annual board report medical appraisal and revalidation … · revalidation policy and a doctors’...

ANNUAL BOARD REPORT MEDICAL APPRAISAL AND REVALIDATION

DR VINCENT KIRCHNER 15 JULY 2015

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ANNUAL BOARD REPORT 2014-2015 – MEDICAL APPRAISAL AND REVALIDATION

Medical Appraisal and Revalidation 2013-2014

1. Executive Summary

During the period 1 April 2014 to 31 March 2015, the C&I Designated Body had 98 doctors with a prescribed connection. All doctors were engaged in the appraisal process and all doctors were accounted for in terms of their participation. For 31 doctors their revalidation date fell during this year. A total of 9 recommendations were made to defer and of these five went onto positive recommendations within the year. The remaining four will be made in the current financial year. A total of 27 positive recommendations for revalidation were made to the GMC. No doctors are deemed to be ‘not engaging’. All doctors joining the trust received recruitment and engagement in appraisal background checks. The Trust has 23 trained appraisers, which is a sufficient. There is an appraisal and revalidation policy and a doctors’ remediation policy in place. The Trust uses a software program for doctors’ appraisals which allows the Responsible Officer to keep track of the appraisal process. There is a system in place whereby the Responsible Officer is informed of an upcoming Revalidation recommendation date and whether all documentation is in place so that timely recommendations are made. The Responsible Officer has provided quarterly and annual reports to NHS England to demonstrate compliance with the Framework of Quality Assurance for Responsible Officers and Revalidation. Other quality assurance processes include feedback for appraisers, quality check of appraisal documentation by the Responsible Officer before a revalidation recommendation is made, appraiser workshops and appraiser peer group e-mail support.

2. Purpose of the paper

Revalidation is the process by which licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practice. Revalidation aims to give extra confidence to patients that their doctor is being regularly checked by their employer and the GMC.

This paper is to provide the Board with information about processes in place in C&I for appraisal, revalidation recommendations and remediation, including governance.

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3. Background

Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system. All doctors are allocated to a Designated Body through the General Medical Council (GMC). Each Designated Body has a Responsible officer, who has responsibility for implementing appraisal and revalidation.

C&I is the Designated Body for all consultants, specialty doctors and locum doctors working in the Trust. Doctors in training are in the Deanery Designated Body and therefore are not included in this report.

The GMC record of the Designated Body is accessible online. The Responsible Officer receives an e-mail if any doctor is added to the Designated Body. We then check if this doctor has a prescribed connection. We also keep our own list of doctors in the C&I Designated Body and ensure they are on the GMC list. As doctors are recruited into the Trust or leave, the list is adjusted.

The GMC decides whether or not to revalidate a doctor based on the recommendation made to it by the Responsible Officer. A positive revalidation decision means the doctor’s license to practice is extended by five years. Deferral is a neutral recommendation resulting in a new date for the doctor’s revalidation. It does not impact the doctor’s license to practice. Non-engagement indicates a doctor’s license is at risk of being withdrawn. Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations1 and it is expected that provider boards will oversee compliance by:

monitoring the frequency and quality of medical appraisals in their organisations;

checking there are effective systems in place for monitoring the conduct and performance of their doctors;

confirming that feedback from patients 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 pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.

1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The

General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012’

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C&I has been required to submit self-assessments to the NHS England quarterly and

annually. The last Annual Organisational Audit was submitted in May 2015 for the

period 1 April 2014 to 31 March 2015 and we returned an appraisal rate of 93.8%,

which was based in the Designated Body on the 31st of March 2015.

4. Governance Arrangements

The Responsible Officer for C&I is Dr Vincent Kirchner, who has responsibility to ensure processes for appraisal, revalidation and remediation of doctors in the C&I Designated Body are in place. Dr Koye Odutoye, the Deputy Medical Director, is the Revalidation lead and has responsibility for the day to day running of these processes. Appraisals are conducted by appraisers who have all attended required training. The Trust uses Revalidation Management System (RMS), a software program to record and monitor appraisals. This software allows the Responsible Officer to check the quality of individual appraisals and to get overview reports of progress.

NHS England have produced the Framework of Quality Assurance with a checklist of core standards. This gives us a framework against which to check that we are compliant with regulations. This report is designed to address those standards.

As part of the governance arrangements, this report is submitted to the Trust Board annually. A statement of compliance will be signed by the Trust Board Chair and submitted to NHS England.

