1. Introduction Medical Revalidation was introduced in the UK in December 2012 and has been effected in the Trust since March 2013 (cycle 1). The Medical Director is the Responsible Officer and issues recommendations on revalidation for all doctors with designated connections to the Trust. This recommendation can be positive, deferred or non-engagement. Nationally, in the first year of implementation, nearly 21,000 doctors in England were revalidated, including 409 responsible officers. In the words of Niall Dickson, the GMC's Chief Executive and Registrar: These are very early days but we are pleased with the progress made in the first year. This new system of checks is a world first and over time we believe it will make a significant contribution towards making sure patients in the UK receive safe, effective care. The past 12 months have been dedicated to setting up robust systems to support enhanced appraisal incorporating 360 degree (or multi-source- MSF) feedback and supporting information linked to the General Medical Council s domains for Good Medical Practice, as well as to embedding the concept of revalidation amongst clinicians. Enhanced appraisal furnishes an opportunity for the Trust to raise the bar in terms of expectations and development of its medical staff. The domains of Good Medical Practice (2013) include: Domain 1: Knowledge, skills and performance Domain 2: Safety and quality Domain 3: Communication, partnership and teamwork Domain 4: Maintaining trust This Paper summarises the progress the Trust has made as well as setting out the next steps which are required to ensure that processes within the Trust are robust and nationally compliant. Medical Director s Office January 2014 Page 1
2. Context 2.1 Current Revalidation Activity Revalidation activity summary for CUH demonstrates: 59 Decisions issued from amidst 307 doctors with prescribed connection. This equates to 19.2 % of doctors (12.7% recommended). In March 2013, this team informed the Board: by March 2014 it is expected that roughly 1/5 of Consultants will have been put forward for Revalidation. This means that approximately 50 doctors will need to have had an enhanced, revalidation-ready appraisal before March 2014. It is expected that all doctors will have been put forward for revalidation by March 2016. We remain on trajectory for revalidation. Thirty nine positive recommendations have been made. Twenty deferrals involving fifteen doctors have been issued. Three doctors were deferred twice, one three times. Reasons for deferral: Incomplete documentation: n=12 three times Local investigation: n=5 including 1 doctor deferred twice and 1 doctor deferred External revalidation process: n=1 Maternity leave: n=1 Recent addition to trust insufficient time for valid appraisal: n=1 Current interrogation of e-rms January 2014 46.4% Online Appraisal Engagement. 1.1 Tracking appraisal compliance Appraisal at CHS was historically performed using a paper-based system. An electronic appraisal and revalidation management system (e-rms) has now been procured and launched as of August 2013, providing automatic, central, dynamic, electronic tracking of appraisal. Between March and August an interim solution based on an interactive pdf model appraisal form (MAG) with electronic capture of MSF was used to transition appraisal. Paper forms were suspended and a temporary amnesty granted to facilitate the introduction of the electronic system, alignment of appraisal dates with revalidation dates and reassignment of all appraisers. The previous system relied on manual updates of an excel Medical Director s Office January 2014 Page 2
spread-sheet to track appraisal compliance. The e-rms allows real time compliance audit. Archived appraisals will need to be uploaded to provide a seamless account of current and historic appraisal status across the trust. 1.2 Auditing complete and missed appraisals The e-rms will be interrogated quarterly to inform reports to the board. Linkage to finance will continue and provide a second check point for auditing missed appraisals. Internal quality assurance by the Medical director s Office continues to address incomplete/inadequate appraisals. Group email reminders can be sent through the e-rms to non-compliant medics. 1.3 Escalation process for non-engagement Non-engagement in appraisal is a recognized challenge both nationally and locally. There was no systematic system previously in place to address non-engagement which was identified on a case by case basis. Since March 2013, an augmented process seeks to reduce non-engagement by: 1. Averting non-engagement: Appointment of Associate Medical Director (AMD) and dedicated team with HR input provides focused responsibility, high visibility of appraisal agenda, clear signposting, education and support. Appraisal policy re-written April 2013 to root out poor practice and render explicit expectations and processes. Appraisal policy states Where the practitioner fails to achieve satisfactory progress in appraisal and/or there are concerns raised over practice, Croydon Health Services NHS Trust should facilitate the Responsible Officer to deal with this in line with Handling Concerns about Doctors Performance Policy and/or Remediation for Medical and Dental Staff, and should readily seek external expert advice from their GMC Employer Liaison Adviser or National Clinical Advisory Service (NCAS). Strict adherence to financial consequences Targeted education and engagement of SAS doctors dedicated event. Medical Director s Office January 2014 Page 3
