THE ROUTE TO REVALIDATION Obstetricians and gynaecologists wishing to be revalidated will undergo an annual appraisal to ensure that they are meeting their continuing professional needs and are on track for revalidation. They will then need to submit their appraisal documentation for the revalidation cycle to the GMC. Although appraisal and revalidation will have different objectives (the former formative and the latter summative) they will be based on the same underpinning evidence and appraisal forms. It is anticipated that a revalidation group of two doctors (of which one will be an obstetrician and gynaecologist) and a professional lay person will consider the doctor s information. If the revalidation group judges that the criteria and standards in this document have been met, they will recommend the individual s application to the GMC for revalidation. The system described in this document is a method for securing a revalidation group s recommendation for revalidation. Provided that these processes are conducted fairly and properly and the evidence is honest and accurate, the GMC will normally accept a group s recommendation as sufficient evidence for revalidation. In some cases where the initial evidence is not satisfactory, the revalidation group might decide to seek additional information. In such cases the GMC will consider what action to take. Such lack of recommendation should not be seen as a criticism of individual s reputation or standards as it only suggests that the information available to the revalidation group was 1

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS insufficient to support the individual s application. It is the individual s responsibility to satisfy the GMC of their fitness to practise. Doctors who choose not to revalidate because they do not want or need a licence to practise will still be able to maintain their names on the Medical Register if they so choose. However, they will not have the legal rights that have hitherto been associated with registered medical practitioners (including the right to prescribe). Doctors no longer in active practice have the choice of not taking part in revalidation, losing their licence to practise, but remaining on the Medical Register. But many doctors retiring from an NHS post will wish to maintain their licence to practise and undertake some forms of practice such as locum work. Arrangements such as appraisal for NHS locums mean that revalidation will certainly be achievable for many doctors who have retired from substantive NHS posts. Doctors taking a career break who do not want to participate in revalidation can remain on the medical register and can apply for a licence when they want to return to practice. It should be remembered that, as currently, an individual can be referred to the GMC at any time (and by any person) if there are serious concerns about fitness to practise. In the interests of patient safety, a referral should not be delayed until a revalidation group has first considered the matter. 3. THE GMC REVALIDATION FOLDER It is understood that the GMC will provide a revalidation folder for doctors to use to organise their information if they so wish. Their pilot folder contained the following sections: Section 1: Your personal and registration details Section 2: What you do Section 3: Information about your practice: Good professional practice Maintaining good medical practice Relationships with patients Working with colleagues Teaching and training Probity Health Section 4: Appraisal General Declaration 2 At present, the GMC revalidation folder requires evidence of good medical practice in the seven areas outlined above (Section 3) and this document addresses them all. Some sections are clearly more relevant to the theme of patient safety and bearing in mind that the main purpose of revalidation is to

ensure that patients are treated by competent doctors, we shall concentrate on the components of clinical governance that will provide essential core evidence for appraisal and revalidation, namely participation in the following: regular audit (Section 3.1) continuing professional development (Section 3.2) complaints monitoring (Section 3.3). Data collected in these areas are likely to be more robust and easier to quantify than other forms of evidence when it comes to practical assessment. Nevertheless, this guidance also covers criteria, standards and evidence for all the sections in the piloted GMC revalidation folder. 4. THE RCOG GUIDANCE The GMC will provide generic guidance on the systems for revalidation. In the meantime, the professional bodies, including the Royal Colleges, have been charged with producing supplementary specialty-specific standards and criteria against which their members can be assessed by the revalidation groups. Thus, the aim of this guidance is to contribute to the processes of appraisal and revalidation by describing what is expected of an obstetrician and gynaecologist. Revalidation in obstetrics and gynaecology The obstetric and gynaecology standards and criteria are developed based on the RCOG working party report Maintaining Good Medical Practice in Obstetrics and Gynaecology 2 and the discussion document Revalidation in Obstetrics and Gynaecology. 3 It also builds on the guidance issued to consultant obstetricians and gynaecologists on their compulsory NHSE annual appraisal 4 which in turn was developed taking cognisance of comments received from obstetricians and gynaecologists who participated in the pilot of the College s appraisal documentation in September 1999. 5 This guidance describes why each particular aspect of care is important for obstetricians and gynaecologists. The general descriptions are summarised under each heading, describing attributes of a good obstetrician and gynaecologist. Each obstetrician and gynaecologist would be expected to meet the criteria most of the time since revalidation aims to ensure that all obstetricians and gynaecologists are working to an acceptable minimum standard. Only those whose care falls consistently or frequently below the standards expected of a good obstetrician and gynaecologist will be at risk of not being revalidated. The RCOG expects trusts to take responsibility for circulating validated patient and professional teams surveys, as well as for the resultant data analysis. 5. TO WHOM DOES THIS GUIDANCE APPLY? It is hoped that obstetricians and gynaecologists will use this as a guide, as well as those with responsibility for appraising and assessing their performance and those considering how revalidation for obstetricians and gynaecologists might 3

