Presentation Title Annual Board Report, 36pt Arial Bold Surrey and - PowerPoint PPT Presentation

A Framework of Quality Assurance for Responsible Officers and Revalidation Presentation Title Annual Board Report, 36pt Arial Bold Surrey and Sussex Healthcare NHS Trust Sub heading 24pt Arial August 31 st 2017 Mr Adam Stacey-Clear Responsible Officer for Revalidation

Executive Summary • This report Follows the NHS England template as outlined in the Framework for Quality Assurance and is an annual requirement for all designated bodies. • The annual Organisation Audit findings for Surrey and Sussex Healthcare NHS Trust will be presented • 353 doctors with a GMC connection to The Trust were included in the audit, April 1st 2016-March 31 st 2017 • A statement of compliance confirming compliance with The Medical Profession (Responsible Officers) regulations 2010 needs to be signed by either the CEO or Chairman following this report.

Governance Arrangements • Surrey and Sussex Healthcare NHS Trust (SASH) has a Medical Appraisal Policy on the Trust website which is available for all doctors to read • The Responsible Officer is Adam Stacey-Clear who regularly attends network RO meetings on a regular basis throughout the year. The RO and Medical director Des Holden also attend quarterly meetings with the GMC Liaison Officer, Michael Cotton. • The human resources dept. maintains a list of employed doctors at the Trust. • All completed appraisal forms are read by AS-C.

Access, Security and Confidentiality • All appraisals are stored in a secure folder on the G drive • No patient identifiable data is stored in any appraisal folders • No information management breaches. • The GMC have provided ASC with a secure link which lists all doctors with a prescribed connection to the Trust (designated body). • The list is regularly updated. • Transfer of information between designated bodies. Slide 4

Conduct and Performance • All Trust doctors are subject to the organizational policies e.g. capability and disciplinary in line with Maintaining High Professional Standards best practice. The Trust recognizes the BMA code of conduct. • The Trust reviews doctors performance in the yearly job plan, supported by the annual appraisal process for all medical and dental staff. Linking job planning with appraisal is currently being developed as part of a new Trust strategy. • The clinical effectiveness strategy supports Medical and Dental staff in their practice by ensuring evidence is practice based and clinically effective. The complaints procedure is Trust policy. This is part of doctor’s • feedback and concerns are raised at job planning stage to enable improvement in doctor’s practice and patient care. Slide 5

Pre-employment background checks • Medical staffing check qualifications against persons specifications for the post. DBS (formerly a CRB) • Photographic ID • Visa or Biometric card as proof of the right to work in the UK • 2 proofs of address • GMC registration check • Must be on specialist register- substantive consultants • 2 references • Occupational health check Locums employed through medacs Slide 6

Responding to Concerns The Trust responds to concerns in respect of a doctor’s practice by • supporting them with regular and ongoing development opportunities. • Fitness to practice concerns from The GMC about a doctor are dealt with following the GMC guidelines. • The Trust has an active whistleblowing (raising concerns) policy Slide 7

Risks and Issues • Medical Practice Information Transfer Form for new/visiting doctors whose current designated body is not SASH. • Appraisals in March- cohort of doctors have now been moved to earlier in the year to offset the March crush. • Appraisal policy changes to incorporate sanctions imposed for late appraisals. • All doctors will be sent a link to the new appraisal policy when reminders are sent out • The RO regulations are adhered to as strictly as possible, and the annual appraiser update meetings enhance this. Slide 8

Appraisals – Why? • Revalidation demonstrates that a Doctor is up to date and fit to practice through Appraisal and Clinical Governance • This leads to improved Safety and Quality in Healthcare • Fit for Practice – minimum standards as per GMC guidelines • Fit for Purpose – above and beyond requirement for GMC – able to undertake the roles for which they are employed

Pen Hawk Rolling Stone Example More Horses Courses Less Precept Moss Dove Sword

Appraisal Objectives • Covering total scope of practice in terms of evidence seen • Documenting review of last year's personal development plans & recording origin of newly identified PDP items • Objective exploration of quality improvement activity • Recording that reflection has occurred & learning shared • Stage of revalidation and any outstanding requirement • Speciality guidance followed & mandatory training recorded

Appraisers • 44 trained appraisers in faculty of appraisers. • Rather unequal distribution of appraisals from those who responded to request for number of appraisals carried out. • Appraisal year runs from April 1 st to March 31 st . • Recent guidelines from NHS England recommend new appraisal categories: Slide 12