Education, support and visibility by regular small group workshops, dedicated training, robust on line support mechanisms (static &interactive help system, video training) high uptake 2. Better recognizing, quantifying and pre-empting non-engagement: Introduction of the e-rms providing real time update on appraisal compliance, issuing appraisal reminders and identifying non-engagers. 3. Communicating awareness and consequences of non-engagement: Written correspondence to doctors for non-engagement, deferral and positive recommendations introduced for revalidation to be utilized for all appraisals. 1.4 Key Achievements Key achievements over the first three quarters of 2013/14 include: Policies New appraisal policy written, agreed and ratified with key stakeholder input including appraisers, LNC. Remediation policy written, agreed and ratified with key stakeholder input including appraisers, LNC Local revalidation team Set up with members including RO, AMD, Business Manager to the MD, Revalidation Support Officer (0.5 WTE) Set up of dedicated email contact revalidationsupport@croydonhealth.nhs.uk with significant volume of activity channelled through this. regular meetings to maintain momentum and progress revalidation within the Trust. Support for scanning and upload of MSF Communication Setting up regular workshops providing small group and 1:1 support for revalidation. Sessions are well attended, received and hosted by Medical HR business partner and/or AMD. Medical Director s Office January 2014 Page 4
Production and dissemination of clear local guidance including FAQs and SOPS to support revalidation Setting up intranet page signposting local and national guidance on revalidation and appraisal Regular updates on revalidation at Consultants meetings Recommendation decisions communicated via written correspondence with clearly articulated justifications. Copies to HR file. Fitness to practice affidavit document produced and solicited from external sites of practice. In this way the comprehensive scope of practice is reviewed. Appraisal meeting group (AMG) Set up monthly appraisal meeting group providing an active forum for cross pollination of experience and sharing of learning both from successful and less successful appraisals. Represents a form of group mentorship and intrinsic quality assurance. This group has been a key success, well attended and received with active, relevant discussions and a commitment to robust process. IT presence and support has been particularly helpful in navigating local IT issues and informing choice of definitive e-rms. This group reports to the Medical Productivity Steering Group. Systems Procurement of the Allocate MSF software to supplement MAG forms as interim solution for revalidation appraisals March 2013-August 2013 Clear articulation of specifications for electronic revalidation management system (e-rms) Funding, procurement, acquisition and go live of e-rms system from SARD with successful launch 19 th August 2013 Training Further expansion of trained appraisers current total of 42 appraisers. Increase skill base with respect to feedback Mentoring/Coaching training negotiated for appraisers through reputable external firm. Also constructive conversations training to better support them in analysing and providing feedback. Training delivered by Healthcare performance. Medical Director s Office January 2014 Page 5
Wider trust subscription to programme of mentorship and coaching. External partners Memorandum of Understanding set up with St. Christopher s Hospice for RO function this involves CUH providing infrastructure for revalidation to the hospice with nominal payment and appraisal provision by the Medical Director of St. Christopher s for equal number of our doctors. Quality Assurance Engagement of MIAD (leaders for appraiser training) for external quality assurance of revalidation process Initial review 27 th September 2013. Positive review with excellent elements identified. Onward focus on depth of reflection, enhanced appraisal summary and Personal development plans. Follow up review planned post implementation of the SARD e-rms. Review included the findings of a feedback exercise as below: Twenty-five randomly selected appraisees were asked to complete a feedback exercise on all aspects of the appraisal process. This included the appraisal meeting, their appraiser and the organisation s support of the appraisal process. The questions were asked via an on-line system; Survey Monkey and the results were anonymised. Most appraisal discussions (52%) lasted between 1 and 2 hours with an overwhelming majority (87%) satisfied that there was sufficient protected time for the discussion. Medical Director s Office January 2014 Page 6