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS be approached. It will also help consumers know what standards they can expect from obstetricians and gynaecologists. Every doctor who wishes to remain in practice will enter the revalidation cycle once revalidation is introduced. The above GMC process will apply to consultants, non-consultant career grades and academics. Additional guidance for the appraisal of academics with clinical contracts will be provided by universities, taking account of the report to the Secretary of State for Education and Skills. 6 The report recommends that universities and NHS bodies should work together to develop an agreed annual joint appraisal and performance review process based on that for NHS consultants. Locum doctors (working within and outwith the NHS) and doctors in the NHS Flexible Careers Scheme will also need to submit information for revalidation to demonstrate their fitness to practise medicine. The standards for clinical practice as set out in this document will apply to all those working within the specialty of obstetrics and gynaecology. It is anticipated that, for trainees, it will also be underpinned by their annual appraisal and summative/formative assessment processes, e.g. for specialist registrars (SpRs) the Record of In-training Assessment (RITA) process, and for pre-registration house officers (PRHOs) and senior house officers (SHOs) similar processes. These will be in addition to the evaluation of training progress and competencies as assessed for progression of training by the Specialist Training Committee. 6. DEFINITIONS USED IN THIS GUIDANCE Attributes of a good obstetrician and gynaecologist, based on the GMC s Good Medical Practice, are outlined in Section 3. These are not exhaustive, but give a general view of behaviour that should underline the expected level required for revalidation. Criteria have been drafted from these attributes. A criterion is a statement of a test that can be applied to an obstetrician and gynaecologist to determine whether they have the required attributes. For each criterion, there is a standard that defines the level of performance against which the performance of an obstetrician and gynaecologist can be assessed. For each criterion, the evidence that would be needed to demonstrate that the standard has been met is specified. Examples are given for each criterion, although these are not meant to be exhaustive. For the most part, the evidence acquired for annual appraisal can be summated for five-yearly revalidation. 4

7. SUMMATION OF DOCUMENTATION It is suggested that trainees in the specialty of obstetrics and gynaecology (SHOs and SpRs) collate their additional evidence for revalidation in their Personal Development Files (available from the College to registered trainees). This is in addition to that required for their annual RITA. Consultants, nonconsultant career grade doctors, academics and those wholly in private practice might collate their documentation in the folder entitled Appraisal/Revalidation (circulated to consultants in September 2001). The content of the folder is available for others on the College website http://www.rcog.org.uk/mainpage.asp?pageid=100. This guidance is meant to supplement that already issued by the College for NHS consultant appraisal and has been developed in the light of GMC refinements and agreement on the process of revalidation. It is likely to need further update with time as the process matures and lessons are learned in practice. Revalidation in obstetrics and gynaecology SECTION 1: Your personal and registration details This section of the appraisal and revalidation folder simply asks the individual for details of their GMC registration and any breaks in registration. It would be used by those looking at the revalidation folder to understand the registration context of the application. Personal details GMC registration details, including any breaks in registration A sample completed form is available on the College website: http://www.rcog.org.uk/mainpage.asp?pageid=228 5

