The Scotland Deanery. Annual Quality Report 2016

Transcription

1 The Scotland Deanery Annual Quality Report 2016

2 NHS Education for Scotland 2016 You can copy or reproduce the information in this document for use within NHSScotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.

3 Contents Glossary 2 Foreword 3 1. Key Achievements 4 2. How We Govern Quality of PGMET in Scotland 7 3. Our Annual Quality Cycle Our Processes and Procedures Our Team The GMC Dean s Report The Training Year in Numbers 2015/ The Training Year 2015/16 25 Foundation 30 General Practice, Public Health, Occupational Health 34 Anaesthetics, Intensive Care Medicine, Emergency Medicine 39 Diagnostics 42 Medicine 46 Mental Health 61 Obstetrics, Gynaecology and Paediatrics 65 Surgery The GMC National Training Survey (NTS) The Scottish Training Survey (STS) TIQME The Sharing Intelligence for Health & Care Group Our Working Groups Our Lay Partners 103 1

4 Glossary Acronym QM QM-QI PGMET QRP LEPs NTS sqmg LDD QIM QIA APGD-Q rapgd DME STS TPD MDRG RAG QI STC NES SMEC TIQME DQMG MDET QL PGD MD LETBs HIS QuEMP CopMed STB Full name Quality Management Quality Management and Quality Improvement Postgraduate Medical Education and Training Quality Review panel Local Education Providers National Training Survey specialty Quality Management Group Lead Dean Director Quality Improvement Manager Quality Administrator Associate Postgraduate Deans for Quality Regional Associate Postgraduate Deans Directors of Medical Education Scottish Training Survey Training Program Director Medical Data Reporting Group Red and Green Quality Improvement Specialty Training Committee NHS Education Scotland Scottish Medical Education Conference The Taskforce to Improve the Quality of Medical Education Deanery Quality Management Group Medical Directorate Executive Team Quality Lead Postgraduate Dean Medical Director Local Education & Training Boards. Healthcare Improvement Scotland Quality Education Managers Partnership Conference of Postgraduate Medical Deans Specialty Training Board 2

5 Foreword Professor Stewart Irvine I am extremely pleased to introduce the first Scotland Deanery Annual Quality Report which sets out the extensive work that has been done to refocus Scotland s Quality Management (QM) system from four separate regional quality systems to a consistent national way of working, ensuring that our programmes of training meet the standards and requirements set by the regulator, and delivering positive change in the training environment. Change that can be largely credited to the efforts of Scotland s training providers who, under the leadership of Scotland s Directors of Medical Education, have engaged and responded to the many new demands that have been made of them. The evidence based, rational approach has undoubtedly placed greater emphasis and focus where required and I am conscious that it has been a challenging year with major service change and requirements for improvement. Whilst acknowledging that much of the initial activity under the new framework has centred on reactive scrutiny, it is our firm belief this position will change over the next few years to more scheduled engagements where identification, promotion and sharing of best practice will be to the fore. The recently established Task Force to Improve the Quality of Medical Education (TIQME) in Scotland demonstrates a clear willingness to maintain and build on Scotland s reputation for excellent medical education and training, underlining just how valuable and timely it has been to introduce a common, well understood system of QM, so that in time, we can be sure that training in any specialty in any of Scotland s regions or cities can be adjudged to be of the same high quality as elsewhere and be excellent whenever possible. I never tire of reminding colleagues that education and training is our investment in patient safety for the next 30 years and getting the quality jig-saw right is central to what we do. I therefore commend the inaugural Scotland Deanery Annual Quality Report to you as a baseline for future reports on the road to continued excellence over the coming years. Professor Stewart Irvine Medical Director and Deputy Chief Executive NHS Education for Scotland September

6 Scotland Deanery Annual Quality Report Key Achievements 4

7 Key Achievements A new quality framework: The Quality workstream of the Scotland Deanery is responsible for the Quality Management and Quality Improvement (QM-QI) of Postgraduate Medical Education and Training (PGMET) in Scotland. Working as a single system across Scotland, the workstream is structured around eight specialty groups that relate to our eight specialty Quality Management Groups (sqmgs). We have now completed our first annual quality cycle and each part in our QM-QI process outlined in this report has played a key role in promoting excellence in training. A new Scotland wide focus: The annual Quality Review Panel (QRP) has provided the opportunity to consider quality of training within specialties across all of our Scottish local education providers (LEPs). Bringing together the key quality indicators for each specialty; the GMC National Training Survey (NTS), the Scottish Training Survey (STS), Deanery Report entries, reports on training and notifications of concerns, a pan Scotland view of training in each specialty at each training site takes place at the annual QRP. General Practice and Foundation QRPs provide views on the quality of their training within secondary care specialties which are then considered at each specialty QRP. A new system of review: QRPs consist of specialty Quality Management Group (sqmg) members - a Lead Dean Director (LDD), a Quality Improvement Manager (QIM), a Quality Administrator (QIA) and Associate Postgraduate Deans for Quality (APGD-Q). Local post and programme knowledge is provided by regional Associate Postgraduate Deans (rapgd) who are joined by lay representation and by Directors of Medical Education (DMEs) from our LEPs as well as representation from Royal Colleges. The QRP membership ensures all appropriate expertise is gathered together at one time. The main output from the QRPs is a specialty calendar for QM-QI visiting for the year ahead. At QRP, a unique Decision Aid, using the matrix of quality indicators, is used to organise and rank the data. A new survey: During the last year the Scottish Training Survey (STS), a trainee end of post questionnaire, was further developed into a reliable benchmarking tool that provides information that is complementary and additional to the General Medical Council NTS. Our Medical Data Reporting Group (MDRG) worked closely with the Robertson Institute at the University of Glasgow who provided the statistical methodology for the STS Red and Green (RAG) ratings. The STS Dashboard is now available online, to key stakeholders, pending public release. A new focus on improvement: Central to our quality framework is our role in ensuring that LEPs deliver education and training that meet the requirements set out in the GMC standards, overseeing any improvements or changes required. However, while ensuring improvements produce significant local impact, it has less effect on the quality of medical education and training across Scotland, which requires a wider Quality Improvement (QI) approach. A new valued partnership approach: Our Quality Improvement (QI) drive brought into focus the need for partnership and collaborative working between Universities, Health Boards, Medical Schools, trainers and trainees. Close working and involvement of Health Boards DME s in each of our Quality Working Groups has been a real achievement. Bringing quality information and feedback to the front line of training through our Specialty Training Committee (STC) and Training Program Director (TPD) structure has been a major success. A high energy workshop at this year s NHS Education Scotland (NES) Scottish Medical Education Conference (SMEC) demonstrated the value of quality feedback and close working with those delivering and managing training within the service. Collaboration has also worked well at the strategic leadership level. TIQME - The Taskforce to Improve the Quality of Medical Education, brings together Health Board Medical Directors, DMEs and the NES Medical Executive Team. This group shares leadership between all parties and is a forum for sharing information about the 2017 GMC visit and the engagement of Health Boards in medical education and training. 5

8 A new way to share best practice: The Scotland Deanery Quality Workstream has developed SHARE, a website to showcase case studies of good practice. This is an opportunity for trainers and departments to promote excellence in postgraduate and undergraduate medical education and training in Scotland, so that others can learn: what can be done, how to make it happen and who to contact for more information. SHARE - Sharing Achievement to Replicate Excellencehttp:// A new way to engage trainees: The Quality Workstream is developing and piloting educational improvement toolkits to support a culture within training environments where a good educational environment is considered to be integral to safe patient care. This work will be taken forward by a Scottish Clinical Leadership Fellow and is aimed at ensuring trainees feel at the heart of an environment centred on their educational development through meaningful and representative trainee involvement in all of our quality work. A new shared agenda around common standards: The new GMC standards covering both undergraduate and postgraduate medical education and training have provided a focus to pilot joint undergraduatepostgraduate QM-QI visits to LEPs have been undertaken. Early feedback indicates that while flexibility is required, a joint visiting process can work well for Universities and the Scotland Deanery. This pioneering work and is already generating interest across the UK. A new focus on staff development: The considerable volume of information to be considered and the fact that the QRP was a new process required our APGD-Q and QIMs to work together to produce a training package for all who would be involved in the QRP. The value of this training in producing consistency across each of the specialities was a key message from our QRP review day. Similarly training for the role of lead visitor, no matter how experienced individuals were in their local visiting processes, was given priority and the Quality Workstream delivered a very successful lead visitor training day. This will now be rolled-out to other visitors and trainees who wish to become involved in quality work. A new drive towards standardisation: A shift towards standard calibration guides and standardisation of requirements has begun with all APGD for Quality contributing to the exercise. The GMC s 10 standards for medical education and training specify 76 requirements which state how an organisation can demonstrate that they are meeting the required standards. Accordingly, our Calibration Guides now make clear what the standards mean. These guides will help LEPs make changes when required. They also provide our QM-QI visitors with a reference guide to help standardise any requirements for visitors, ensuring consistency across all specialties in Scotland. A new will to continuously improve: The key achievements highlighted above are only a part of the immense activity that has occurred within the Quality Workstream over the past year. The task is now to learn from last year s activities and move forward with equal enthusiasm and innovation, keeping Scotland s focus firmly on improving quality, partnership working, staff development and listening to feedback to ensure greater consistency contributes to safe, effective care for patients in Scotland, both for now and in the future. 6

9 Scotland Deanery Annual Quality Report How We Govern Quality of PGMET in Scotland 7

10 How we Govern Quality of PGMET in Scotland How we govern quality of PGMET in Scotland Deaneries are required to quality manage postgraduate medical education. This requirement is embedded in statute and the Deanery s role in quality management is a pivotal component of the GMC s Quality Assurance Framework (figure). The Quality Assurance Framework also requires Scotland s Local Education Providers to take responsibility for the quality control of the medical education and training they provide while the GMC Quality Assures the whole system to ensure that its standards for medical education and training are met. Quality Assurance GMC Quality Management Medical Schools Deaneries Commissioners and lead providers Royal Colleges/ Faculties Quality Control Local Education Providers Figure: the GMC s Quality Assurance Framework Within Scotland Deanery, it is the Quality Workstream that is tasked with the responsibility to effect the quality management of postgraduate medical education and training. The 3 key aims of this workstream are to: Effect improvements when deficiencies are identified, Monitor & manage the quality of postgraduate medical education and training provided within training environments within Local Education Providers against the standards that have been set by the GMC, Identify and promote implementation of good practice in postgraduate medical education and training and thus support the quality improvement of medical education and training in all specialties, throughout Scotland. The Quality Workstream is led by a Postgraduate Dean, a GP Director and a General Manager. Deanery Quality Management Group Governance of the Workstream s activities is through the Deanery Quality Management Group (DQMG), that is chaired by the Workstream s lead Postgraduate Dean and GP Director. The Deanery Quality Management Group is accountable for: Compilation of the Dean s Report to the GMC, a key part of the GMC s quality assurance requirements, Determining what intelligence, data and information are necessary to inform our QM and QI processes and to fulfil our quality management responsibilities (including the development of Scotland Deanery s own survey tool, the Scottish Trainee Survey), Ensuring that there is consistent and effective quality management of training across all programmes, 8

11 and that incorporates training in all posts, in all local education providers across Scotland. Delivery of quality management and quality improvement activities is effected through 8 specialty Quality Management Groups, that are described in more detail, below. All of these specialty Quality Management Groups report on their activities to each meeting of the DQMG. Setting the strategy for the Quality Workstream. Development of the Quality Workstream s processes through 6 Quality Workstream working groups. There are working groups on: a. The Quality Improvement of postgraduate medical education and training in Scotland, b. The Improvement of Quality Workstream processes, c. Trainee engagement in Quality Workstream processes, d. Training of Quality Workstream and associated personnel, e. Specialty Training Committee (STC) and TPD engagement, and f. Developing joint undergraduate-postgraduate QM-QI processes including visits. Engagement with internal and external stakeholders (including the Scottish Government & the GMC) Managing the resources (including the personnel) within the Workstream. Membership of the DQMG comprises the 3 Workstream leads, and representation from all 8 specialty Quality Management Groups (see below). The Deanery Quality Management Group meets bimonthly. The Deanery Quality Management Group reports internally within NES to the monthly Medical Directorate Executive Team and to the NES Education and Research Governance Committee (that reports in turn to the NES Board). Specialty Quality Management Groups (sqmg) Surgery Anaesthetics ICM EM Obstetrics, Gynaecology Mental Health Paediatrics Specialty Quality Management Groups Diagnostics Foundation Medicine General Practice, OM & PH Figure: The Quality Workstream s 8 Specialty Quality Management Groups 9

