Planning a visit. 1
Before the visit it is important to consider the types of assessment which are available to a Trust and from that to understand why they have chosen a College assessment visit. Is this related to an isolated event or is it part of a wider process of review? Understanding what the assessment can contribute is a key thing to know. Discussion will have taken place with the Trust to make sure that a College assessment visit is the correct choice for the issues they need to address. 2
The decision to request an assessment visit will usually have been made by the Chief Executive, Head of Human Resources, Medical Director, Director of Nursing and Clinical Director of Obstetrics & Gynaecology. All visits must be agreed by the Medical Director. The internal assessment process is Maintaining High Professional Standards which usually relates to the conduct or capability of an individual. This is a standard national process but particularly with Foundation Trusts some variation in the way in which this policy is applied can occur. Trusts may seek an external source of support for a review process either locally from an independent clinician of from somebody beyond their region. This may have been following discussions with the College and the College does occasionally suggest individual expert assessors to help with such a process. An invited review from the College could either consider an individual or more usually a service. The National Clinical Assessment Service has a particular role for assessing individual practitioners in the context of their practise. This is with the aim of a remediation process to allow a return to practise. The General Medical Council as our professional regulator has mainly views on conduct, probity and clinical practise. Its scope for acceptance of referrals are evidence of serious or repetitious issues. 3
It is also important to bear in mind what a College visit is not. It is not meant to be an inquisition, a trial or some form of punishment. But if you try to see this from the view of people within the department, it may actually seem like that. Examples of phrases which have been used to me by other Medical Directors are: "We just need a quick fix, can you please just sort this out." Or "We really think this is just a tick box exercise but I suppose we have to do it", "We view this as a necessary evil". I do not think these are very positive ways to welcome an assessment team. I believe that most often the request can be summarised as “Help, we need somebody to guide us out of this issue, we have tried to sort it out locally and we cannot, please can you provide your support?” That I think is an honest and realistic view of what this process can offer. 4
It is important to understand how an assessment starts. Considering an individual practitioner or a trainee represents less than 20% of referrals to the College. The GMC guidance of serious or repetitious issues would usually be the standard applied and also an issue that has failed to be addressed by any of the local processes. This may result from a series of complaints. It may increasingly come about following external scrutiny particularly from bodies such as the Care Quality Commission. There is often evidence of internal conflict or dysfunction within the clinical team or the larger department. Whenever an assessment considers a single practitioner it always must be that practitioner viewed in the context of their practise. It can never be seen as just a difficult doctor. 5
An assessment of a service can have been prompted by a series of untoward events, maternal deaths, still births, serious untoward incidents or complications or complaints from patients. Also external scrutiny by a range of bodies such as, the Clinical Commissioning Groups, NHS England, the Care Quality Commission, the Deanery, or Monitor the regulator of Foundation Trusts. The coroner using his schedule five letters powers can also raise concerns. These are often following on from a failure of a local process. It is important that you understand the background and origin which has led to the request for a College assessment. 6
A team is assembled with a Lead Assessor and a second independent expert assessor. There may also be other invited assessors often midwives. The makeup of the team will have been tailored to the nature of the concerns described to the College. Do not forget the wider team at the College is there to support you and give guidance and is always available for telephone advice. The team choice is because of their experience, their expertise, their neutrality and often it has to be said, because of their availability. You will all be asked to sign a declaration that you have no conflict of interest. 7
The terms of reference are key to any enquiry and do take some time to develop. It is sometimes difficult to agree terms of reference without prior knowledge of the Trust. It is a negotiated process which is led by the College in conjunction with the Lead Assessor and the Trust. Keeping the terms of reference tight and pertinent to the issues and achievable is the key. Many people like to apply the SMART thinking at this stage. If the terms of reference are too vague it makes it very difficult for an assessment process to succeed. 8
In terms of a legal process, the RCOG will formally agree the terms of reference with the institution. Team members will be offered indemnity and support and also travel insurance and health insurance for the purpose of the visit. There will always be a named identified Trust contact, and support will be available locally in terms of secretarial support, photocopying etc. The initial team contact will be made by the Lead Assessor. It is often by either e ‐ mail correspondence or a teleconference. 9
Organisation of the visit is one of the duties of the Lead Assessor and I believe this is where they can really be viewed as the team captain. You need to make an assessment of how long you will need but there must be some flexibility built into any programme you devise. Tasks should be allocated according to expertise and a fair distribution of time. In the early stages sharing information and progress together with the team as often as possible is very useful. Travel arrangements will be coordinated, accommodation arranged, any specialised individual needs identified. 10
It is important to remember when the process begins that you are acting as an agent of the College process and as a neutral assessor. You are there to provide a fresh pair of eyes and make judgements as a peer. I believe being able to act as a critical friend is one of the key roles of team membership. 11
The nature of the jobs that we do and the training that we have had means that we are all by our very nature fixers. Remember that you are not there to provide a quick fix and you are not there to offer individual advice. You are not there to say "oh well, this worked for us in a very similar set of circumstances“. You are there to provide a neutral view and any advice will come later in the final report. 12
An assessment should be viewed as a four stage process. Firstly, gathering evidence, this can be from information before the visit or evidence seen and heard during the visit. Secondly, making findings once that evidence has been collated and reviewed. Thirdly, reaching conclusions based on those findings. And fourthly, the making of recommendations. This is the final process and is always done by the team in conjunction with the College. 13
To recap. Before the visit clearly understand the terms of reference, share initial thoughts within the team and agree the data requests. Agree case notes selection pertinent to the terms of reference. Agree broadly who you would like to interview. Guidance for this is given in the College booklet. The timetable will retain some flexibility. Without doubt this process will always take longer than you think at the planning stage. Try to avoid asking for too much data as anything you do receive has to be considered, understood and discussed. It’s very tempting to say “Oh, that’s an interesting audit – can we have the last 3 years please?” But just think, is it realistic to spend the time that it will take to truly evaluate that amount of data? And what will be the value that you gain from it? And finally. Don’t forget that you need to be flexible. 14
An important consideration is the Data Protection Act and Caldicott rules. The Lead Assessor must arrange access in advance. It is useful to have access to the Trust intranet as this is now where most protocols are held. No patient identifiable data must be held on any of the College records or pro ‐ formas, a reference number must be used. No patient identifiable data should be taken from the Trust apart from that one reference scheme held by the Lead Assessor. Anything shared electronically should be encrypted or sent via a secure network; NHS Net is preferred for this. Remember that in legal terms everything, even the smallest note on a scrap of paper, could be disclosable. 15
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