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS SECTION 2: What you do This section of the folder requires a description of the nature of the doctor s work with emphasis on their practice in obstetrics and gynaecology. This will include: A short description of your work in your specialty and your actual practice. What different types of activity do you undertake? Subspecialist skills and commitments Emergency, on-call and out-of-hours responsibilities Outpatient work Any other clinical work To which hospitals and clinics do you have admitting rights and what is the nature of these rights? If your practice differs from your NHS practice at some or all of these locations, details should be provided Non-clinical work that you undertake Work for regional, national or international organisations Other professional activities CRITERION, STANDARD AND EVIDENCE Criterion: The obstetrician and gynaecologist will define what he or she does Standard: Evidence: The statement covers all areas of the obstetrician and gynaecologist s work, taking into consideration the context in which he or she practises. The content of this statement forms the basis of the evidence given in the subsequent sections of the folder. A job plan and a statement of the obstetrician and gynaecologist s activities. Doctors returning to clinical practice after a break may require a period of supervision before resumption of independent clinical practice, as outlined in the College guidance. 7 Evidence that this has been carried out reasonably and professionally will need to be included in the documentation submitted for revalidation. A sample completed form is available on the College website: http://www.rcog.org.uk/mainpage.asp?pageid=249 6

SECTION 3: Information about your practice This section applies to all obstetricians and gynaecologists undertaking clinical work. You can identify any data that you think demonstrate the quality of your practice. Those with major responsibility in the area of teaching, research or management will need to ensure that the information and evidence reflects their actual activities. Section 3.1: Good professional practice The following is a synopsis of aspects of care that relate to good clinical practice in obstetrics and gynaecology. ATTRIBUTES Clinical care A good obstetrician and gynaecologist: takes time to listen to patients and allows them to express their own concerns uses clear language appropriate to the patient has access to up-to-date equipment and is skilled in its use is aware of all relevant investigations and understands the results makes sound management decisions which are based on good practice guidelines and evidence maintains his or her knowledge and surgical skills and is aware of his or her limitations. Revalidation in obstetrics and gynaecology Record keeping A good obstetrician and gynaecologist: records appropriate information for all consultations and procedures ensures legibility uses only abbreviations where they are in common use accepts responsibility for the record by signing it communicates regularly and clearly with those making the referral respects the patient s right to confidentiality. Access and availability A good obstetrician and gynaecologist: aims to provide a polite, responsive and accessible service makes it clear how, where and when they can be contacted ensures that it is easy for GPs to arrange immediate and urgent referrals. Emergency and out-of-hours cover A good obstetrician and gynaecologist: has policies for the organisation and management of emergencies and ensures that all members of his or her team are aware of them is always easy to contact when on duty is always prepared to come into the hospital to support his or her team when on duty and at other times if requested by the consultant on call. 7

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS CRITERIA, STANDARDS AND EVIDENCE Clinical care Criterion: Regular review of clinical practice demonstrates the achievement of acceptable standards of care. Standard: Evidence: Good record keeping Criterion: Standard: Evidence: Access and availability Criterion: Makes him or herself available to patients and staff as needed. Standard: Review of clinical practice shows willingness to participate in audit organised/promoted by his or her department/trust or in reflective practice. Reports on clinical audit, case note review and significant event auditing in which the doctor has been involved. Keeps legible, accurate and confidential records. Records are legible and include appropriate information, with a demonstration of the importance of confidentiality. Summary of case-note review; copy of clinic confidentiality policy; copy of clinic record-keeping policy accompanied by self-declaration of adherence to policy. Provides appropriate patient care and has an easy contact pathway. Evidence: A contact pathway and feedback from multidisciplinary teams. Treatment in emergencies Criterion: Deals with emergencies effectively and knows how to use and supervise staff and use equipment. Standard: Evidence: Attends regular training updates and monitors performance; records and reflects on significant events. Training certification; significant event log with outcome data and reflection on implications for future action. 8

Providing care out of hours and absences Criterion: Procedure to ensure continuity of clinical care and/or service provision out of hours and during absences. ADDITIONAL EVIDENCE OF RELEVANCE Standard: Evidence: Ensures compliance with the departmental/trust policy and adequate notification of planned and emergency absences. A statement to the above from line manager; reflective statement of own practice. logbook, if available one or two typical operating lists (length of stay, complications or unintentional returns to theatre, blood transfusion, etc.) number of audit meetings attended and projects supervised up-to-date audit data including information on audit methodology (if available) record of how results of audit have resulted in changes to practice record of how relevant clinical guidelines are reviewed by yourself and your team and how these have affected practice results of clinical outcomes as compared to the RCOG, FFPRHC or recommendations of specialist societies any resource shortfalls which may have compromised outcomes how any in-service educational activity may have affected service delivery a description of any issues arising in relation to adherence to employer clinical governance policies any other routine indicators of the standards of your care that you yourself use any relevant events that have gone particularly well for you as well as adverse events records of outcome of any investigated formal complaints in which the investigation has been completed in the past twelve months or since your last appraisal a description of how the outcome of any complaints has resulted in changes to practice outcome of external reviews (peer and otherwise). Revalidation in obstetrics and gynaecology Suggested minimum audit topics are given in Appendix 1. 9