12 The Quality Workstream has 8 sqmgs (figure on previous page): these are responsible for effecting 4 key functions (figure), on behalf of the workstream, for the specialties within their scope: Management of the data and intelligence relating to training in their specialties including their Quality Review Panel (see below). Management of quality management-quality improvement visits in their specialties Management of the lines in the Deanery Report to the GMC that relate to their specialties, and Engagement with external and internal stakeholders around the quality management-quality improvement remit for their specialties (including support for the STB for the same specialties). The work of each specialty Quality Management Grouping, while ongoing and continuous, conforms to an annual cycle (that is described in the following section). sqmgs are separate from, but do work in parallel with and support Specialty Training Boards in their contributions to the QM-QI of postgraduate medical education and training. Engagement QRP, Data & intelligence Management Specialty Quality Management Groups (sqmg) Visit Management Governance Figure: the core functions of the specialty Quality Management Groups Each sqmg is chaired by a LDD, has at least one APGD-Q, has at least one QIM and the support of at least one QIA. The membership of these groups also includes Associate Postgraduate Deans for specialties who bring intelligence around training issues in their specialties, representatives of Foundation and GP-OM- PHM specialty Quality Management Groups, where appropriate, and also have lay, College and trainee input. SQMGs meet bimonthly, and each reports on its activities to each DQMG. Each sqmg also compiles an Annual Report to the DQMG and undergoes an Annual Review of its workload and achievements. 10

13 Scotland Deanery Annual Quality Report Our Annual Quality Cycle 11

14 Our Annual Quality Cycle DQMG STS sqmg STS sqmg DQMG DEC JAN NOV FEB DQMG QRPs sqmg OCT SEP QM-QI visits Throughout cycle Updating Dean s Report to GMC MAR APR STS sqmg GMC NTS open DQMG AUG MAY JUL JUN QRPs DQMG sqmg sqmg TPD reports DME reports GMC NTS results STS DQMG Annual Speciality Reports & Reviews Figure: The Scotland Deanery annual quality cycle The Scotland Deanery quality workstream s QM-QI activities are continuous and on-going, but many of these activities conform to a predictable cycle, our annual quality cycle (figure above). Quality Management (and Improvement) and governance are the principle drivers of this cycle of activity. The cycle starts in August and ends the following July and maps to the training year. Quality management driving the annual quality cycle. Each of the 8 sqmgs starts its annual quality cycle with its QRPs. Among the data considered at the QRP are surveys of trainees feedback from the GMC s annual NTS (this survey typically runs for 6 weeks starting in early April, with results being available to the Quality team from June) and from the NES STS (this end-of-post survey is run over 3 weeks in late November, late January, late March and mid-june with results available 2 weeks later); TPDs and DMEs contribute annually to the information and intelligence considered at the QRP through their TPD and DME reports, respectively, that are submitted in July. The outputs of the QRPs inform the action plans of the 12 sqmgs including the prioritisation of the ensuing QM-QI visits that are conducted throughout the cycle, typically from September through to the following June or July. Following their QRPs, the sqmgs convene bimonthly through the cycle to monitor and respond to further runs of the STS, and to consider new notifications of concern as well as to manage the visits, the reporting of the outcomes of visits and following through on post-visit action plans with DMEs to ensure that improvements result.

15 Scotland Deanery Annual Quality Report Our Processes and Procedures 13

16 Our processes and procedures Central to all of our QM-QI activities is the pursuit of consistency of processes across all of our 8 sqmgs. The journey towards this goal is being managed by the DQMG primarily through its working group on Quality Improvement of Workstream processes. This working group has developed Standard Operating Procedures (so far) for: Quality Review Panels Organisation and management of QM-QI visits A key achievement of has been the development of Visit Calibration Guides that incorporate markers of best practice. These calibration guides describe our expectations of what trainees must experience in training environments to fulfil the requirements that have been defined by the GMC, to meet their standards. These will be used to support QM-QI visit panels in their assessment of the quality of training against the GMC s standards, going forward. QM-QI visits reporting and Enhanced Monitoring. Quality Review Panel 1. The Quality Review Panel is managed by the sqmg that is responsible for managing and responding to the data, information and intelligence about the quality of training and of the training environment in posts that provide training in specialties and programmes within scope of the sqmg. 2. The Quality Review Panel provides the first opportunity, at the beginning of each new training year, for all members of the sqmg (with representatives from Specialty Training Boards, Colleges, DMEs, etc.) to meet together to consider all the quality data, information and intelligence relating to each post in each Local Education Provider, and all training programmes, that have been compiled across the previous 12 months. The aim is to identify those posts or programmes where there are a) potential signals of good practice, b) potential signals suggesting poor practice in training (where GMC standards may not be met) and c) where further information may be required to inform understanding around the quality of training. The Quality Review Panel will determine for each post delivering training and for each programme whether a visit is required to explore issues further or whether any other action may be required. 01 GMC National Training Survey 02 NES Scottish Trainee Survey Quality Review Panel (QRP) 03 Deanery Reports entries 04 Reports on training 05 Notifications of concern 06 Outputs from other QRPs 07 Other reports 14

17 Enhanced Monitoring Enhanced monitoring is a GMC process that can be initiated by the GMC or by the Deanery, in association with the GMC. The Deanery s criteria and escalation processes for Enhanced Monitoring are outlined below. Escalation by Scotland Deanery to enhanced monitoring may be triggered by the following criteria: Existence of significant concerns about training or about the training environment despite Deanery QM processes. Examples (but not the only circumstances) of significant concerns include: a. persisting issues such as GMC National Trainee Survey triple reds or quadruple reds linked to any GMC NTS indicator or b. recurrence of red flags for indicators indicating that improvements have not been sustained, c. further deterioration in indicators of quality of training while engaging in Deanery QM processes d. any circumstance where doctors in training are exposed to risk, undermining would be an example. e. Deterioration of quality of training or training environment despite Deanery QM processes. And Where the local context or circumstances suggest that resolution is unlikely without escalation to enhanced monitoring. Or alternatively Where there has been an external scrutiny process e.g. by HIS or by College that either explicitly highlights significant concerns about the training environment, or that in the context of known Deanery QM data or information suggests that there are likely to be significant implications for the training environment. 15

18 Potential role for EM identified by sqmg following ORP or visit or HIS/College review LDD of sqmg Liaison with Regional PGD Liaison with GMC, NES, MD, Workstream Lead as necessary LDD of sqmg confirms that care fulfils Scotland Deanery EM criteria Press Release QL & QIM of sqmg Summary of issues Regional PG Dean Plan future visits Regional PGD Escalates case to EM & writes to Board MD, CE, DME Head of Medical School/s (If medical students who train in affected department) LDD of sqmg Relevant APGD & TPD Workstream Leads Education QA Manager GMC Liaison with Senior QIM to maintain log Repeated visits as required to demonstrate sustained resolution of issues, until, with GMC approval, case can be closed Regional PGD confirms closure of EM case and QM-QI processes revert to sqmg & LDD of sqmg 16

19 Process for escalation (see flowchart): Responsibility for identifying a site where training or the training environment fulfils the above criteria lies with the LDD for the sqmg. The LDD for sqmg discusses with the local, regional Postgraduate Dean (PGD) prior to finalising the decision to escalate to enhanced monitoring (this step is needed to keep the regional PGD aware and to take account of criterion 3 above) Advice can also be sought from the Quality Workstream Leads, from the NES Medical Director or from the Education QA Programme Manager of the GMC Visits and Monitoring Team. When the decision to escalate to enhanced monitoring has been made the specialty Quality Lead (QL) and QIM should prepare a brief report for the specialty LDD to add any further comments and share with the regional PGD (who hereafter will be the point of contact for the GMC and for the affected Health Board, and the Scotland Deanery enhanced monitoring log) with the following: a. the issue/all issues (that necessitate escalation to enhanced monitoring), b. the Board and the site, and which cohorts of trainees (Foundation, GP, Core &/or Higher) are affected and whether there are medical students as well as doctors in training in this department c. the history including when the issue/issues were first recognised, what QM activity and actions have been effected so far, and why enhanced monitoring has been invoked, and d. the name of the regional PGD who will be the point of contact until the issue is resolved. The specialty LDD should produce a succinct press release (to be available for all cases in the event of this scenario generating press interest) with support from the NES communications department & the NES Medical Director (MD). Both the summary and the press release should be ed to the Quality Workstream Leads including senior QIM (who will update the enhanced monitoring log), and to the regional PGD who will take the lead on this issue through the period of enhanced monitoring and to the NES MD. The regional PGD who will lead on management of the problem through enhanced monitoring will then write a formal letter to confirm that as of the date of the letter, the site & specialty will hereafter be managed and monitored under the GMC s enhanced monitoring process. The summary provided by the LDD will (with editing, if appropriate) be the main substance of the letter. This should be sent to: a. the MD, Chief Executive and the DME for the Health Board responsible for the LEP in question, & copied to b. the LDD originally involved in the decision, c. the APGDs and TPDs for specialty and for the cohorts of trainees covered by the scope of the case (consider higher training, core, GP training and Foundation APGDs and TPDs) and to d. the Quality Workstream leads & e. the Education QA Programme Manager of the GMC Visits and Monitoring Team. The Quality Workstream Leads will liaise with the sqmg to agree (when there are more than one of either or both) which QL and which QIM will work with the regional PGD on supporting the associated QM activities going forward. The QL and QIM of the specialty QMG will be responsible, with the regional PGD, for providing updates to the senior QIM who will update the enhanced monitoring log on SharePoint including updating dates of next visits, as these become available When eventually the issues have been addressed, and when the PGD has agreed with the GMC that resolution of the issue/s is evidenced and shown to be sustained - closure of the enhanced monitoring case should be formally communicated by the regional PGD through written communication, to all those listed in section 7. The enhanced monitoring log will be updated to reflect removal of this case. 17

20 Governance of quality processes relating to enhanced monitoring sites Responsibility for the quality management and quality improvement processes relating to a site (irrespective of specialty or training programme) that has been escalated to the enhanced monitoring process lies with the regional PGD; the regional PGD will also be the point of contact for communications around this site and its issues with the GMC, the Health Board responsible for the site and with Scottish Government Health Department. Administrative support to the regional PGD for the quality management and quality improvement processes relating to a site that has been escalated to the enhanced monitoring will be from the QL/s and QIM/s of the QMG for the specialty/specialties that are within scope of the enhanced monitoring case. In all circumstances other than for sites under enhanced monitoring, responsibility for the quality management and quality improvement processes relating to training in any specialty in any site in any region within Scotland Deanery lies with the LDD for that specialty and administrative support is provided by their sqmg. Tracking and sharing awareness of progress in sites on enhanced monitoring A log of all sites on enhanced monitoring within Scotland Deanery will be maintained and be accessible on NES SharePoint. This log will include the background to the need for enhanced monitoring, and progress towards resolution will be updated after each visit. Responsibility for the maintenance and integrity of the log lies with the Quality Workstream senior QIM. The Quality Workstream Lead will provide a status report on all enhanced monitoring sites monthly (by end of the first week of each calendar month) for the Scottish Government Health Department; this will be shared with the NES MD. The Quality Workstream senior QIM will provide quarterly updates on the status of all sites on enhanced monitoring to the GMC for publication on their website, as required by the GMC. 18