5. Medical Appraisal

a. Appraisal and Revalidation Performance Data

During the period 1 April 2014 to 31 March 2015, the C&I Designated Body had 98 doctors with a prescribed connection and 86 had appraisals in year. Eight locum doctors left before the appraisal cycle so did not have an appraisal. One locum doctor joined the Trust late in the year and had not had an appraisal for over a year, but has had one in the current appraisal cycle. Three doctors were on maternity leave. During that year, 19 doctors left the trust and 19 started.

The Annual Organisation Audit covered the 2014-2015 financial year and the information related to who was in the Designated Body on the 31st of March 2015. On that day C&I had 81 doctors: 56 consultants, 13 SAS doctors and 12 locums (all grades). Appraisals that were completed were: consultants 54, SAS doctors 13 and locums 9. The reasons appraisals were not completed in the year were: maternity leave and new starters.

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For 31 doctors their revalidation date fell during this year. A total of 9 recommendations were made to defer and of these five went onto positive recommendations within the year. The remaining four will be made in the current financial year. The deferrals were because 6 were struggling to get their documents together, and two were on maternity leave. A total of 27 positive recommendations for revalidation were made to the GMC. No doctors are deemed to be ‘not engaging’.

(See Annual Report, Appendix A; Audit of all missed or incomplete appraisals audit)

b. Appraisers

C&I have 23 trained appraisers, three of them were newly trained in November 2014. All attended appraisal training as recommended by the Revalidation Support Team, the equivalent of two days training with a set curriculum.

c. Quality Assurance

Outline of quality assurance processes: For the appraisee:

Doctors upload documents into a portfolio on RMS (Revalidation Management System) covering the GMC domains as outlined in Good Medical Practice. RMS requires the completion of pre-appraisal declarations by doctors regarding their own health and probity. Their previous Personal Development Plan and Job Plan are part of the portfolio. This portfolio is submitted to their appraiser at least two weeks prior to their appraisal meeting. The appraiser reviews it and if there is insufficient, inadequate or too much information, they will return it to the doctor to amend.

In each 5 year Revalidation cycle, each doctor is obliged to gather patient and colleague feedback once. There is a system built into RMS to collect this information. This feedback is valued by clinicians. It is discussed in appraisal and feeds into the personal development plans.

The Responsible Officer or the Revalidation Lead reviews the outputs and portfolio prior to making a Revalidation recommendation for quality assurance purposes. Appraisal outputs include: the doctor’s profile, portfolio and reflective notes; the doctor's self-assessment; the appraiser’s assessment of the portfolio; the personal development plan; the appraiser’s summary and sign off; and the doctor’s summary and sign off.

Key items such as Serious Incident inquiries, Datix incident reports and a summary of their clinical activities drawn from Rio are sent to the Revalidation administrator and then uploaded to the doctor’s portfolio.

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For the individual appraiser

All appraisers have attended required training and a record is kept of this.

Their learning needs with regard to being appraisers is discussed in their own appraisal meeting and if learning needs are identified, these are added to their PDP.

Two workshops occur per year in September and January for appraisers to share experiences, set standards and prepare for the next appraisal cycle.

An appraiser peer group mailing list has been set up for appraisers to communicate with each other during the appraisal cycle to share ideas, thoughts and queries. Where the Responsible Officer picks up quality issues when reviewing appraisal outputs, these are fed back directly to the appraiser.

For the organisation

There is a Responsible Officer appointed by the Trust to oversee quality.

RMS has a dashboard and generates reports for the Responsible Officer.

Feedback of appraisals for 2014-2015 are now electronically available on RMS. These are uploaded to the individual appraiser portfolios for them to include and discuss in their own appraisal meetings.

The quarterly and annual organisation assessment and the board report are further processes to provide quality assurance.

(See Annual Report, Appendix B; Quality assurance audit of appraisal inputs and outputs)

d. Access, security and confidentiality

RMS (Revalidation Management System) is a secure, online program provided by Equiniti. During the procurement process the C&I ICT established that it met security requirements. Appraisal folders are confidential and accessed by the doctor using a username and password. The administrator can upload documents to their portfolio. Once a portfolio has been published by the doctor, the Responsible Officer and the administrator can view it. Once an appraisal is completed, the Responsible Officer can view the outputs. No patient identifiable information should appear in any documents in the appraisal portfolio. In their training appraisers are taught that it is a requirement to inform the doctor if they do find patient identifiable information and this information must be removed. Failure to do so will trigger a disciplinary process as it breaches Information Governance policy.

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e. Clinical Governance

Doctors are required to complete an audit cycle every five years. Audit is included in the portfolio and discussed at appraisal. Audit may form part of the personal development plan.