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS GMC Good Medical Practice, paragraphs 1 9 1. All patients are entitled to good standards of practice and care from their doctors. Essential elements of this are professional competence; good relationships with patients and colleagues; and observance of professional ethical obligations. 2. Good clinical care must include: an adequate assessment of the patient s conditions, based on the history and symptoms and, if necessary, an appropriate examination providing or arranging investigations or treatment where necessary taking suitable and prompt action when necessary referring the patient to another practitioner, when indicated. 3. In providing care the doctor must: recognise and work within the limits of your professional competence be willing to consult colleagues be competent when making diagnoses and when giving or arranging treatment keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed keep colleagues well informed when sharing the care of patients provide the necessary care to alleviate pain and distress whether or not curative treatment is possible prescribe drugs or treatment, including repeat prescriptions, only where you have adequate knowledge of the patient s health and medical needs. You must not give or recommend to patients any investigation or treatment which you know is not in their best interests, nor withhold appropriate treatments or referral report adverse drug reactions as required under the relevant reporting scheme, and cooperate with requests for information from organisations monitoring the public health make efficient use of the resources available to you. 4. If you have good reason to think that your ability to treat patients safely is seriously compromised by inadequate premises, equipment, or other resources, you should put the matter right, if that is possible. In all other cases you should draw the matter to the attention of your trust, or other employing or contracting body. You should record your concerns and the steps you have taken to try to resolve them. Decisions about access to medical care 5. The investigations or treatment you provide or arrange must be based on your clinical judgement of patients needs and the likely effectiveness of the treatment. You must not allow your views about patients lifestyle, culture, beliefs, race, colour, gender, sexuality, disability, age, or social or economic status, to prejudice the treatment you provide or arrange. You must not refuse or delay treatment because you believe that patients actions have contributed to their condition. 6. If you feel that your beliefs might affect the advice or treatment you provide, you must explain this to patients, and tell them of their right to see another doctor. 7. You must try to give priority to the investigation and treatment of patients on the basis of clinical need. 8. You must not refuse to treat a patient because you may be putting yourself at risk. If patients pose a risk to your health or safety you should take reasonable steps to protect yourself before investigating their condition or providing treatment. Treatment in emergencies 9. In an emergency, wherever it may arise, you must offer anyone at risk the assistance you could reasonably be expected to provide. 10

Section 3.2: Maintaining good medical practice The purpose of this section is to record continuing professional development (CPD) and continuing medical education (CME) activities. If there have been problems in attending these activities, they should be identified. The College makes it mandatory for all those involved primarily in obstetrics and gynaecology or its specialties to participate in the RCOG CME programme, unless other arrangements have been made with other regulatory bodies. While this programme should assist individuals to maintain and improve their practice standards, the analysis of development needs and the ways in which their needs can be met must be addressed by the trusts. The development needs of the consultant, for example, as a manager, leader, team member, budget holder and employee can be met in a number of ways locally or through NHS resources, as well as through the College s programme. ATTRIBUTES A good obstetrician and gynaecologist: maintains his or her knowledge and skills keeps up-to-date with developments in clinical practice is aware of his or her limits of experience has a personal development plan (PDP). Revalidation in obstetrics and gynaecology CRITERION, STANDARD AND EVIDENCE Criterion: Standard: Evidence: An awareness of learning needs, activities to meet those needs and changes in clinical practice as a result. Has registered and participated in the RCOG CME/CPD programme and undergone satisfactory annual appraisal. RCOG CME/CPD diary. Personal development plan*. *A personal development plan will form part of the appraisal process outlined in Section 4. The two fundamental components of the PDP are the requirements of an individual s job plan and the aspirations for professional career development. ADDITIONAL EVIDENCE OF RELEVANCE RCOG roll of those completing the CPD cycle (including your name) The Obstetrician and Gynaecologist CME answer sheets with scores reflection on valuable CME/CPD activities undertaken documentation related to attendance at meetings/workshops (e.g. copies of programmes), supervised learning, distance learning. 11