21 Scotland Deanery Annual Quality Report Our Team 19

22 Professor Alastair McLellan Workstream Postgraduate Dean Mr Duncan Pollock Workstream General Manager Professor David Bruce Workstream GP Director Mrs Lesley Metcalf Senior Quality Improvement Manager Medicine Mental Health Anaes/ICM/EM Diagnostics Surgery Obs/Gyn/Paeds Foundation GP/OM/PH Lead Dean/ Director Associate Postgraduate Deans Quality Improvement Managers Professor Alastair McLellan Professor Hazel Scott Dr Stephen Glen Dr Alan McKenzie Vacancy Ms Helen Renton Professor Ronald MacVicar Dr Santinder Bal Professor Hazel Scott Ms Theresa Savage Professor Ronald MacVicar Dr Kim Walker Dr Claire Vincent Professor Clare McKenzie Dr Fiona Ewing Ms Kelly More Ms Kelly More Professor William Reid Dr Adam Hill Dr (Ms) Kerry Haddow Vacancy Ms Megan Lanigan Ms Jill Murray Professor David Bruce Dr Peter MacDonald Dr Kevin Holliday Ms Theresa Savage Professor Anthea Lints Dr Fiona Drimmie Dr Geraldine Brennan Professor Moya Kelly Dr Kenneth Lee Dr Amjad Khan Dr Ali Sneddon Dr Gordon McLeay Dr Mei Ling Denney Dr Sharon W Ogilvie Ms Jill Murray Ms Jane Walls Regional Office Inverness Aberdeen Dundee Edinburgh Glasgow Quality Improvement Administrators Ms Lorna McDermott Ms Maggie Read Mr Steven Young Ms Gayle Hunter Vacancy Ms Anna Armstrong Mr Bryan Ewington Ms Elizabeth Johnstone Ms Fiona Conville Administrative support is provided on a regional office basis, broadly aligned to the local QIM portfolio and to regional work required by QIMs based elsewhere. 20

23 Scotland Deanery Annual Quality Report The GMC Dean s Report

24 The GMC Dean s Report The Dean s Report is a key component of the GMC s quality assurance system whereby postgraduate deaneries report on their quality management activities. The report is populated with significant concerns about training or about training environments that have been identified by the GMC and by the deanery. The 2015 Scotland Deanery Dean s Report contained our commentary on 117 published items, on 74 confidential items and on 9 enhanced monitoring cases. The GMC routinely provides feedback on the content of every Dean s Report. What the GMC said about the 2015 Scotland Deanery Dean s Report: The quality of the information provided in this Dean s report is excellent. This is a high quality submission, reflecting both the creation of a single Scotland Deanery (April 2014) and the more recent reorganisation of quality management processes along specialty rather than geographical lines. It is clear that a lot of work has been undertaken to ensure that the responses provided and decisions made regarding RAG Ratings and Statuses are consistent across sites and specialties, in light of both changes. Overall, we agree with 95% of your RAG ratings. The range across all deaneries and HEE local offices is % and the average is 91%. We agree with 98% of your statuses. The range across all deaneries and HEE local offices is % and the average is 90%. It was agreed that 48 published items could be closed (many related to LEPs in Greater Glasgow & Clyde that had been closed in association with the opening of the Queen Elizabeth University ). We have since provided an update to the GMC (as requested) on whether the issues noted at the sites that have since closed have carried across to the Queen Elizabeth University (QEUH); this commentary was informed by several QM-QI visits that the sqmgs have undertaken to look at speciality training across this site, as this is a new training location. Significant concerns were identified in training in Medicine at the QEUH, and following 2 visits, this has since been escalated to the GMC s enhanced monitoring process. Following sqmg triggered visits to other sites, since receiving the GMC s feedback on the Dean s Report, we have also updated the GMC on 17 items in the Dean s Report relating to issues in NHS Ayrshire & Arran (University Ayr & University Crosshouse), and on other issues in NHS Greater Glasgow & Clyde (Inverclyde Royal multiple specialties), NHS Lothian (Royal Infirmary of Edinburgh Obstetrics & Gynaecology, & Western General Medical Oncology) and NHS Tayside (Ninewells Obstetrics & Gynaecology). On our joint management of cases on enhanced monitoring the GMC said: The GMC have supported a number of Deaneryled enhanced monitoring visits this year, and it is encouraging to see that a number of these cases are progressing, despite considerable challenges. What the GMC said about the 2015 Scotland Deanery Dean s Report: The updates from the deanery on patient safety and undermining comments from the National Training Survey (NTS) indicate that these concerns have been investigated thoroughly and that appropriate action has, or is being taken to address issues. The introduction of Quality Review Panels (QRPs) has contributed to this, with evidence in the DR updates that concerns at particular sites are being discussed at the QRP, resulting in decisions being taken for triggered visits where required. A good example of where the QRP found concerns over the lack of progress and therefore recommended a triggered visit is item WOS In 2016, the GMC introduced a new Online Dean s Report whereby reporting on QM activities has changed from an annual submission (by 31st October) to real time online reporting. The Scottish rollout of this new system, that aims to be more responsive to risks including concerns about patient safety, was in June To pave the way for this radical change in the process for reporting to the GMC, the Quality workstream ran a workshop for the Quality team on the new system on Friday 11th March Now that we have access to the system, a further workshop for the Quality team and for LDDs was held on the 9th September 2016, to review our learning from using the new system and to refine our workflow around by drafting a standard operating procedure(sop) A key element of NHS Education Scotland s Board Governance processes is presentation of the Scotland Deanery Dean s Report and the GMC s feedback on our report. Both were presented to and discussed by NES Education and Research Governance Committee on the 18th February

25 Scotland Deanery Annual Quality Report The Training Year in Numbers

26 The Training Year in Numbers Scotland Deanery Quality Workstream Doctors in Training Enhanced Monitoring Cases* GMC Approved Programmess QM-QI Visits Programme Visits 6 70 Site Visits Triggered Visits Scheduled Visits GP ES Approvals GP Practice Approvals *EM cases at end of

27 Scotland Deanery Annual Quality Report The Training Year

28 The training year Enhanced monitoring Enhanced monitoring is a GMC process that can be initiated by the GMC or by the Deanery, in association with the GMC whereby the GMC provides support to a Deanery to facilitate resolution of issues within a training environment, that otherwise might be difficult or slow to resolve. The GMC published guidance in 2016 on its enhanced monitoring process for organisations with quality management responsibilities. The quality workstream conducted a workshop on 11th March 2016 for workstream personnel on enhanced monitoring (and also on the Dean s Report) to review our processes and learning from current cases. This learning was incorporated into the Scotland Deanery policy on enhanced monitoring that was endorsed by MDET on 14th March Overview of enhanced monitoring in Scotland In August 2015 Scotland Deanery had 10 cases on enhanced monitoring. 2 new cases were added to Scotland Deanery s log of enhanced monitoring cases between 1st August 2015 & 31st July 2016: NHS Lothian Dermatology at the Lauriston Clinic, escalated to enhanced monitoring in September 2015, NHS Greater Glasgow & Clyde (GG&C) Medicine at QEUH, escalated to enhanced monitoring in May Between 1st August 2015 & 31st July 2016, 1 enhanced monitoring case was closed due to resolution of the concerns and has now been removed from Scotland Deanery s log of enhanced monitoring cases: NHS Grampian Emergency Medicine at Aberdeen Royal Infirmary. Between 1st August 2015 & 31st July 2016, 1 enhanced monitoring case was partially closed: NHS Lanarkshire Emergency Medicine at Hairmyres has been removed from the enhanced monitoring log due to resolution of concerns, but training in Medicine, Surgery and Trauma & Orthopaedic Surgery at Hairmyres remain on enhanced monitoring, currently. As of 31st July 2016 Scotland Deanery had 11 cases on enhanced monitoring. Table shows the QM-QI visits that have been conducted by Scotland Deanery in association with the GMC to sites on enhanced monitoring in Scotland between 1st August 2015 & 31st July joint visits with the GMC under the auspices of enhanced monitoring have been conducted during this period, with a further 2 visits conducted by the Medicine QMG to QEUH-Medicine that resulted in subsequent escalation of this site to enhanced monitoring on 17th May

29 GMC ref Board: LEP Unit/ programme/ trainee cohorts Date placed on EM Visits in Outcome QA4775 GG&C: Royal for Sick Children Paediatric Cardiology (FY, GPST, CMT & Higher) 30/04/16 22/01/16 Revisit Sept/Oct-16 QA4888 & QA5157 GG&C: Beatson West of Scotland Cancer Centre Clinical Oncology and Medical Oncology (FY, GPST, CMT & Higher) 09-Oct-2014 for Foundation, GPST & CMT. 01 June 2015 for ST in Clinical & Medical Oncology 01/12/15 Revisit 01/10/16 QA4926 GG&C: Vale of Leven General Medicine (Foundation, GPST) 28/01/15 19/01/16 Revisit Nov 2016 Lanarkshire: Hairmyres Medicine (Foundation, Core, GPST, Higher) 17/03/14 03/12/15 Revisit Sep 2016 QA5336 Lanarkshire: Hairmyres General Surgery, T&O (Foundation, Core, GPST, Higher) 17/03/14 04/03/16 Mar-17, date tbc Lanarkshire: Hairmyres Emergency Medicine (Foundation, Core, GPST, Higher) 17/03/14 19/04/16 Closed QA4757 Lanarkshire: Monklands Lanarkshire: Monklands Medicine (Foundation, Core, GPST, Higher) General Surgery, T&O (Foundation, Core, GPST, Higher) 17/03/14 17/12/15 Revisit Oct /03/14 18/03/16 ~Mar-17 tbc 27

30 GMC ref Board: LEP Unit/ programme/ trainee cohorts Date placed on EM Visits in Outcome QA5337 Lanarkshire: Wishaw General Lanarkshire: Wishaw General Medicine (Foundation, Core, GPST, Higher) General Surgery, T&O (Foundation, Core, GPST, Higher) 17/03/14 [Last visit June- 15] Sept-16 tbc 17/03/14 03/12/15 27-Sept-16 QA4924 Grampian: Aberdeen Royal Infirmary General Surgery (Foundation, Core, GPST, Higher) 08/12/14 19/11/15 ~Nov-16 tbc QA4876 Grampian: Aberdeen Royal Infirmary Emergency Medicine (Foundation, ACCS, GPST, Higher) 27/08/14 04/05/16 Closed QA5026 Highland: Caithness General General Surgery, Medicine (Foundation, GPST) 31/03/15 [Last visit May- 15] No trainees at site, revisit after resolution and trainees are reallocated to site QA5156 Lothian: Royal Infirmary of Edinburgh Vascular Surgery (Higher) 01/06/15 07/04/16 tbc QA5356 Lothian: Royal Infirmary of Edinburgh (Lauriston Buildings) Dermatology (Foundation, Higher) 29/09/15 21/01/16 ~Jan-17 QA8234 GG&C: Queen Elizabeth University Medicine (Foundation, Core, GPST, Higher) 17/05/16 [27-Oct-15 & 13-May-16 & escalated to EM subsequently] ~Dec-16 28