10 12 14 16 18 0 2 4 6 8 Dr Alison Newlyn Dr Andrea Stewart Dr Jila Nadjafi Number of appraisals carried out by Dr – April 2016: March 2017 Dr Munazah Akhtar Dr Ursula Davies Mr Usama Suleiman Dr Rita McAvinchey Dr Neemisha Jain Miss Karen Jermy Miss Catherine Wykes Miss Zara Nadim Mr Adrian Ball Mr Mushtaq Shuja Dr Ben Mearns Dr Hina Gandhi Dr Catherine Greenway Dr Debbie Pullen Dr Frederic Sage Dr Kamal Veeramuthu Dr Phil Williams Mr George Tselentakis Dr Ajay Pankhania Number Dr Vijaya Ramaiah Mr Thiyagarajan Pangayat-Selvan Mr Waleed Ziyada Dr Babak Daneshmand Dr Bruce Stewart Mr Hugh Maurice Mr Nandana Wijayaweera Dr Barbara Bray Dr Csaba Dioszeghy Dr Sarah Rafferty Prof Abhay Rane Dr Gary Mackenzie Dr Patrick Morgan Dr Syed Ali Dr Shrilla Banerjee Mr Alan James Dr Chandra Prajapati Dr Raad Makadsi Mr James Penny Mr Julian Webb Dr Frederick Van Damme Dr Virach Phongsathorn Number

NHS England appraisal guidelines

Medical Appraisal • 353 doctors were included in this audit, 178 consultants and 175 associate specialists/Trust doctors/staff grade. • 166 consultants completed an annual appraisal between 1/4/2016 and 31/3/2017. • 7 late consultant appraisals were approved, 5 were not • 165 associate specialists/Trust doctors completed an appraisal. • 8 late SAS appraisals were approved, 2 were not. • Audit sheet for late appraisals is maintained. • Late appraisals default to the original due date the next year Slide 15

2016/17 AOA indicator Your Same sector: All sectors: organisation’s SECTION 2: Appraisal DBs in sector: 54 Total DBs: 821 response No. of doctors Total no. of doctors Total no. of doctors (in organisation) (in SAME sector) (across ALL sectors) Consultants 178 15381 50102 Staff grade, associate 175 4084 11974 specialist, specialty doctor Slide 16

Completed appraisals (Measure 1a & 1b) Your Same sector ALL sectors organisation’s appraisal rate appraisal rate response and (%) calculated appraisal rate 166 (93.3%) 93.6% 91.7% 165 (94.3%) 87.5% 87.0% Slide 17

Approved incomplete or missed appraisal (Measure 2) Your Same sector ALL sectors organisation’s response appraisal rate appraisal rate and (%) calculated appraisal rate 7 (3.9%) 3.5% 4.7% 8 (4.6%) 6.6% 7.4% Slide 18

Unapproved incomplete or missed appraisal (Measure 3) Your organisation’s Same sector ALL sectors response and (%) appraisal rate appraisal rate calculated appraisal rate 5 (2.8%) 2.9% 3.5% 2 (1.1%) 5.9% 5.6% Slide 19

Recommendations submitted to GMC • 22 revalidation recommendations made. • 4 deferrals • 18 positive recommendations • Deferrals mainly due to lack of supporting information • 108 doctors left the Trust • 45 doctors were correctly connected to the Trust. 6 doctors were in training posts (and therefore not AS- C’s • responsibility) but had told the GMC that we were their DB. • 7 doctors were found to be GPs • 1 doctor died • 49 doctors told GMC they were here but we could not get information from them Slide 20

Late appraisals without prior permission Dr Michael Wilde Dr Matthew Cowan Dr Helena Wright Dr Rahi Yallapragada Dr Usha Limbu Miss Jean Arikosamy Dr Domo Kiss Slide 21

WHAT’S GONE WELL • New form for Locums with scope for feedback • Attachment of Achievement Reviews to Appraisals • Embedding Trust Values and Behaviours into Appraisal • Reasonable good appraisal rates obtained • Majority of doctors respond to e-mails confirming dates of booked- in appraisals Updated e-mails in relation to reminders / new doctors / 360 ◦ s • • New doctors acceptance letter includes requests to give Jenny Cawthorne details of current RO and DB Good relations with St Catherine’s Hospice • Slide 23