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS GMC Good Medical Practice, paragraphs 10 12 10. You must keep your knowledge and skills up to date throughout your working life. In particular, you should take part regularly in educational activities which maintain and further develop your competence and performance. 11. Some parts of medical practice are governed by law or are regulated by other statutory bodies. You must observe and keep up to date with the laws and statutory codes of practice which affect your work. 12. You must work with colleagues to monitor and maintain the quality of the care you provide and maintain a high awareness of patient safety. In particular, you must: take part in regular and systematic medical and clinical audit, recording data honestly. Where necessary you must respond to the results of audit to improve your practice, for example by undertaking further training respond constructively to the outcome of reviews, assessments or appraisals of your performance take part in confidential enquiries and adverse event recognition and reporting to help reduce risk to patients. Section 3.3: Relationships with patients This section is intended to demonstrate that you interact appropriately with patients and have good communication skills. You are required to give details of any substantiated complaints about you that have been made by members of the public. Trusts should be organising patient surveys in all specialties. Many initiatives are underway to develop tools to capture patient involvement and satisfaction, including work by the GMC, the Commission for Health Improvement and the Clinical Governance Support Team. In the meantime, the RCOG patient satisfaction audit template may be used (Appendix 2). The RCOG expects trusts to take responsibility for circulating validated patient questionnaires, as well as for the resultant data analysis. ATTRIBUTES Clinical care A good obstetrician and gynaecologist: respects the patient s right for confidentiality ensures good communication with patients whether face to face, by letter or by telephone treats patients politely and with consideration gives patients the information that they require about their problem involves patients in decisions about their care obtains informed consent to treatment treats all patients equally. 12 If things go wrong A good obstetrician and gynaecologist: contacts the patient immediately if a mistake has occurred fully informs the patient of any significant complication of surgery tells the patient what has happened and whether or how it can be put right

informs the patient s relatives (if appropriate) cooperates with any investigation arising from a complaint tries to maintain a professional relationship with the patient or family after the mistake has occurred. CRITERIA, STANDARDS AND EVIDENCE Clinical care Criterion: A demonstration by the obstetrician and gynaecologist of assessment of his or her communication skills and reflection on the results. Standard: Evidence: The assessment of communication skills demonstrates a standard considered acceptable by patients. Patient information, consent procedures and patient survey feedback. If things go wrong Criterion: An effective complaints procedure is in place and is being used. Revalidation in obstetrics and gynaecology Standard: Evidence: Ensures compliance with the formal trust/hospital complaints procedure. A summary of complaints received and any subsequent changes in practice. ADDITIONAL EVIDENCE OF RELEVANCE examples of good practice or concern in your relations with patients a description of your approach to handling informed consent a validated patient survey, if it exists departmental questionnaire on obtaining patient feedback from antenatal/gynaecology clinics access to and use of patient information sheets compliments. GMC Good Medical Practice, paragraphs 17 33 Obtaining consent 17. You must respect the right of patients to be fully involved in decisions about their care. Wherever possible, you must be satisfied, before you provide treatment or investigate a patient s condition, that the patient has understood what is proposed and why, any significant risks or side effects associated with it, and has given consent. You must follow the guidance in Seeking Patients Consent: The Ethical Consideration. 8 Respecting confidentiality 18. You must treat information about patients as confidential. If in exceptional circumstances there are good reasons why you should pass on information without a patient s consent, or against a patient s wishes, you must follow our guidance on 13