31 Case Study From intense scrutiny to inspirational quality improvement. The GMC, as the regulator of medical education in the UK has shown significant interest in NHS Grampian over the last two years. This feeling of scrutiny was heightened by a review of services from Healthcare Improvement Scotland (HIS), press coverage and significant pressure on the Board s managerial structures. One of the departments under intense scrutiny was the Emergency Medicine department at Aberdeen Royal Infirmary. Some concerns relating to the quality of the learning environment and the trainee experience, in particular for senior trainees emerged in 2013 and were foregrounded at a routine Deanery Quality Management visit. Challenges relating to the quality of communication, service pressures (including those resulting from service redesign) and recruitment challenges were found to be having an adverse impact on training, and concerns about the variability of clinical supervision provided a particular focus. A lack of progress against the conditions that had been set at this visit was evident through the regular monitoring process, and apprehensions were fuelled by; a concerning number of red flags relating to the Emergency Department from the 2014, a number of trainee-reported patient safety concerns raised through the survey, and concerns that had emerged at the HIS inspection visit. A visit team that included a HIS representative and the Chair of the relevant Specialty Training Board in Scotland visited in October 2014 and found some improvement but remaining concerns resulted in the department being escalated to the GMC s Enhanced Monitoring arrangements. These concerns included: Patient flow issues and the impact on training A lack of a common understanding and language between clinical and senior managerial staff A loss of focus from the senior medical staff on the importance of training Variable quality and availability of supervision As a result of this level of scrutiny it became clear to the staff in the department that its continuing role in training was under significant threat and that fundamental change was required. The Deanery through its QM-QI responsibilities supported this necessary change, which has resulted from transformational educational and clinical leadership within the department a renewed focus on the importance of training to the senior medical staff and the department as a whole investment in developing the educational culture within the department meaningful trainee engagement a relentless focus on the trainee experience, including rostering, protected time, provision of feedback, induction and handover At a re-visit six months later, which included GMC representation, significant improvements were evident. The improvements were seen to be sustained at a further visit in May 2016 (again under the Enhanced Monitoring arrangements) and the results of the GMC s 2016 National Trainee Survey has shown maintained excellent trainee feedback about their training experience. The result has been that the department has now been de-escalated from the Enhanced Monitoring. At the end of the most recent Enhanced Monitoring process visit, on completion of the extremely positive verbal feedback from the lead visitor, the visited received a round of applause from the visitors: not an every-day occurrence! Professor Ronald MacVicar Postgraduate Dean 29

32 Foundation Foundation Doctors in Training Enhanced Monitoring Cases* GMC Approved Programmess QM-QI Visits Programme Visits 0 2 Site Visits Triggered Visits 2 0 Scheduled Visits The quality of Foundation training was assessed in 54 of the 70 site visits conducted by the Deanery *EM cases at end of

33 Overview Professor Anthea Lints, GP Director and Lead Dean/Director for Foundation I am delighted to be the Lead Dean/Director for Foundation and have enjoyed working with an efficient, professional and hard-working team, all of whom have engaged with the new Quality Management Programme with enthusiasm. We are particularly grateful for constructive comments from our lay member which have brought a different and helpful perspective to our discussions and decisions. It has become apparent that the quality management of Foundation Programmes in Scotland is complex, involves large numbers of trainees and an enormous volume of information and data to assimilate, manage and evaluate. The Foundation Specialty Training Board chaired by Duncan Henderson, has been particularly helpful in enabling the integration of the Foundation QMG report into its agenda, enabling useful discussion and sharing relevant intelligence. In addition, the willingness of other Specialty Quality Management Groups (sqmg) to include a Foundation representative has been invaluable in triangulation and identification of issues that would otherwise have been less well understood. Overall satisfaction with Foundation Training in Scotland compared to the rest of the UK Overall satisfaction with Foundation training in Scotland markedly improved in the period covered with both Foundation Years moving to 7th in the UK rankings in 2016 from 11th (FY1) and 12th (FY2) place in Overall satisfaction 2015 NTS 2016 NTS Foundation Yr1 11th of 15 7th of 16 Foundation Yr2 12th of 15 7th of 16 The 2015 GMC NTS identified three Scottish Foundation Programmes in the top 10 for overall satisfaction, namely those in Dumfries and Galloway, Fife & Forth Valley Health Board areas. Foundation QRPs 2015 The QRP for Foundation Training having reviewed all of the available data, information and intelligence relating to Foundation Training determined need for the following actions: 19 triggered visits 61 APD enquiries 4 FPD enquiries 4 QIM enquiries There were 57 visits that included Foundation trainees. Visit to education providers involving exclusively Foundation Trainees Trainee Site NHS Board Specialty Visit type cohorts University Ayr Dr Gray s Ayrshire and Arran Date of visit General Surgery Triggered FY1, FY2 10/03/2016 Grampian Whole site visit Triggered FY1, FY2 18/03/2016 NB: Foundation Trainees are addressed by other specialty visits, limiting the requirement for Foundation only visits. 31

34 Governance Under the Chairmanship of Professor Anthea Lints, the Foundation QMG met 5 times (including the QRP) over the course of the training year and was represented at all DQMGs via highlight papers and formal minutes to ensure transparency and formal oversight. Key issues and improvements Our first annual quality review on the 20th June enabled a critical review of our first year. We identified our key priorities for improvement. In summary: i) Content of Posts The length of some foundation placements were too short to be of real educational value. Attendance at protected teaching was often trumped by service demand. Foundation trainees are often expected to do non-educational tasks. Some posts lack appropriate experience. Moreover, gaps in rotas contribute inevitably to a less satisfactory clinical and educational experience. These recurring issues will be specifically addressed during Deanery QM visits. ii) Inclusion in Visits involving Foundation Trainees The Foundation QMG would like to be included in the visiting team where foundation trainees are involved and if that is not possible, be invited before the visit to provide information ahead of the visit. Whilst recognising the value of generic visiting teams, there are often issues unique to foundation training that risk being overlooked. In line with this, the Foundation QMG would prefer any visit it triggers to be allocated to Foundation Associate Postgraduate Deans (Q). iii) Engagement with the Quality Agenda The frequency and timing of Foundation QMG meetings was noted as an issue particularly for consortia leads in the West and those with limited protected time. The solution lay in better programming of meetings. Nevertheless, the Foundation QMG is confident that the new QM-QI system gives robust consideration to Foundation trainee concerns and that all are taken seriously and dealt with appropriately. Foundation training is seen as an equal partner in the QM- QI system. To strengthen this, Foundation QMG representatives have been aligned to other sqmg to provide information and support. Foundation QMG members proactively review all other sqmg visit schedules and regularly offer support. On further reflection, the success of the Foundation sqmg has been influenced by: a clear understanding of purpose sensitive to trainee opinion and concerns working together as a team representation from all regions supported by two quality leads and a quality manager commitment to improvement and equality of opportunity constitution of group is such that the majority have worked together within the Scotland Foundation School before so that roles and responsibilities are clear and communication well-established. 32

35 Achievements in the last twelve months include: creating an agenda that is fit for purpose engagement more active involvement in quality management visits especially those to sites that include foundation trainees Moving forward the group has identified as priorities for as: maintaining the Foundation School as a distinct and recognisable entity need to develop a more robust system for the approval/re-approval of General Practices which host Foundation Trainees identifying and promoting examples of best practice a section dedicated to Foundation on the Scotland Deanery website enabling trainees to find relevant information in one place aspiring to improve clinical experience and educational opportunity working to improve retention within Scotland 33

36 General Practice, Public Health, Occupational Health General Practice OM & PH Doctors in Training Enhanced Monitoring Cases* GMC Approved Programmess 20 2 QM-QI Visits Programme Visits 1 (OM) 1 Site Visits Triggered Visits 1 0 Scheduled Visits The quality of GP training in hospital posts was assessed in 44 of the 70 site visits GP ES Approvals GP Practice Approvals *EM cases at end of

37 Overview The first year of the new Quality Management process is coming to an end and it has had significant impact on General Practice. GP teams have always worked on a Scottish basis but the new process has allowed even more collaboration across regions resulting in communal paperwork for practice visits and educational supervisor accreditation as well as ensuring regional QM meetings function in the same way. Professor Moya Kelly, GP Director and Lead Dean Director for General Practice OH and OM The sqmg has enabled a global view of the quality of GP training in both primary and secondary care and we value the greater focus and involvement of GP in hospital visits. The biggest challenge for the sqmg has been managing the workload related to the large number of practice visits. We are continually refining the process. Externality is something that is valued by the group and we have external representation on the rqmgs from the APGDs (Q) that we hope to extend to practice visits. The sqmg wishes to develop our processes further in the next 12 months. We will be looking at QM of out of hours training and have an action plan in place. Details of that can be seen in this report. Overall satisfaction with training in General Practice in Scotland compared to the rest of the UK. There has been a significant improvement in Overall satisfaction across General Practice posts in hospital based placements as reported in the 2016 NTS. The GP placements also rated highly and although down in position from 2015, the difference in score from 1st to 5th was not statistically significant. The results for Occupational Medicine are marginally worse with Scotland s posts rated the least satisfying in the UK, having previously been second worst. Public Health by contrast rated very highly in 2016 moving up six places from 8th place to 2nd place in the UK. Overall satisfaction 2015 NTS 2016 NTS GP posts in secondary care 15th of 17 8th of 16 GP posts in Practice 2nd of 17 5th of 17 Occupational Medicine 10th of 11 10th of 10 Public Health 8th of 16 2nd of 15 General Practice/OM/PH QRP 2015 The QRP for General Practice Training, having reviewed all of the available data, information and intelligence relating to General Practice Training determined need for the following actions: The role of the QRP is to review the quality of training provided in sites approved for GP training in the hospital sector. It does not review the General Practice based training sites. This is undertaken by the sqmg and the activity can be seen in the activity of sqmg section below. The QRP reviewed 68 hospital training sites for GP and the panel made 15 recommendations for a triggered visit, and five recommendations for enquiries. No immediate triggered visits were recommended. The panel also flagged up some sites as being of concern but recommended triangulation of data with other trainee levels before making recommendation for a visit. The panel noted lots of excellent experience in psychiatry training posts across a number of sites in 35

38 Scotland. The panel also noted the transition period in NHS GG&C where a number of posts have transferred to the new QEUH and recognised that some of the survey data referred to the old posts, whereas any visits taking place will be to the new posts. These sites would be reviewed in more depth at the 2016 QRP once more site-specific data will be available. The QRP for Occupational Medicine Training, having reviewed all of the available data, information and intelligence relating to Occupational Medicine Training determined need for the following actions: The QRP recommended a scheduled visit in 2016 in the form of a national/programme visit, bringing together all trainees and trainers to one location The QRP for Public Health Medicine Training, having reviewed all of the available data, information and intelligence relating to Public Health Medicine Training determined need for the following actions: The QRP agreed that a future visit was necessary but that it should be a scheduled visit, arranged for 2017 following a further review of data (including STS) at the 2016 QRP. A decision as to whether to arrange a programme/national visit or separate regional visits will be made at the QRP stage in Activity of GP/OM/PH sqmg Each region has a regional Quality Management Group (rqmg) that reviews all the approval paperwork submitted by the ES and the training practices. The group make recommendations on some ES approvals and practice approvals where formal visits are not required. These reports and the reports from the practice visits go to the sqmg for a final decision. Each rqmg has an external from another region to ensure consistency of process and decision making. The activity of the sqmg covers the following areas 1. Review of all hospital visit reports involving GP trainees 2. Approval of all Training practice accreditation 3. Approval of all GP educational Supervisor accreditation 4. Approval of Foundation training practices that are also GP training 5. Approval of Retainer practices New Educational Supervisors are approved for two years, with existing ES s being approved for a maximum three years. Similarly, new training practices are accredited for a maximum of 2 years and revisited and existing practices for a maximum of 3 years. Educational Supervisors and Training Practices that are in need of additional time due to outstanding items or concerns will be given a shorter length of approval and will be followed up by the GP/OM/PH sqmg. GP Practice Visits managed by GP- QMG Triggered (site) 15 Triggered (programme) N/A Triggered (revisit) 0 Enhanced monitoring (revisit) 0 Enhanced monitoring (initial) 0 Scheduled (site) 296 Scheduled (programme) N/A Joint Undergraduate -Postgraduate visits (Triggered/scheduled) 0 Total 311 visits 36