Reports are generated by the complaints department regarding complaints, compliments and incidents. If any are identified for individual doctors these are uploaded into their portfolio by the administrator and the relevant doctor is also informed.

If a doctor is mentioned in a Serious Incident inquiry, it is uploaded to their portfolio.

6. Revalidation Recommendations

Number of recommendations 2014-201

36

Recommendations completed on time

35

Recommendations completed not on time

1

Positive recommendations

27

Deferrals requests

9*

Non engagement notifications

0

Reasons for all missed or late recommendations n/a

*Five were subsequently given positive recommendations

See Annual Report, Appendix C; Audit of revalidation recommendations

7. Recruitment and engagement background checks

Along with the Permission to Work form, the following information is gathered: appraisal outcome documents and personal development plans for each of the years relating to the doctor’s current revalidation cycle; the name and contact details of their current Responsible Officer. This is collected Medical Staffing. When new starters sign on the following pre-employment checks are made: copy of DBS clearance, current GMC registration, Fitness to Practice form to declare criminal convictions, self-declaration of health and probity, qualifications, photographic identification, most recent NHS payslip and utility bills to verify address. All doctors joining the trust during 2014-2015 had these checks completed by the medical staffing team.

See Annual Report, Appendix E; Audit of recruitment and engagement background

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8. Responding to Concerns and Remediation

A rehabilitation and remediation of doctor’s performance policy is in place. Concerns were raised about three doctors. One was treated as a complaint following the complaints procedures and resulted in no further action for the doctor. One doctor was investigated for capability issues and no further action was taken. One doctor was investigated for conduct issues and was given a final written warning. No doctors were in remediation in 2014-2015. It is expected that issues of conduct and capability are dealt with as they arise and not during appraisal meetings. If issues of conduct or capability arise during an appraisal meeting, these are escalated to the Medical Director or Deputy Medical Director so that appropriate action can be taken.

9. Costs for 2014-2015

Revalidation Lead 1 PA £11,500

Administrator 0.5WTE Band 5 £15,975

RMS Licenses £6,127

Training £2,148

TOTAL £43,738

10. Risk and Issues

The GMC has delegated responsibility for determining doctors’ fitness to practice to Responsible Officers and Designated Bodies. A risk that has yet to surface nationally is what the organisation’s responsibility would be if a doctor, who was deemed fit to practice, subsequently is negligent or incompetent. There are reports from other Trusts of doctor’s lodging a grievance when recommendations for deferral have been made. It is also possible that a doctor could make a legal challenge if a recommendation for deferral or non-engagement is made.

11. Recommendations

1. The Board is requested to accept this report noting it will be shared, along with the annual audit, with the higher level responsible officer and to consider any needs/resources.

2. To approve the ‘statement of compliance’ confirming that the organisation, as a designated body, is in compliance with the regulations

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Annual Report Appendix A

Audit of all missed or incomplete appraisals

Doctor factors (total) Number

Maternity leave during the majority of the ‘appraisal due window’ 3

Sickness absence during the majority of the ‘appraisal due window’ 0

Prolonged leave during the majority of the ‘appraisal due window’ 0

Suspension during the majority of the ‘appraisal due window’ 0

New starter within 3 month of appraisal due date 0

New starter more than 3 months from appraisal due date 1

Postponed due to incomplete portfolio/insufficient supporting information 0

Appraisal outputs not signed off by doctor within 28 days 0

Lack of time of doctor 0

Lack of engagement of doctor 0

Other doctor factors 8

(describe) Short term locums

Appraiser factors Number

Unplanned absence of appraiser 0

Appraisal outputs not signed off by appraiser within 28 days 0

Lack of time of appraiser 0

Other appraiser factors (describe) 0

(describe)

Organisational factors Number

Administration or management factors 0

Failure of electronic information systems 0

Insufficient numbers of trained appraisers 0

Other organisational factors (describe) 0

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Annual Report Appendix B

Quality assurance audit of appraisal inputs and outputs

Total number of appraisals completed 86

Number of

appraisal

portfolios

sampled (to

demonstrate

adequate sample

size)

Number of the

sampled

appraisal

portfolios

deemed to be

acceptable

against

standards

Appraisal inputs 27 27

Scope of work: Has a full scope of practice been described? 27 27

Continuing Professional Development (CPD): Is CPD

compliant with GMC requirements?

27 27

Quality improvement activity: Is quality improvement activity

compliant with GMC requirements?

27 27

Patient feedback exercise: Has a patient feedback exercise

been completed?