Category Organisational: Appraisers: Personal & Organisational Impact of Appraisal: Findings Most of the appraisees (92%) felt that, generally, the appraisal process was satisfactory and there was easy access to the forms and materials they needed to complete the process (96%). 96% of appraisees were able to collect the necessary supporting information from the organisation, with the administrative support meeting the needs of 84% of the appraisees. 92% of the appraisees felt that their appraisers were satisfactory or above when it came to establishing rapport with the remaining 8% as borderline. 8% of appraisees felt there appraiser had not prepared sufficiently for the appraisal meeting. 92% felt their appraiser was able to listen to the appraisee during the meeting and gave them adequate time to talk. 8% felt their appraiser did not give constructive or helpful feedback, although the majority felt supported at their appraisal (92%). The majority of appraisees (92%) felt positively challenged by their appraiser, with the same number reporting that their appraiser had reviewed their practice. The majority (92%) of appraisees felt that their appraiser had helped them identify gaps in their portfolio and had also helped them to review progress against their previous personal development plan (PDP).92% of appraisees felt their appraiser had helped them to produce a robust PDP, with the majority (92%) happy to have a further appraisal with the same appraiser. 88% of appraisees felt that appraisal had aided their personal development, with 92% reporting it had helped their professional development. The majority (84%) felt that appraisal had helped promote quality improvements at their place of work, with 80% feeling it had improved patient care. Medical Director s Office January 2014 Page 7
SAS engagement: Staff Grade, Specialty and Associate Specialist (SAS) doctors have been identified as a lost tribe for appraisal and revalidation and require concerted efforts for engagement. To this aim, CUH successfully bid for 10,000 from NHS England as part of revalidation resources. The bid was awarded to support SAS engagement and quality assurance of appraisal both internally (IQA) and externally (EQA). Dedicated SAS event successfully delivered 25 th September 2013. GMC, BMA, MIAD and SARD contributors. Commitment to and achievement of inclusion of SAS doctors as appraisers and members of the AMG. 1.5 Progress against suggested objectives EQA report progress. MIAD process commissioned in two sections initial pre RMS delivered - realised. SAS engagement progress. Recognition of need for specific SAS engagement realised Inclusion of SAS on appraisers meeting group and as appraisers realised Dedicated SAS event hosted at CUH with contributions from BMA, GMC, MIAD, SARD realised Peer review of anonymised PDPS Not achieved. o Initial suggestions to provide peer review of anonymised PDPs proved operationally challenging without breach of confidentiality as the PDPs were such that they could not be culled sufficiently to anonymise them without compromising the substance of the PDP. Medical Director s Office January 2014 Page 8
2.8 National Reporting The Organisational Readiness Self -Assessment (ORSA) reports were utilised to evaluate performance/preparation of Trusts. No issues were identified in the 2013 report for CUH. 2. Next Steps The next focus of the Revalidation Support Team will include: Continued appraiser recruitment and refinement - Time commitments for robust appraisals are considerable restrict number to 7 per appraiser. Continue to increase appraiser recruitment and training to allow for staff flux and ensure 100% appraiser allocation. Investment in the design, rigour and integrity of multi-source feedback questionnaires which are both fit for purpose and GMC compliant. Current systems though basic allow for comparability within and across trusts. Aim to investigate supplementation with leadership and educational supervisor elements. Need to gather, collated and disseminate feedback to appraisers currently generic not specific feedback. Future plans to provide bespoke feedback to individual appraisers. Although audit of incomplete appraisals conforms, need to formalise and report regularly on this system. Private and other practices interrogated via fitness to practice affidavit. Current system is manual and laborious. Plan to integrate and automate such interrogation into routine appraisal process. Established linkages with Trust governance systems. Set up of decision making group to inform remediation decisions. Medical Director s Office January 2014 Page 9