39 Governance Under the Chairmanship of Professor Moya Kelly, the GP/OM/PH QRP met once and the sqmg met 5 times over the course of the training year and was represented at all DQMGs via highlight papers and formal minutes to ensure transparency and formal oversight. Key issues and improvements General Practice The GMC survey of trainees in GP Practice posts ranks the Scotland Deanery 2nd of 17th in the United Kingdom. This is a major achievement and a tangible measure of the high quality education and training that takes place in practices, provided by GP Educational Supervisors with Deanery support. In comparison to the GMC survey results for GP posts, the Scotland Deanery was ranked 15th of 17 in the UK for secondary care posts used in GPST. This is disappointing and a significant contrast to trainee experience in General Practice. The sqmg seeks a better understanding of the issues to help facilitate an improvement in the training environment and experience in secondary care GP training posts. Routine visiting to all LEPs will now take place every 5 years with greater focus on specialty training groups including GPST. Specific recommendations relevant to GPST are now being made with action plans being put in place. It is hoped this will raise training standards and that this will be reflected in the GMC survey. The advent of sqmg has successfully drawn together a large number of individuals in each region, with already established local processes, to work together in taking forward QM for GP. The logistics of managing such a large group has been challenging at times and has resulted in procedural change for all, but the group is now working collaboratively with good regional representation to progress QM across Scotland. Although significant progress has been made in sqmg structure and function the workload of the group is vast. Due to the large number of Practice locations and individual ES s requiring approval/re-approval in General Practice, rqmgs have been established to cope with the workload involved. The groups produce summary recommendations for sqmg for new Educational Supervisors and those practices and ES s whose re-approvals are being considered without an actual visit or meeting. Alterations to documentation submission have already been made. To help with this new Educational Supervisor applications are being dealt with at RQMG level with a summary provided to sqmg. The group will further review process and documentation with the aim of further streamlining. There is some inconsistency between regions as regards which date should be used for approval/reapproval on GMC Connect. Some regions use the date of the meeting as the starting point for the approval and others advance existing approval dates by the new approval period recommendation. A consistent approach should be established. However different approaches to rqmgs have been observed. While some regional variation needs to be taken into account e.g. geography and numbers of ES s and practices to be considered. Terms of reference for the rqmg will be developed. A set of principles have been agreed and will be implemented in the coming year. Prior to the establishment of the sqmg the Assistant Directors worked to produce common documentation for the approval and re-approval of GP Training Practice locations and Educational Supervisors mapped to the Academy of Medical Educator and GMC standards. Further document modification has taken place to refine the summary reports allowing greater consistency of recommendations and approval periods and facilitating easier collation of data. Progress has been made on consistency of recommendations for practice/es approvals and requirements e.g. time frames set for WPBA calibration, peer review of teaching, E&D training etc. and the differentiation of mandatory requirements and developmental suggestions. Actual site visiting/es meetings within the approval/re-approval process is well-established across Scotland and a common set of documentation is now in use. New ES s and Training Practices are initially approved for 2 years with 3 years being the norm for re- approval. A set of conditions that would trigger an earlier review has been developed. 37

40 External representation is now routinely occurring at rqmgs providing national oversight of procedures and approvals locally. A process has been developed for Quality Managing training locations following practice mergers. Retaining practice approval process has been refined by the Retainer Scheme Associate Advisors and incorporated into the rqmg/sqmg system. An agreed process and documentation for the QM of Occupational Medicine The sqmg has decided that all data will be handled at a programme level due to the lack of site data. The TPD for OM is a member of the sqmg. This allows a focus on this specialty which is an outlier in terms of quality indicators. Occupational Medicine is well represented at the Public Health Public Health is unique because non-medical applicants may be accepted for PH training. There are currently only 16 trainees, which means that data is difficult to gather and use meaningfully. As with OM this dictates a tailored programme approach reliant on TPD input to the sqmg. GP trainee experience in the Out of Hours environment has been produced. This involved protracted but successful negotiation with the national out of hours service operational group. This will be piloted this summer in the East Region Foundation Training It has been agreed that where a GP Training Practice also take Foundation trainees, that approval will be given for Foundation at the same time as for GP training. STB and benefits from specific time built into the STB agenda to discuss OM business including Quality of training. There are currently 12 approved OM trainee posts in Scotland, but only 8 are filled, due in part to a shortage of supervisors. This situation is now being addressed. It is recognised that OM and PH are different from many medical specialties and therefore the pre-visit forms used for trainee feedback and the question guide for visitors have been modified with bespoke questions to be used in visits 38

41 Anaesthetics, Intensive Care Medicine, Emergency Medicine Anaesthetics, ICM & Emergency Medicine Doctors in Training Enhanced Monitoring Cases* GMC Approved Programmess 30 6 QM-QI Visits Programme Visits 0 6 Site Visits Triggered Visits 4 2 Scheduled Visits *EM cases at end of

42 Overview The Lead Dean/Director role for Emergency Medicine, Anaesthetics and Intensive Care Medicine has been a fulfilling one over the last year. The Specialty Training Board is a very cohesive Board, ably led by Eddie Wilson and it has welcomed the addition of the sqmg report and intelligence into its agenda and discussions. The Quality Review Panel (QRP) in September 2015 was a new venture for all of us and it became rapidly evident that we had over-estimated the time it would take to address the task at hand, but significantly under-estimated the work involved for Kelly More and her team in preparing for this task. The quality of support offered by Kelly and her team has been excellent. The quality agenda in this specialty Professor Ronald MacVicar, GP Director and Lead Dean/Director for Anaesthetics, ICM and EM grouping has been expertly supported and driven forward by our two Quality Leads, Kim Walker and Claire Vincent. The visits that have taken place as a result of the decisions taken in the QRP have been described elsewhere in this report, and, having led the majority of them it has been really pleasing to see the level of engagement, transparency and enthusiasm that has been evident in these visits. Also evident in the two Enhanced Monitoring sites in our specialty grouping that were visited, were significant improvements, to the level that we anticipate that they will be deescalated from Enhanced Monitoring status. This is no mean achievement and testament to the commitment and leadership within these units. The final act in one of these visits was a round of applause offered to the visited by the visitors. Not something I have witnessed before! Overall satisfaction with Anaesthetics, ICM and EM Training in Scotland compared to the rest of the UK. ACCS posts were viewed relatively as the second most satisfying ACCS posts in the UK having moved up 8 places from 10th position in Anaesthetics saw a marginal improvement from 4th to 3rd in the UK. Core anaesthetics, like ACCS also jumped 8 points, moving from 11th position to 3rd most highly rated posts in the UK. Likewise, Emergency Medicine also improved, rising form 8th in the UK to 4th. Conversely, Intensive Care Medicine fell away to 5th position, having previously been ranked 2nd in the UK. Overall satisfaction 2015 NTS 2016 NTS ACCS 10th of 16 2nd of 17 Anaesthetics 4th of 17 3rd of 17 Core Anaesthetics 11th of 17 3rd of 17 Emergency Medicine 8th of 17 4th of 17 Intensive Care Medicine 2nd of 14 5th of 14 Anaesthetics, ICM and EM QRPs 2015 The QRP for Anaesthetics, ICM and EM Training having reviewed all of the available data, information and intelligence relating to Anaesthetics, ICM and EM Training determined need for the following actions: 4 Triggered visits 1 DME enquiry 2 Scheduled visits 13 TPD enquiries QIM enquiries

43 Visits to education providers Site NHS Board Specialty Visit type Queen Elizabeth University Queen Elizabeth University Inverclyde Royal Hairmyres Hairmyres Aberdeen Royal Infirmary Trainee cohorts Date of visit GG&C EM Scheduled FY, ST, GPST 05/11/15 GG&C Anaes Scheduled FY, Core, ST 05/02/16 GG&C Anaes Triggered Core 16/03/16 Lanarkshire EM Enhanced Monitoring FY, GPST, ST 19/04/16 Lanarkshire Anaes Triggered Core, ST 20/04/16 Grampian EM Enhanced Monitoring FY, GPST, ST 04/05/16 Governance Under the Chairmanship of Professor Ronald MacVicar, the Anaesthetics, ICM and EM sqmg met 6 times (including the QRP) over the course of the training year and was represented at all DQMGs via highlight papers and formal minutes to ensure transparency and formal oversight. Key issues and improvements Many of the Consultants in the departments visited did not have protected time in their job plans specifically for supervision but this is not unique to EMA and should hopefully be rectified by the GMC Recognition of Trainers deadline of 31 July Other common themes, again not unique to EMA, were around non-medical staff not being formally involved in induction and around achieving the balance between service versus training. There is a need to strengthen the interface and attendance on the sqmg of the APGDs. To rationalise the use of sessional time spent in meetings, a pragmatic decision was made to programme the sqmg to immediately precede the STB. It is hoped that this may improve attendance at these meetings by APGDs. There needs to be visits undertaken to Intensive Care Medicine as there is not much data available about this specialty and also consideration given as to how to obtain feedback from ACCS trainees. The sqmg Team is fully engaged with the quality process and found visits to be very positive with high levels of engagement, transparency and enthusiasm shown by Boards. All visits identified by the QRP have been undertaken and action plans are in place to ensure that any requirements outlined are met. The two sites that were under Enhanced Monitoring in Emergency Medicine in Hairmyres and Aberdeen Royal Infirmary have now been taken off Enhanced Monitoring. The joint UG/PG visit with Aberdeen University to EM in Aberdeen went very well and it was fully integrated with all groups being asked about their interaction with UG students and all comments included in the visit report. The sqmg is team proud of how well it works together and of its engagement and interactions with Boards. All reports were received by the DME and departments within the six-week turnaround time and often before that timescale. 41

44 Diagnostics Diagnostics Doctors in Training Enhanced Monitoring Cases* GMC Approved Programmess 16 9 QM-QI Visits Programme Visits 1 8 Site Visits Triggered Visits 3 6 Scheduled Visits *EM cases at end of

45 Overview The diagnostics specialties are a diverse group of specialties with many containing only a small number of trainees. This has posed difficulties in collating survey data in some specialties and hence our ability to have a full overview of the quality of training at QRP. There are other specialties that have sufficient trainees to gather important survey data about training and this has been very useful. These sqmg has undertaken both triggered and routine visits. In light of the data issues we have also piloted a multisite programme visit using video and teleconferencing. This format seemed to work well however it should be highlighted that the programme is performing well and for programmes which have more issues, the process may not be as useful. Further pilots will be necessary. None of the diagnostic specialties are on enhanced monitoring. Informal feedback from TPDs in some of the specialties visited has been mixed about the new Professor Clare McKenzie, Postgraduate Dean and Lead Dean/Director for Diagnostics Scotland QM-QI process. They have raised issues about the format of the set questionnaire which they feel does not allow the full opportunity to emphasise work that has been undertaken to improve training within their programmes. To address this, I have set up two Scotland wide meetings with specialty wide TPDs following the visits. At these meetings, we have the QM reports and focused on the positive changes TPDs have made. These have been seen as helpful and provide peer support for TPDs. Staffing issues are causing some difficulties in the diagnostic specialties both in terms of failure to recruit to niche specialties and also in terms of the non-medical staffing levels. It is recognised that these staffing issues do not receive as much attention as acute front door staffing problems but none the less are causing pressure within the training environment. The implementation of the new Core Infection Training programme is starting to have an effect on trainee availability within the associated specialties this has not been anticipated by service leads and will need further discussion as the effect increases with increased number of CIT trainees. This will be taken forward by STB. Overall satisfaction with Diagnostics Training in Scotland compared to the rest of the UK Clinical Radiology remains high in the UK ranking whilst Histopathology has climbed from eighth in the UK to 6th. Medical Microbiology & Virology and Chemical Pathology were not reported in Overall satisfaction 2015 NTS 2016 NTS Clinical Radiology 3rd of 17 4th of 17 Histopathology 8th of 15 6th of 15 Medical Microbiology & Virology 10th of 11 N/A Chemical Pathology 4th of 17 N/A Diagnostics QRP 2015 The QRP for Diagnostics Training having reviewed all of the available data, information and intelligence relating to Diagnostics Training determined need for the following actions: 3 Triggered visits 5 Scheduled visits 1 Scheduled programme visit 43