Yes

Colleague feedback exercise: Has a colleague feedback

exercise been completed?

27 27

Review of complaints: Have all complaints been included? 27 27

Review of significant events/clinical incidents/SUIs: Have all

significant events/clinical incidents/SUIs been included?

27 27

Is there sufficient supporting information from all the doctor’s

roles and places of work?

27 27

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?

27 27

Appraisal Outputs

Appraisal Summary 27 27

Appraiser Statements 27 27

PDP 27 27

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Annual Report Appendix C

Audit of revalidation recommendations

Revalidation recommendations between 1 April 2014 to 31 March 2015

Recommendations completed on time (within the GMC recommendation window) 35

Late recommendations (completed, but after the GMC recommendation window

closed)

1

Missed recommendations (not completed) 0

TOTAL 36

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 0

New starter/new prescribed connection established within 2 weeks of

revalidation due date

0

New starter/new prescribed connection established more than 2 weeks

from revalidation due date

0

Unaware the doctor had a prescribed connection 0

Unaware of the doctor’s revalidation due date 0

Administrative error 0

Responsible officer error 0

Inadequate resources or support for the responsible officer role 0

Other 1

Describe other: IT system down

TOTAL [sum of (late) + (missed)] 1

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Annual Report Appendix D Audit of concerns about a doctor’s practice

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

1 2 3

Capability concerns (as the primary category) in the last

12 months

2 2

Conduct concerns (as the primary category) in the last 12

months

1 1

Health concerns (as the primary category) in the last 12

months

0

Remediation/Reskilling/Retraining/Rehabilitation

Numbers of doctors with whom the designated body has a prescribed connection as at

31 March 2014 who have undergone formal remediation between 1 April 2013 and 31

March 2014

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

0

Consultants (permanent employed staff including honorary contract holders, NHS and

other government /public body staff)

0

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)

0

General practitioner (for NHS England area teams only; doctors on a medical performers

list, Armed Forces)

0

Trainee: doctor on national postgraduate training scheme (for local education and training

boards only; doctors on national training programmes)

0

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)

0

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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 fixed-term employment contracts,

etc.) All DESIGNATED BODYs

0

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 DESIGNATED BODYs

0

TOTALS 0

Other Actions/Interventions

Local Actions: 1

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

0

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

0

Number of doctors who have had local restrictions placed on their practice in the last 12

months?

1

GMC Actions:

Number of doctors who:

0

Were referred to the GMC between 1 April and 31 March 0

Underwent or are currently undergoing GMC Fitness to Practice procedures

between 1 April and 31 March

1

Had conditions placed on their practice by the GMC or undertakings agreed with

the GMC between 1 April and 31 March

0

Had their registration/licence suspended by the GMC between 1 April and 31

March

0

Were erased from the GMC register between 1 April and 31 March 0

National Clinical Assessment Service actions: 0

14


Number of doctors about whom NCAS has been contacted between 1 April and 31

March:

For advice 0

For investigation 3

For assessment 0

Number of NCAS investigations performed 0

Number of NCAS assessments performed 0


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)

23

Permanent employed doctors 4

Temporary employed doctors 19

Locums brought in to the designated body through a locum agency n/a

Locums brought in to the designated body through ‘Staff Bank’ arrangements n/a

Doctors on Performers Lists n/a

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.

n/a

TOTAL 23

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For how many of these doctors was the following information available within 1 month of the doctor’s starting date (numbers)

Tota

l

Identity

check

Past G

MC

issues

GM

C c

ond

itio

ns

or

und

ert

akin

gs

On-g

oin

g

GM

C/N

CA

S

investigations

DB

S

2 r

ecent

refe

rences

Nam

e o

f la

st

responsib

le

offic

er

Refe

rence fro

m

last re

spo

nsib

le

offic

er

Lang

uag

e

com

pete

ncy

Local co

nd

itio

ns

or

und

ert

akin

gs

Qualif

icatio

n

check

Revalid

atio

n d

ue

date

Appra

isal du

e

date

Appra

isal

outp

uts

Unre

solv

ed

perf

orm

ance

concern

s

Permanent employed doctors 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Temporary employed doctors 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19

Locums brought in to the

designated body through a

locum agency

n/a

Locums brought in to the

designated body through

‘Staff Bank’ arrangements

n/a

Doctors on Performers Lists n/a

Other

(independent contractors,

practising privileges,

members, registrants, etc.)

n/a

Total (these cells will sum

automatically)

23 23 23 23 23 23 23 23 23 23 23 23 23 23 23 23

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