3. Key challenges/risks Recruiting and retaining adequate staffing in the Medical Director s office to support significant administrative burden of revalidation including archiving of previous appraisal documentation. two band 5 posts currently being configured Building and enhancing internal quality assurance systems for revalidation including if possible cross fertilisation with neighbouring trusts around policy. Reduce unnecessary deferrals. Likely to be used as a performance indicator moving forward. This will involve greater prospective planning supported by increased administrative staff. Provide administrative support for patient feedback including electronic capture. This would fully divorce doctors from the process of feedback and would better ensure random sampling two tablets under procurement Linkage with governance systems for automatic extraction of quality data to better inform Quality and Safety domain of GMP liaison with raising the bar group and chief information officer. Defining and ring-fencing where possible funding for remediation. Develop high level reflection as standard in appraisals to better utilise this as a formative tool reflective templates identified, customised and to be included in e- RMS. Guidance on intranet 4. Actions from the Board The Board is asked to note the progress already made, the plans in place for implementation and the challenges to be faced. Specifically, the Board is asked to support in principle the administrative assistance required to support it. Medical Director s Office January 2014 Page 10
REPORT TO TRUST BOARD Date: 5 February 2014 Agenda No: 8.6 Title of Document: Report Author: Lead Director: Revalidation Report Progress to-date. Associate Medical Director for Revalidation and Medical Productivity Steve Ebbs, Medical Director Summary: Medical Revalidation was introduced in the UK in December 2012 and has been effected in the Trust since March 2013 (cycle 1). The Medical Director is the Responsible Officer and issues recommendations on Revalidation for all doctors with designated connections to the Trust. This recommendation can be positive, deferred or non-engagement. The past 12 months have been dedicated to setting up robust systems to support enhanced appraisal incorporating 360 degree (or multi-source- MSF) feedback and supporting information linked to the General Medical Council s Domains for Good Medical Practice, as well as to embedding the concept of Revalidation amongst clinicians. Enhanced appraisal furnishes an opportunity for the Trust to raise the bar in terms of expectations and development of its medical staff. In March 2013, this team informed the Board: by March 2014 it is expected that roughly 1/5 of Consultants will have been put forward for Revalidation. This means that approximately 50 doctors will need to have had an enhanced, revalidation-ready appraisal before March 2014. It is expected that all doctors will have been put forward for revalidation by March 2016. We remain on trajectory for Revalidation. This Paper summarises the progress the Trust has made as well as setting out the next steps which are required to ensure that processes within the Trust are robust and nationally compliant. Key Achievements Development of new Trust-wide policies; Establishment of a local Revalidation Team; Implementation of a robust communication strategy; Establishment of an Appraisal Group consisting of consultants trained in enhanced appraisal methods; Funding, procurement and implementation of an electronic Revalidation Management System; On-going training; and Establishment of external Quality Assurance systems.
Challenges Recruiting and retaining adequate staffing in the Medical Director s Office; Reducing unnecessary deferrals; Linkage with governance systems; Defining funding for remediation; and Developing high level reflection as standard in appraisals. Recommendations: The Trust Board is asked to consider this report and approve the arrangements for continued compliance with national and local Revalidation requirements. Corporate Objectives - Corporate Objectives : To deliver high quality, integrated, patient centered care which improves outcomes, patient safety and patient experience. Who has been consulted in the production of this report: The Medical Director; the Associate Medical Director, Chairs of Medical Productivity Working Groups. Has an equality impact assessment (EIA) form been completed? No If not applicable, Please state why an EIA is not applicable. Has legal advice been taken? Does this report have any financial implication? No No If so, has the report been approved by the Finance Directorate? Key Risks: Failure to meet our corporate objectives; and Reputational Risk.