46 Visits to education providers Site NHS Board Specialty Visit type Queen Elizabeth University Queen Elizabeth University Royal Infirmary of Edinburgh Royal Infirmary of Edinburgh Queen Elizabeth University Glasgow Royal Infirmary Hairmyres Aberdeen Royal Infirmary Scotland) GG&C Chem Path & Histopathology, Trainee cohorts Date of visit Scheduled FY, ST 23/11/15 GG&C Radiology Scheduled ST 27/11/16 Lothian Lothian GG&C GG&C Histopathology, RIE Medical Microbiology Medical Microbiology Medical Microbiology, Triggered FY, ST Scheduled FY, ST 27/01/16 Triggered FY, ST 18/02/16 Triggered FY, ST 19/02/16 Lanarkshire Radiology, Scheduled ST 21/04/2016 Grampian Histopathology Scheduled FY, ST 03/05/16 Scotland-wide Chemical Pathology Programme ST Governance Under the Chairmanship of Professor Clare McKenzie, the Diagnostics sqmg met 6 times (including the QRP) over the course of the training year and was represented at all DQMGs via highlight papers and formal minutes to ensure transparency and formal oversight. Key issues and improvements Generally, most visits undertaken in this visit year have been positive. The scheduled visits to Histopathology, Chemical Pathology and Radiology at the new Queen Elizabeth University did not highlight any major issues. Nor did the scheduled visits to Medical Microbiology in the Royal Infirmary of Edinburgh, Radiology at Hairmyres and Histopathology at Aberdeen Royal Infirmary. Common issues that were noted were lack of trainer time in job plans and trainees requiring more experience in a particular clinical area such as ultrasound. Engagement with the visit process was generally very good with strong engagement from trainers and trainees. Triggered visits were undertaken to Histopathology at the Royal Infirmary of Edinburgh and Medical Microbiology in Glasgow Royal Infirmary and the Queen Elizabeth University. The QM team on the visit to the Microbiology visits in Glasgow noted some common themes across the two sites consultants did not have time in their job plans for training, the out of hours handover process needs to be more robust and trainees require more experience in Paediatric Microbiology. Changes in workload between the two sites seems to have changed with the opening of QEUH and this has had an effect on training. The visit teams noted good progress at 44

47 Glasgow Royal Infirmary compared to the previous visits so are content that when the action plan is implemented, the site can revert to a scheduled visit cycle provided that no other issues arise in subsequent surveys or from local intelligence. However, the QEUH site was of slightly more concern as there was a discrepancy over what trainees and trainers reported was happening in terms of Consultant contribution to the service. Some of these issues relate to a new site with changes in clinical workload and the visit panel appreciated that this has posed a number of challenges. The WoS APGD has continued to monitor the situation and further data has been reviewed at SQMG, resulting in the decision to undertake a follow up visit in Jan The issues highlighted at the RIE Histopathology visit were lack of local cytology experience (in relation to curriculum requirements), further updating and expansion of induction content and clinical and educational supervision roles to be clearly identified with the educational structure strengthened. This continues to be reviewed with NTS data showing improvement. A pilot programme visit to Chemical Pathology was undertaken in May which went very well. It was held in Dundee, trainees joined in person or by teleconference and trainers linked in via VC. Despite initial reservations about the use of IT, the sessions flowed smoothly and a positive consequence was that all participants were more likely to speak as each of them was specifically asked for their viewpoint. The visit team found that the programme was cohesive and supportive. The only issue uncovered related to IT access in certain sites. Historically data collection for smaller specialties has been limited, hopefully once more programme visits and scheduled visits have taken place the knowledge gaps will be lessened. Local intelligence remains important in the face of lack of survey data. Overall it has been an encouraging first year for the Diagnostics sqmg. Despite the challenges of some small and diverse specialties there is very good local knowledge and feedback from the APGDs at sqmg meetings and the QRP. The visits have identified strengths such as very good local and national teaching (facilitated via VC) in medical microbiology and chemical pathology. Where deficiencies have been identified at triggered visits there is a clear action plan in place and feedback to the sqmg and at the next QRP will provide further evidence as to progress made. 45

48 Medicine Medicine Doctors in Training Enhanced Monitoring Cases* GMC Approved Programmess QM-QI Visits Programme Visits 3 24 Site Visits Triggered Visits 21 6 Scheduled Visits *EM cases at end of

49 Overview It is a privilege to be the LDD of the Medicine sqmg, and I start by commending the commitment and diligence of the whole team through The Medicine sqmg has contended with a substantial workload, of which our 27 visits are the tip of that iceberg; everyone has pulled their weight to support delivery of that substantial workload. We have learned through doing! Our approach to sqmg meetings has rapidly evolved to manage better the substantial workload and associated paperwork. Our approach to QM-QI visits has rapidly evolved to incorporate programme visits, to ensure our QM processes address whether speciality training meets GMC standards, in addition to the training in General Internal Medicine that is the primary focus of the majority of our site visits. This has significant resource implications. If we are going to achieve consistency of approach to QM-QI across all sqmg, we have to lead by example by ensuring consistency of approach within the Medicine sqmg, and we are getting there. A potential weakness that remains to be addressed fully is APGD-Medicine (not APGD-Quality) input to ensure we have optimal gathering and sharing of intelligence around Scotland from all regions but some have multifaceted portfolios that include more than Medicine. Professor Alastair McLellan, Postgraduate Dean and Lead Dean/Director for Medical Specialties The 2 pilot joint undergraduate-postgraduate QM-QI visits have given a foretaste of just how well these can work (Dumfries visit) but have also highlighted what we should expect from our Medical School partners as we go forward, into a future that is built around joint visiting (where appropriate to do so) Having undertaken 27 QM-QI (scheduled (6) and triggered (21, including 6 visits with the GMC under the auspices of enhanced monitoring)) visits to sites (that were in addition to 3 other visits that were conducted as programme visits) it is clear that in Scotland, training in Medicine, in particular, in General Internal Medicine with commitments to acute medical take, is becoming more challenging than ever before; the pressures of service delivery are impacting on the quality of the training opportunities that are available. But we remain clear that our mission is to champion training and to support improvements in training and training opportunities to ensure that training in Scotland not only meets GMC standards but, we hope, does even better. Through our visits we are identifying good practice everywhere (even in some of our most challenging sites) and we are already signposting those we visit to sites that do things really well but we still have much to do to capture as much of that good practice as we can through SHARE, to ensure wider access to awareness of good practice. I remain very optimistic that the Medicine sqmg is fit for purpose to deliver what is required of it with regard to the quality management of PGMET in Medicine and in Medical specialties, but also is well placed as a catalyst for improvement in the quality of PGMET in Scotland as a whole. Overall satisfaction with training in Medical Specialities in Scotland compared to the rest of the UK The majority of Medical specialities associated with General Internal Medicine (GIM) in Scotland have risen in the rankings for overall satisfaction with training compared to programmes in Deaneries and LETBs in the rest of the UK. The most noteworthy improvement has been in the overall satisfaction among Core Medical Trainees across Scotland as a whole (ranking 2nd out of 16) that reflects concerted efforts of the APGD and his team of TPDs for CMT around Scotland, who have targeted efforts to improve performance against the JRCPTB s quality criteria. While the trend in overall satisfaction rankings for training programmes in Medical specialities that are not aligned to General Internal Medicine are mixed, the rankings for overall satisfaction for Haematology and for Palliative Medicine are noteworthy. 47

50 Overall satisfaction 2015 NTS 2016 NTS Acute Medicine 10th of 16 13th of 16 Cardiology 14th of 17 13th of 16 Core Medical Training 12th of 17 2nd of 17 Endocrinology/Diabetes 2nd of 17 7th of 17 Gastroenterology 4th of 16 8th of 16 Geriatric Medicine 7th of 16 6th of 16 Infectious Diseases 7th of 10 5th of 9 Renal Medicine 3rd of 16 7th of 17 Respiratory Medicine 17th of 17 14th of 16 Rheumatology 15th of 16 14th of 16 Clinical Pharmacology & Not applicable Not applicable Therapeutics Clinical Oncology 12th of 14 13th of 16 Dermatology 9th of 16 12th of 16 Genitourinary Medicine 14th of 14 9th of 11 Haematology 5th of 16 3rd of 15 Medical Oncology 13th of 14 14th of 15 Neurology 11th of 16 16th of 16 Palliative Medicine 12th of 14 1st of 14 Clinical Genetics Not applicable 9th of 12 Clinical Neurophysiology Not applicable Not applicable Rehab Medicine Not applicable 7th of 10 Medical QRPs 2015 The QRP for Core Medical Training, having reviewed all of the available data, information and intelligence relating to Core Medical Training determined need for the following actions: 1 triggered visit 2 letters of recognition for good practice 3 enquiries The QRP for Higher Medical Training for specialties associated with General Internal Medicine, having reviewed all of the available data, information and intelligence relating to training determined need for the following actions: 3 triggered visits 4 enquiries 2 priority scheduled visits 8 letters of recognition for good practice The QRP for Higher Medical Training for specialties that are not associated with General Internal Medicine having reviewed all of the available data, information and intelligence relating to training determined need for the following actions: 6 triggered visits In addition to the specific actions listed against each QRP, there was also an agreement to undertake 14 2 priority scheduled visits revisits, many of which related to ongoing enhanced 4 enquiries monitoring cases. 8 letters of recognition for good practice 48

51 Visits to education providers Site NHS Board Specialty Visit type Queen Elizabeth University Queen Elizabeth University University Ayr University Crosshouse Beatson West of Scotland Cancer Centre Wishaw General Hairmyres Monklands Victoria, Fife Vale of Leven District General Royal Infirmary - Edinburgh, Lauriston Building Inverclyde Royal WoS Cardiology Programme visit St John s GGC GGC Medicine Geriatric Medicine New site check - triggered due to issues at feeder sites New site check - triggered due to issues at feeder sites Trainee cohorts Date of visit All 27/10/2015 All 27/10/2015 A&A Medicine EM re-visit All 04/11/2015 A&A GGC Medicine Clinical Oncology/ Med Oncology/ Haematology Triggered - poor NTS results All 04/11/2015 EM re-visit All 01/12/2015 Lanarkshire Medicine EM re-visit All 03/12/2015 Lanarkshire Medicine EM re-visit All 11/12/2015 Lanarkshire Medicine EM re-visit All 17/12/2015 Fife Medicine Re-visit All 13/01/2016 GGC Medicine EM re-visit FY & GPST 19/01/2016 Lothian Dermatology New EM case FY2, ST 21/01/2016 GGC Medicine Triggered - concern over NTS comments & DME request for visit All 27/01/2016 GGC Cardiology Triggered ST 02/03/2016 Lothian Medicine Acute Medicine, Geriatric Medicine and Respiratory Medicine Early scheduled All 16/03/

52 Site NHS Board Specialty Visit type Ninewells Aberdeen Royal Infirmary Queen Elizabeth University Borders General SES Cardiology Programme visit Dumfries Royal Infirmary SES Respiratory Programme Visit Queen Elizabeth University Tayside Grampian Medicine including Clinical Oncology & Medical Oncology Clinical Oncology, Medical Oncology and Haematology Trainee cohorts Date of visit Triggered All 24/03/2016 Re-visit All 31/03/2016 GGC Non GIM Triggered ST 01/04/2016 Borders Medicine Triggered All 14/04/2016 Lothian Cardiology Triggered programme visit ST 15/04/2016 D&G Medicine Early scheduled All 20/04/2016 Lothian GGC Respiratory ST3+ Medicine Scheduled ST 11/05/2016 Triggered REVISIT All 13/05/2016 Forth Valley Forth Valley Medicine Scheduled All 24/05/2016 Royal Infirmary - Edinburgh Lothian Cardiology Triggered visit FY, CMT 08/06/2016 Perth Royal Infirmary Tayside Medicine Scheduled All 09/06/2016 Raigmore Highland Medicine Scheduled All 14/06/2016 Western General Lothian Medicine Triggered All 01/07/2016 Governance Under the Chairmanship of Professor Alastair McLellan, the Medicine sqmg met 9 times (including 3 QRPs) over the course of the training year and was represented at all DQMGs via highlight papers and formal minutes to ensure transparency and formal oversight. 50