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS Confidentiality: Protecting and Providing Information 9 and be prepared to justify your decision to the patient, if appropriate, and to the GMC and the courts, if called on to do so. Maintaining trust 19. Successful relationships between doctors and patients depend on trust. To establish and maintain that trust you must: be polite, considerate and truthful respect patients privacy and dignity respect the right of patients to decline to take part in teaching or research and ensure that their refusal does not adversely affect your relationship with them respect the right of patients to a second opinion be readily accessible to patients and colleagues when you are on duty. 20. You must not allow your personal relationships to undermine the trust which patients place in you. In particular, you must not use your professional position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to them. Good communication 21. Good communication between patients and doctors is essential to effective care and relationships of trust. Good communication involves: listening to patients and respecting their views and beliefs giving patients the information they ask for or need about their condition, its treatment and prognosis, in a way they can understand, including, for any drug you prescribe, information about any serious side effects and, where appropriate, dosage sharing information with patients partners, close relatives or carers, if they ask you to do so by, having first obtained the patient s consent. When patients cannot give consent, you should share the information which those close to the patient need or want to know, except where you have reason to believe that the patient would object if able to do so. 22. If a patient under your care has suffered harm, through misadventure or for any other reason, you should act immediately to put matters right, if that is possible. You must explain fully and promptly to the patient what has happened and the likely long- and short-term effects. When appropriate you should offer an apology. If the patient is an adult who lacks capacity, the explanation should be given to a person with responsibility for the patient, or the patient s partner, close relative or a friend who has been involved in the care of the patient, unless you have reason to believe the patient would have objected to the disclosure. In the case of children the situation should be explained honestly to those with parental responsibility and to the child, if the child has the maturity to understand the issues. 23. If a child under your care has died you must explain, to the best of your knowledge, the reasons for, and the circumstances of, the death to those with parental responsibility. Similarly, if an adult patient has died, you should provide this information to the patient s partner, close relative or a friend who has been involved in the care of the patient, unless you have reason to believe that the patient would have objected. Ending professional relationships with patients 14 24. Rarely, there may be circumstances, for example where a patient has been violent to you or a colleague, has stolen from the premises, or has persistently acted inconsiderately or unreasonably, in which the trust between you and the patient has been broken and you find it necessary to end a professional relationship with a patient. In such circumstances, you must be satisfied your decision is fair and does not contravene the guidance in paragraph 5; you must be prepared to justify your decision if called on to do so. You should not end relationships with patients solely because they have made a complaint about you or your team, or because of the financial impact of their care or treatment on your practice.

25. You should inform the patient, orally or in writing, why you have decided to end the professional relationship. You must also take steps to ensure that arrangements are made quickly for the continuing care of the patient, and hand over records to the patient s new doctors as soon as possible. Dealing with problems in professional practice: conduct or performance of colleagues 26. You must protect patients from risk of harm posed by another doctor s, or other health care professional s, conduct, performance or health, including problems arising from alcohol or other substance abuse. The safety of patients must come first at all times. Where there are serious concerns about a colleague s performance, health or conduct, it is essential that steps are taken without delay to investigate the concerns to establish whether they are well founded, and to protect patients. 27. If you have grounds to believe that a doctor or other healthcare professional may be putting patients at risk, you must give an honest explanation of your concerns to an appropriate person from the employing authority, such as the medical director, nursing director or chief executive, or the director of public health, or an officer of your local medical committee, following any procedures set by the employer. If there are no appropriate local systems, or local systems cannot resolve the problem, and you remain concerned about the safety of patients, you should inform the relevant regulatory body. If you are not sure what to do, discuss your concerns with an impartial colleague or contact your defence body, a professional organisation or the GMC for advice. 28. If you have management responsibilities you should ensure that mechanisms are in place through which colleagues can raise concerns about risks to patients. Further guidance is provided in Management in Health Care: The Role of Doctors. 10 Revalidation in obstetrics and gynaecology Complaints and formal inquiries 29. Patients who complain about the care or treatment they have received have a right to expect a prompt, open, constructive and honest response. This will include an explanation of what has happened, and where appropriate, an apology. You must not allow a patient s complaint to prejudice the care or treatment you provide or arrange for that patient. 30. You must cooperate fully with any formal inquiry into the treatment of a patient and with any complaints procedure which applies to your work. You must give, to those who are entitled to ask for it, any relevant information in connection with an investigation into your own, or another health care professional s, conduct, performance or health. 31. If you are suspended from a post, or have restrictions put on your practice because of concerns about your performance or conduct, you must inform any other organisations for whom you undertake work of a similar nature. You must also inform any patients you see independently of such organisations, if the treatment you provide is within the area of concern to which the suspension or restriction relates. 32. Similarly, you must assist the coroner or procurator fiscal, by responding to inquiries, and by offering all relevant information to an inquest or inquiry into a patient s death. Only where your evidence may lead to criminal proceedings being taken against you are you entitled to remain silent. Indemnity insurance 33. In your own interests, and those of your patients, you must obtain adequate insurance or professional indemnity cover for any part of your practice not covered by an employer s indemnity scheme. 15

