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 September 24 th 2015 Adam Stacey-Clear

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 245 doctors with a GMC connection to The Trust were included in the • audit, April 1st 2014-March 31 st 2015 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. A record of all doctors connected with the Trust is maintained • The Responsible Officer is Adam Stacey-Clear who regularly attends • network RO meetings, and attended as visiting Peer review RO to Portsmouth Hospitals NHS Trust on 8 th September 2015. The human resources dept. maintains a list of employed doctors at the • Trust. All completed appraisal forms are read by AS-C. •

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 4

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 5

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. 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 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

Recommendations submitted to the GMC 114 revalidation recommendations made. • 14 deferrals • 100 positive recommendations • Deferrals mainly due to lack of supporting information • Slide 8

Medical Appraisal 245 doctors were included in this audit, 166 consultants and 79 • associate specialists/Trust doctors 161 consultants completed an annual appraisal between 1/4/2014 and • 31/3/2015, of which 2 were approved and 3 unapproved. 78 associate specialists/Trust doctors completed an appraisal, the late • appraisal being unapproved. Audit sheet for late appraisals is maintained. • Late appraisals default to the original due date the next year • Slide 9

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: • Measure 1a- Appraisal took place 9-15 months from previous appraisal, signed off , all • between 1 April and 31 March 1b-1 April-31 March but less than 9 months or more than 15, or signed off 1 April-28 April • of following appraisal year, or signed off more than 28 days after appraisal meeting 2-approved incomplete appraisal- neither 1a or 1b-but RO gave prospective approval for • cancellation or postponement 3- unapproved incomplete or missed appraisal-1a,1b or 2 do not apply. • Trust is going to stick with annual appraisals, +/- one month. • Slide 10

DISTRIBUTION OF APPRAISALS Appraisal number 20 18 16 14 12 10 8 6 4 2 0 Slide 11

Comparator Report Nationally 731 designated bodies (ALL), 58 in same sector (SS)= NHS • England south. SASH compared with both groups. • Completed appraisal consultants 97% SASH, ALL 87%, SS 87% • Completed appraisal SAS/Trust doctors 98% SASH, ALL 84%, SS • 81%. Approved late appraisals consultants 1.2% SASH, ALL 6.3%, SS 6.7% • Approved late SAS/Trust doctors 0% SASH, ALL 8.6%, SS 9.1% • Unapproved appraisals consultants 1.8% SASH, ALL 6.5%, SS 5.6% • Unapproved SAS/Trust doctors 1.3% SASH, ALL 7.5%, SS 5.6%. • Slide 12

Are doctors organised? Some are • The good ones are excellent ambassadors for the Trust and proud of • their achievements Some need direction • Brownian (Robert Brown) motion-random movement of water vapour • particles, bumping into each other. Wilson’s cloud chamber (Charles Thomson Rees Wilson)- water vapour • condenses on ionizing particles from a powerful alpha emitting source (MW) Slide 13

http://www- outreach.phy.cam.ac.uk/camphy/cloudchamber/cloudchamber1_1.ht m http://www- outreach.phy.cam.ac.uk/camphy/cloudchamber/cloudchamber4_1.ht m http://www- outreach.phy.cam.ac.uk/camphy/cloudchamber/cloudchamber9_1.ht m Slide 14

Famous Michael Wilsons Michael Henry Wilson (1901-1985) British anthroposophist and founder of Sunfield Children's Home, • Clent Michael Wilson (writer) (1914-1978), Hollywood screenplay writer • Michael Wilson (Australian politician) (born 1934), member of the South Australian House of Assembly • Michael Wilson (Canadian politician) (born 1937), Canadian politician and diplomat • Michael G. Wilson (born 1942), producer and screenwriter of James Bond films • Michael Wilson (guitarist) (born 1952), Jamaican guitarist for Burning Spear from 1977 to 1984 • Michael Wilson (cyclist) (born 1960), Australian cyclist • Michael Wilson (director) (born 1964), artistic director of Hartford Stage • Michael Wilson (Australian footballer) (born 1976), Australian rules footballer for Port Adelaide • Michael Wilson (New Zealand footballer) (born 1980), New Zealand association football player • Michael Wilson (ice hockey) (born 1987), Canadian ice hockey defenceman • Michael Wilson (presenter), British journalist and business presenter (formerly on Sky News) • Michael Wilson (basketball), former player of the Harlem Globetrotters aka 'Wild Thing' • Slide 15

Quality assurance Currently conducting an external review of appraisers using an NHS • England toolkit concentrating on the appraisal outputs and PDP. External verification visit due soon from NHS England south. • Appraisee feedback working well, reliant on appraisal sign off • certificate. Six month PDP review working well • Appraiser support group meetings carried out in June 2015 (three • sessions spread over 2 days) PDP includes a Trust quality improvement activity • Slide 16

Risks and Issues Information transfer for visiting doctors whose designated body is not • SASH. Appraisals in March • Feedback for locums • Patient feedback-database setup. • Slide 17

Board Reflections Working party to explore patient and public involvement in revalidation • PDP six month check • Verification visit • Appraiser quality assurance audit • Transfer of information form between SASH and other organisations • Improved appraisee feedback • Slide 18