53 Key issues and improvements Sites with good trainee feedback had high levels of continuity in terms of ward placements, protected and scheduled time with trainers, and the opportunity to follow patients with real time feedback from their supervising consultants. The corollary was the negative impact on trainee satisfaction caused by the lack of team working and high frequency base ward rotations seen in multiple sites, particularly affecting trainees at core medicine level. Many sites reported difficulty in releasing trainees at all levels to attend outpatient clinics, and at higher level there were several sites in the West of Scotland who did not provide adequate consultant supervision in this setting. Consultant workforce issues affect trainee satisfaction and where there are units with consultant vacancies or low consultant staffing numbers the feedback from trainees is generally negative. Despite this, few trainees in Scotland report difficulties in accessing formal study leave. Generic hospital based induction is well provided across Scotland, but departmental and regional programme induction is less reliably experienced. Those units who perform well in this respect have named individuals to follow up trainees who might be on night shift or who are starting blocks at non-standard times, for example after maternity leave. Geographic and political considerations continue to have implications for training and patient care models, and lead to multiple acute receiving rotas in nearby sites. The initial response from many sites with poor trainee feedback, somewhat unrealistically, is to request provision of additional trainees, particularly at core and junior ST level to support medical receiving models and to provide ward based cover. Programme visits (to Cardiology in the West of Scotland, to Cardiology in the South-East of Scotland and to Respiratory Medicine in the South-East of Scotland) proved useful in exploring the quality of training across the entirety of training programmes from the trainees perspectives and highlighted the importance of regional induction and regional teaching programmes. The tension between general internal medicine and specialist activity remains a concern for these specialties and is likely to be found in other medical specialties that are linked through dual training programmes with general internal medicine. Visits, have identified some concern from consultants in terms of job planning for educational and clinical supervision although the GMC recognition of trainers initiative has helped, substantially, in terms of quantifying and recognising the importance of time for training and the need for formal training for those with roles as supervisors. A concern is our reliance on aggregated data from survey tools (GMC NTS and even the STS) to gauge the quality of training in some of the smaller Higher Medical Training programme, with very small numbers of trainees. While there has been a rapid increase in the number of sites on enhanced monitoring, there is a need to recognise the consequent engagement in efforts to drive improvements locally and to develop clearer stepdown mechanisms that would facilitate sites coming off enhanced monitoring. There has been an appropriate focus on triggered and enhanced monitoring visits during this first year but we have also embarked upon an elective five year scheduled visit programme. This scheduled visit programme is essential to ensure the quality of training experience across all sites in Scotland and is likely to lead to recognition of more areas of good practice that can be shared nationally to help drive improvements. While good practices have been identified through our 27 visits, relatively few submissions of case studies for the SHARE website have resulted. Proactive quality management support will be required to make this happen, more consistently, going forward. There are 8 enhanced monitoring cases that include training in Medicine. While no cases involving Medicine have yet been removed from the enhanced monitoring process, there is no doubt that this process has been effective in engaging Health Boards, senior management teams as well as training leads in effecting improvements in training environments that are often facing complex issues. Where trainees are encouraged to engage with senior management as partners in addressing the challenges facing training environments, through trainee forums or analogous committees, successful solutions are more likely to be achieved. Trainees feel more valued, and are more likely to understand the issues underpinning the challenges they face. Introduction of a trainee forum is encouraged at all sites. The pioneering development of 51

54 the Chief Resident role in Lanarkshire is a particularly positive move and was recognised at the Scottish Medical Education Conference in May The impact of the workstream s intensive quality management and improvement activities during this first year of the new quality process should become evident in time. The Medicine sqmg is achieving greater consistency in its processes and activities around Scotland including in its benchmarking against the GMC s standards. Consistency in application of the GMC s standards has been a key achievement during this first year of our new system. Medical Specialties: an in depth look 1. QM-QI visits undertaken by the MQMG from 1-Aug-15 to 31-Jul-16 QM-QI visits to sites The MQMG undertook 24 visits to sites in 10 of Scotland s 14 territorial Health Boards to assess the quality of training and of the training environment in Medicine and Medical specialties. QM-QI visits to sites included within their scope Foundation, GP, Core Medical and Higher Trainees with 3 exceptions (GG&C-Vale of Leven Medicine visits that included only Foundation and GP trainees; Lanarkshire Wishaw General Medicine that included only Foundation, GP & Core Medical trainees & Lothian Lauriston -Dermatology that included only Foundation and Higher trainees) All QM-QI visits included interviews with trainers. 2 site visits were conducted as joint undergraduate postgraduate visits (although this aspect is not described further, here). Table: Number of site visits, by type of visit, by Health Board, conducted in Health Board 52 Number of site visits Type of Visit Scheduled Triggered (New site) Triggered (Enhanced Monitoring) Triggered (Revisit*) Ayrshire & Arran Dumfries & Galloway 1 1 Fife 1 1 Forth Valley 1 1 Greater Glasgow & Clyde** Grampian 1 1 Highland 1 1 Lanarkshire 3 3 Lothian Tayside Triggered (other) *Revisits were triggered by earlier QM-QI visits either prior to August 2015, or within the training year. ** QEUH was escalated to enhanced monitoring after an unsatisfactory revisit, and future visits will be undertaken in association with enhanced monitoring.

55 2.QM-QI visits to programmes The MQMG undertook 3 programme visits that were managed centrally, and involved only ST3+ trainees (and their trainers). Table: Programme visits, by type of visit, conducted in Programme Region of programme Number of Health Boards Number of sites/leps Type of visit Cardiology West 2 4 Triggered Cardiology South-East 2 2 Triggered Respiratory South East 1 2 Scheduled 53

56 3. Overall satisfaction with training among doctors in training who engaged in site visits. At the end of each interview session with each cohort of trainees who engaged with site visits, the trainees were asked to score their overall satisfaction on a scale of 0 to 10 (where 0 is the lowest level of satisfaction because the experience of training is so poor, and where 10 is the highest level, because training could not be any better). For each cohort, the site visits that resulted in the bottom three scores (out of ten) among all the scores recorded for that cohort among all the site visits that were conducted are listed as are the sites that generated the top three scores (out of ten) among all the scores recorded for that cohort among all the site visits that were undertaken in Scotland in Table: Site visit locations that featured the lowest 3 scores and the highest 3 scores for overall satisfaction as rated by each cohort of trainees who were engaged in each of the QM-QI site visits. Foundation (1/2 or 1+2) Bottom 3 score out of GPST CMT ST Locations ARI Oncology (T) QEUH Medicine (T-N) QEUH- Non-GIM dermatology (T-N) ARI-Onc (T) MH-Med (T-EM) UHC-Med (T) ARI-Onc (T) BWSCC Onc (T-EM) UHC Med (T) QEUH Med (T-N) WishGH -Med (T=-EM) NH Med AM (T) RH Med (S) BGH Med (T) Top 3 scores out of Locations PRI-Medicine (S) QEUH-COTE (T-N) UHA-Medicine (T) QEUH-Non-GIM-ID (T-N) PRI-Medicine (S) WishGH Med (T-EM) QEUH-Non-GIM-ID (T-N) MH-Med (T-EM) PRI Med (S) QEUM-Non-GIM-Haem (T-N) ARI Onc (T) QEUM-Non-GIM-Haem (T-N) QEUH COTE (T-N) Note: where more than one cohort has scored the same for overall satisfaction within the bottom or top 3 scores, all posts with same score are listed. Note: for some the score is derived from a mixed pool of trainees from more than one cohort in this circumstance the same score is given to each cohort represented. T= triggered visit S = scheduled visit T-N = triggered visit to a new training site T-EM = triggered visit conducted under the auspices of enhanced monitoring 54

57 4.The overall prevalence of the top ten concerns among the GMC s indicators of quality of training visits that were noted during QM-QI visits: in QM-QI visits to sites (24 site visits were undertaken). in QM-QI visits to training programmes (3 programme visits were undertaken). 55

58 5. What concerns were identified that underpinned the failure to meet the GMC s standards for the most prevalent 6 indicators that have been cited as areas of concern? a. Adequate experience (a concern in 23 site and 2 programme visits) (as percentage of those visits where adequacy of experience was an issue). b. Clinical supervision (a concern in 20 site and 3 programme visits) 56

59 c. Reporting systems (a concern in 20 site and 0 programme visits) d. Handover (a concern in 18 site and 1 programme visits) 57

60 e. Teaching (a concern in 18 site and 2 programme visits) f. Induction (a concern in 17 site and 2 programme visits) 58

61 6. Conclusions While the Medicine sqmg s site visit schedule in included sites or LEPs from 10 different territorial Health Boards, 79% of the visits were triggered by a concern or by concerns, so caution needs to be exercised; this should be seen as providing insights into the quality of training in Medicine & medical specialties across Scotland, but from a perspective of pursuing concerns. It highlights the high prevalence among training sites for Medicine, around the country, of quality indicators where the GMC s standards for medical education and training are not being met. The review also gives detail of what deficiencies underpin the failure to meet the GMC s standards. Only one QM-QI site visit in identified that all of the GMC s standards were being met, and therefore there were no requirements to be addressed; this was the scheduled visit to Medicine at Perth Royal Infirmary. It is of interest, also, that Perth Royal Infirmary Medicine featured among the highest 3 scores for overall satisfaction with training for Foundation, for GPST and for CMT that were noted among all of the site visits that were undertaken (Table 3). Training in Medicine at the new training site in GG&C, the Queen Elizabeth University (QEUH), Europe s largest hospital development, triggered a new training site visit in October 2015, and subsequently a triggered revisit in 2016 (because of the extent of concerns including the safety of the training environment) that resulted in escalation to the GMC s enhanced monitoring process (Table 3). Training in Medicine at the QEUH featured amongst the lowest scores for overall satisfaction with training recorded in by Foundation and Core Medical trainees. By contrast, training at the QEUH in Care of the Elderly and for non-gim medical specialties featured among the sites with the highest scores recorded for overall satisfaction in (Table 3). Section 4 highlights the high prevalence of concerns that were noted from site and programme visits around adequacy of experience, clinical supervision, reporting systems, handovers, teaching, induction. In about 50% of visits there was reference, most commonly, to a single individual who exhibited undermining traits; this as commonly related to non-medical personnel, as it did to a Consultant. Section 5 highlights the themes that need to be taken forward to improve the quality of medical training around Scotland, some of which are emphasised here: FY2s, GPSTs & CMTs must have access to outpatient clinic learning opportunities; for CMTs there are specific minimum target numbers to meet curricular requirements. Routine tasks that do not support educational or professional development are a barrier to accessing training and learning opportunities, not just of Foundation trainees, but also commonly for GPSTs and for CMTs and occasionally even for ST3+ trainees, and a strategy to address this burden must be implemented. Foundation, GPST and Core Medical trainees change their base-wards too frequently and this is a barrier to development of team-relationships and to the delivery of feedback that is informed by working together. It also leads to inefficient patient care. Doctors in training are not getting adequate feedback on their input into the management of acutely unwell patients. Feedback must be provided to inform the learning of doctors involved in acute medical receiving. Ward rounds, in general, must be vehicles to support learning and the development of doctors in training, through provision of effective feedback on their input into the continuing care of their patients. Doctors in training must not do clinics in the absence of a Consultant in the clinic; having a Consultant in the clinic is to provide effective clinical supervision and to support the learning of trainees and to ensure safe and effective care. Training environments in Medicine in Scotland, show little evidence of actively engaging doctors in training in a culture of learning around incident reporting and learning that arises from effective incident reporting. It is now unusual for handovers not to take place at the end of shifts in clinical training environments (but we have found occasional exceptions). However, more commonly, handovers could be improved by becoming formalised by conforming to a fixed schedule, and location, involving consistently the correct people, conforming to an agreed format and by maintaining a written or electronic record (or audit trail). 59

62 Attendance of doctors in training at formal educational meetings is very commonly prevented by service commitments; it is very unusual for any cohort of doctors in training to have protected time to attend formal training meetings. Induction must be provided not just to sites, but to all departments within training sites with doctors in training. Induction must cover all roles and responsibilities expected of doctors in training. Commonly induction processes fail to cover duties and commitments linked to out of hours work. Induction must be provided to all doctors in training, whenever they take up their post; this means that any trainee who cannot attend the main induction event at changeover times must experience an induction too. All doctors in training must, by the end of induction, have passwords for all of the essential clinical systems to enable them to effect their clinical duties from the outset. 60

63 Mental Health Mental Health Doctors in Training Enhanced Monitoring Cases* GMC Approved Programmess 20 6 QM-QI Visits Programme Visits 1 5 Site Visits Triggered Visits 1 5 Scheduled Visits *EM cases at end of