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS Section 3.4: Working with colleagues This section applies to all those who work with you, e.g. obstetricians and gynaecologists, midwives, trainees, anaesthetists, nurses, radiologists, clinic staff, administrative staff, etc. This list is not intended to be exhaustive. Trusts should be organising professional teams surveys in all specialties. Many initiatives are underway, in particular the GMC s professionals survey. In the meantime, the RCOG third-party questionnaire template may be used (Appendix 3). The RCOG expects trusts to take responsibility for circulating validated professional teams questionnaires, as well as for the resultant data analysis. ATTRIBUTES Working in teams A good obstetrician and gynaecologist: understands team dynamics has effective systems for communication within the team delegates appropriately to other team members is flexible to accommodate the needs of other team members participates in regular meetings with members of the team encourages all members of the team to play their full role and support their development attempts to ensure that deficiencies in the team are addressed. Colleagues performance A good obstetrician and gynaecologist: puts the safety of patient first at all times is aware when a colleague s performance, conduct or health may be putting patients at risk ascertains the facts of the case, takes advice from colleagues, and if appropriate, refers the colleague for medical advice or local remedial action if appropriate, provides positive support to colleagues who have made mistakes or whose performance gives cause for concern. CRITERION, STANDARD AND EVIDENCE Criterion: A demonstration by the obstetrician and gynaecologist of his or her willingness to work as part of a team and having a professional working relationship with colleagues for the benefit of patients. Standard: Evidence: Feedback from peer reviews demonstrates appropriate working relationships with colleagues. Peer review feedback from staff as part of a questionnaire. 16

ADDITIONAL EVIDENCE OF RELEVANCE an organisational structure of a team/clinical services a summary of a third-party questionnaire annual return statistics: number of consultants/non-consultant career grades/sprs/shos data collected each year by college tutor. GMC Good Medical Practice, paragraphs 34 47 34. You must always treat your colleagues fairly. In accordance with the law, you must not discriminate against colleagues, including those applying for posts, on grounds of their sex, race or disability. And you must not allow your views of colleagues lifestyle, culture, beliefs, colour, gender, sexuality, or age to prejudice your professional relationship with them. 35. You must not undermine patients trust in the care or treatment they receive, or in the judgment of those treating them, by making malicious or unfounded criticisms of colleagues. 36. Healthcare is increasingly provided by multidisciplinary teams. Working in a team does not change your personal accountability for your professional conduct and the care you provide. When working in a team, you must: respect the skills and contributions of your colleagues maintain professional relationships with patients communicate effectively with colleagues within and outside the team make sure that your patients and colleagues understand your professional status and specialty, your role and responsibilities in the team and who is responsible for each aspect of patients care participate in regular reviews and audit of the standards and performance of the team, taking steps to remedy any deficiencies be willing to deal openly and supportively with problems in the performance, conduct or health of team members Revalidation in obstetrics and gynaecology 37. If you lead a team, you must ensure that: medical team members meet the standards of conduct and care set in this guidance any problems that might prevent colleagues from other professions following guidance from their own regulatory bodies are brought to your attention and addressed all team members understand their personal and collective responsibility for the safety of patients, and for openly and honestly recording and discussing problems each patient s care is properly coordinated and managed and that patients know who to contact if they have questions or concerns arrangements are in place to provide cover at all times regular reviews and audit of the standards and performance of the team are undertaken and any deficiencies are addressed systems are in place for dealing supportively with problems in the performance, conduct or health of team members. 38. Further advice on working in teams is provided in Maintaining Good Medical Practice 11 and Management in Health Care: The Role of Doctors. 10 Arranging cover 39. You must be satisfied that, when you are off duty, suitable arrangements are made for your patients medical care. These arrangements should include effective hand-over procedures and clear communication between doctors. 40. If you arrange cover for your own practice, you must satisfy yourself that doctors who stand in for you have the qualifications, experience, knowledge and skills to perform the duties for which they will be responsible. Deputising doctors and locums are 17

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS directly accountable to the GMC for the care of patients while on duty. Taking up appointments 41. You must take up any post, including a locum post, you have formally accepted unless the employer has adequate time to make other arrangements. Sharing information with colleagues 42. It is in patients best interests for one doctor, usually a general practitioner, to be fully informed about, and responsible for maintaining continuity of, a patient s medical care. 43. You should ensure that patients are informed about how information is shared within teams and between those who will be providing their care. If a patient objects to such disclosures you should explain the benefits to their own care of information being shared, but you must not disclose information if a patient maintains such objections. For further advice see our guidance Confidentiality: Protecting and Providing Information. 9 44. When you refer a patient, you should provide all relevant information about the patient s history and current condition. 45. If you provide treatment or advice for a patient, but are not the patient s general practitioner, you should tell the general practitioner the results of the investigations, the treatment provided and any other information necessary for the continuing care of the patient, unless the patient objects. If the patient has not been referred to you by a general practitioner, you should inform the general practitioner before starting treatment, except in emergencies or when it is impracticable to do so. If you do not tell the patient s general practitioner, before or after providing treatment, you will be responsible for providing or arranging all necessary after care until another doctor agrees to take over. Delegation and referral 46. Delegation involves asking a nurse, doctor, medical student or other health care worker to provide treatment or care on your behalf. When you delegate care or treatment you must be sure that the person to whom you delegate is competent to carry out the procedure or provide the therapy involved. You must always pass on enough information about the patient and the treatment needed. You will still be responsible for the overall management of the patient. 47. Referral involves transferring some or all of the responsibility for the patient s care, usually temporarily and for a particular purpose, such as additional investigation, care or treatment, which falls outside your competence. Usually you will refer patients to another registered medical practitioner. If this is not the case, you must be satisfied that any health care professional to whom you refer a patient is accountable to a statutory regulatory body, and that a registered medical practitioner, usually a general practitioner, retains overall responsibility for the management of the patient. 18

Section 3.5: Teaching and training This section deals with the above activities, which may form part of an obstetrician and gynaecologist s work to a greater or lesser degree. Any difficulties arranging cover whilst undertaking teaching and training should be recorded. ATTRIBUTES A good obstetrician and gynaecologist: ensures that the patient s dignity is respected during teaching or training has a personal commitment to teaching and learning and shows a willingness to develop further through education, audit and peer review ensures that patients are not put at risk by not allowing the learner to practise beyond the limits of his or her competence acts when the performance of a learner is inadequate. CRITERION, STANDARD AND EVIDENCE Criterion: Competency in teaching and training. Standard: Regularly reviews and updates teaching and training skills. Revalidation in obstetrics and gynaecology Evidence: Written summary of formal teaching/training activities, feedback from trainees, evaluation from educational meetings/courses, participation in appropriate training courses such as training the trainer. ADDITIONAL EVIDENCE OF RELEVANCE feedback on supervision undergraduates, students, postgraduates, MD/PhD feedback on mentoring students, trainees, consultants. GMC Good Medical Practice, paragraphs 13 16 13. You must be honest and objective when appraising or assessing the performance of any doctor including those you have supervised or trained. Patients may be put at risk if you describe as competent someone who has not reached or maintained a satisfactory standard of practice. 14. You must provide only honest and justifiable comments when giving references for, or writing reports about, colleagues. When providing references you must include all relevant information which has any bearing on your colleague s competence, performance, and conduct. 15. You should be willing to contribute to the education of students or colleagues. 16. If you have responsibilities for teaching you must develop the skills, attitudes and practices of a competent teacher. You must also make sure that students and junior colleagues are properly supervised. 19

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS Section 3.6: Probity In this section you may be required to sign a declaration of past findings related to any convictions, findings against you or disciplinary action and also that you accept the professional obligations placed upon you as a doctor. ATTRIBUTES Professional practice A good obstetrician and gynaecologist: is honest and open regarding financial or commercial dealings and when providing professional documentation ensures that research is carried out to a high standard protects patients rights preserves patients confidentiality. Providing references A good obstetrician and gynaecologist: takes care with references and bears in mind his or her responsibility to a doctor s future patients is honest and objective in comments made in references and does not miss out important information. CRITERIA, STANDARDS AND EVIDENCE Professional practice Criterion: Self confirmation that the doctor is honest in financial and commercial matters relating to his or her work. Standard: Evidence: The attributes of an acceptable obstetrician and gynaecologist apply. A statement signed by a doctor that he or she adopts professional standards that are, and are seen, to be honest in all financial matters relating to work. References Criterion: Standard: Evidence: References for colleagues are honest, justifiable and complete. Provides honest, objective and factual references. A statement signed by a doctor that he or she is fully responsible for providing references that are honest, objective and factual. 20