64 Overview The Lead Dean/ Director role for Mental Health specialties has been a fulfilling one over the last year. The Specialty Training Board is a very cohesive Board, ably led by Rhiannon Pugh and it has welcomed the addition of the sqmg report and intelligence into its agenda and discussions. The Quality Review Panel (QRP) in September 2015 was a new venture for all of us and it became rapidly evident that we had over-estimated the time it would take to address the task at hand, but significantly under-estimated the work involved for Theresa Savage and her team in preparing for this task. The quality of support offered by Theresa and her team has been excellent. The quality agenda in this specialty grouping has been expertly supported and driven forward by our two Quality Leads, Hazel Scott and Satindar Bal. Professor Ronald MacVicar, GP Director and Lead/Dean Director for Mental Health The visits that have taken place as a result of the decisions taken in the QRP have been described elsewhere in this report, and it has been really pleasing to see the level of engagement, transparency and enthusiasm that has been evident in these visits, including in the one triggered visit, which I led. We have undertaken a programme visit to Child and Adolescent Mental Health Services (CAMHS) in the west of Scotland and, at the time of writing, the report is yet to be finalised, although verbal feedback was very positive. As a specialty grouping with specialties with small numbers of trainees across a range of sites, this programmatic approach is a key element of how we will deliver QM and we look forward to learning the lessons from this visit, as well as programme visits that have taken place in other specialty groupings. Our sqmg is in the early stages of its formation but we are fast developing a collegiate way of sharing, challenging and working that will be to the benefit of Mental Health training in Scotland and look forward to the year ahead when all our systems will be more established. Overall satisfaction with Mental Health Training in Scotland compared to the rest of the UK The year on year results show contrasting movements in the Mental Health specialties. Child & Adolescent Psychiatry in Scotland has risen to be the most highly rated region in the UK for overall satisfaction. Intellectual Disability has, in contract dropped from 2nd to 10th, of 12 regions offering the programme. The remaining Mental Health disciplines are largely static. Overall satisfaction 2015 NTS 2016 NTS Child & Adolescent Psychiatry 7th of 15 1st of 15 Core Psychiatry 4th of 16 2nd of 17 Forensic Psychiatry 4th of 12 11th of 15 General Adult Psychiatry 2nd of 17 3rd of 17 Old Age Psychiatry 5th of 16 6th of 16 Intellectual Disability 2nd of 11 10th of 12 Medical Psychotherapy Not applicable Not applicable 62

65 Mental Health QRP 2015 The QRP for Mental Health Training having reviewed all of the available data, information and intelligence relating to Mental Health Training determined need for the following actions: 2 Triggered visits 6 TPD enquires 8 Scheduled visits 1 Programme visit Zero QIM enquiries Zero APGD enquiries Visits to education providers Site NHS Board Specialty Visit type Murray Royal Hairmyres Leverndale Programme visit Dykebar Queen Margaret / Stratheden/ Whytemans Brae Trainee cohorts Date of visit Tayside CPT Triggered FY, GP, ST 15/03/16 Lanarkshire CPT Scheduled FY, GPST, ST 26/04/16 GG&C CPT Scheduled FY, GPST, ST 27/04/16 All Child and adolescent psychology Scheduled FY, GPST, ST 04/05/16 GG&C CPT Scheduled ST3+ 20/06/16 Fife All Psychology Scheduled FY, GPST, ST 14/06/16 Governance Under the Chairmanship of Professor Ronald MacVicar, the Mental Health sqmg met 6 times (including the QRP) over the course of the training year and was represented at all DQMGs via highlight papers and formal minutes to ensure transparency and formal oversight. Key issues and improvements The data provided for the majority of training programmes within Psychiatry was generally very positive and this is further supported by the high ratings for Scotland against the national mean, as evidenced above. The QRP benefited from local intelligence, for example, where concerns around restructuring of services within specific localities and availability of specific aspects of training were raised as a concern. This added intelligence allowed prioritisation and targeting of visits for this quality cycle. Overall the data from the QRP and subsequent visits has been positive in the majority of areas however a highlight has been the level of engagement of trainers with weekly protected time for trainees for clinical 63

66 supervision in many of units visited to date. Notably, the majority of units visited were providing high quality and comprehensive formal teaching, on occasions across multiple sites. The visit panels were pleased to hear that trainees were able to access these formal teaching programmes through protected time. Many units also provide a very comprehensive multiprofessional induction rated highly by all grades of trainees. One scheduled visit was undertaken due to 9 red flags for GP training however the panel did not elicit any particular concerns from the 2 GP trainees present who were unable to offer an explanation for the red flags. Core and Higher trainees present were also generally very satisfied and this was supported by green flags from these trainee cohorts. A single triggered visit was undertaken due to outstanding recommendations from previous visits and available NTS data. The panel was pleased to hear of the appointment of a new TPD which had clearly resulted in renewed enthusiasm and drive. There do, however, remain some concerns and a revisit in 6 months is planned. Many of the subspecialties within psychiatry have small numbers of trainees per site, limiting the validity of the available data. A programme visit to West of Scotland Child and Adolescent Psychiatry was therefore conducted and feedback was very generally very positive. We look forward to further development and standardisation of this programme approach to visits which we envisage incorporating again into the next quality cycle. One good practice item was identified at the QRP (Induction for Trainee Doctors at Royal Cornhill ) and this has been submitted to SHARE. 64

67 Obstetrics, Gynaecology & Paediatrics Obstetrics, Gynaecology & Paediatrics Doctors in Training Enhanced Monitoring Cases* GMC Approved Programmess 9 7 QM-QI Visits Programme Visits 0 7 Site Visits Triggered Visits 5 2 Scheduled Visits *EM cases at end of

68 Overview The two QRP panels (Paediatrics and Obstetrics and Gynaecology) had full engagement from the specialty quality team and nominated DME. In both cases clear presentation of data resulted in unanimous agreement in which sites required to be visited and prioritisation of visits. A number of APGD and TPD enquiries were also requested which have proven difficult to track down and close off. We are aware of the need to be more specific with such requests for information moving forward. Professor David Bruce, GP Director and Lead/Dean Director for Obstetrics, Gynaecology and Paediatrics Our visiting programme has been well organised and we have noted examples of good practice in each site visited. For one visit we were unable to organise a pre-visit teleconference meeting, and as a result of this our visit team did not have the full background information that would have helped understand the full picture of this unit. This has subsequently been discussed with all team members and the DME involved. The importance of the previsit teleconference is a key learning point for our group. Both APGD(Q)s have now received Lead Visitor training and have now or will shortly lead future visits. My thanks to Dr Adam Hill, APGD (Q), for providing APGD support to our new APGD(Q)s. Overall satisfaction with training in Obstetrics, Gynaecology and Paediatrics in Scotland compared to the rest of the UK Scotland now ranks first for overall satisfaction across the UK for O&G training, having improved by 5 positions over the period, out of 16 regions who support O&G training. Paediatrics slipped by 1 place, but remains in 3rd position overall. Overall satisfaction 2015 NTS 2016 NTS Obstetrics & Gynaecology 6th of 16 1st of 16 Paediatrics 2nd of 16 3rd of 16 Obstetrics, Gynaecology and Paediatrics QRP 2015 The QRP for Obstetrics, Gynaecology and Paediatrics Training having reviewed all of the available data, information and intelligence relating to Obstetrics, Gynaecology and Paediatrics Training determined need for the following actions: 2 Triggered visits 2 Scheduled visits 6 TPD enquiries 66

69 Visits to education providers Site NHS Board Specialty Visit type Queen Elizabeth University Ninewells and Perth Royal Infirmary Forth Valley Royal Royal Infirmary of Edinburgh Royal Alexandra Raigmore Royal for Sick Children Trainee cohorts Date of visit GG&C Paediatrics Triggered FY, GPST, ST 22/01/16 Tayside O&G Triggered FY, GPST, ST 29/01/16 Forth Valley O&G Triggered FY, GPST, ST 29/02/16 Lothian O&G Triggered FY, GPST, ST 14/03/16 GG&C Paediatrics Triggered FY, ST 30/03/16 Highland Paediatrics Scheduled FY, ST 16/5/16 Lothian Paediatrics Scheduled FY, GPST, ST 27/5/16 Governance Under the Chairmanship of Professor David Bruce, the Obstetrics, Gynaecology and Paediatrics met 6 times (including the QRP) over the course of the training year and was represented at all DQMGs via highlight papers and formal minutes to ensure transparency and formal oversight. Key issues and improvements Obstetrics & Gynaecology The data provided for the training programme within Obstetrics & Gynaecology was generally very positive and this is supported by the relatively high ratings for overall satisfaction for this programme in Scotland against the national mean, as evidenced in the graphs above. The Quality Review Panel benefited from local intelligence, for example, where concerns around restructuring of services within specific localities or availability of specific aspects of training were raised as a concern. This added specialty specific intelligence allowed prioritisation and targeting of visits for this quality cycle. Findings from the 3 Deanery visits to O&G departments have determined two main GMC standards that are routinely not fully met. The main areas of concerns highlighted at visits with regards to these standards include: Lack of programme specific teaching mapped to curriculums Heavy workload for junior doctors Limited specialist teaching opportunities for higher trainees. 67

70 However, highlights of the QRP process and subsequent Deanery visits include: The level of engagement of trainers with most being described as extremely approachable and supportive by trainees. Continued improvements to Induction and Handover taking place in most departments as a result of feedback from trainees. Learning from Clinical Incidents Several good practice items have been identified at the QRP or at subsequent Deanery visits including: Obstetrics and Gynaecology triage study days, excellent Handover procedures, Clinical Excellence Awards for trainee doctors and weekly rota meetings. All relevant departments have been contacted and invited to submit a case study for SHARE. Paediatrics Again the data provided for the training programme in Paediatrics was very positive and this is supported by the high ratings for Scotland against the national mean, as evidenced in the graphs above. Findings from the 3 Deanery visits for Paediatrics have determined three main GMC standards that are routinely not fully met. The main areas of concerns highlighted at visits with regards to these standards include: Low staffing levels during OOH shifts Lack of programme specific teaching mapped to curriculums Not all named Educational and Clinical Supervisors have adequate time in their job plan. Limited specialist teaching opportunities for higher trainees. However, highlights of the QRP process and subsequent Deanery visits include: The level of engagement of trainers with most being described as extremely approachable and supportive by trainees. Continued improvements to Induction and Handover taking place in most departments as a result of feedback from trainees. Learning from Clinical Incidents Several good practice items have been identified at the QRP or at subsequent Deanery visits including: Neonatal Safety Brief, departmental Induction and Regional Teaching. All relevant departments have been contacted and invited to submit a case study for SHARE. 68

71 Surgery Surgery Doctors in Training Enhanced Monitoring Cases* GMC Approved Programmess QM-QI Visits Programme Visits 0 17 Site Visits Triggered Visits 16 1 Scheduled Visits *EM cases at end of

72 Overview We have been very busy in this inaugural year of our current process. The Surgical sqmg staff have done a terrific job in getting it up and running. The QRP format has bedded in well, with the result that we set ourselves a very challenging programme of visits, which have been accomplished with the minimum of fuss. In general, we have had a very positive reaction from the services visited, with Professor William Reid, Postgraduate Dean and Lead Dean Director for Surgical Specialties demonstrable success on many fronts. We expect to adapt our processes according to feedback gathered over the year, and to streamline the oversight of the visits. Next year will involve us in increasing involvement of TPDs, DMEs and the Surgical Specialty Training Board in our work. In particular I would like to thank the Associate Postgraduate Deans Quality and the Associate Postgraduate Deans for their time, which is both valuable and enormously beneficial to the process. It is a privilege to be part of a team that works so hard and is so professional. Overall satisfaction with Surgical Training in Scotland compared to the rest of the UK The 2015 GMC NTS identified three Scottish Surgical Programmes in the top 4 of their specialty grouping Oral-Maxillofacial Surgery, Ophthalmology and Trauma & Orthopaedic Surgery. Overall satisfaction 2015 NTS 2016 NTS Cardiothoracic Surgery 8th of 12 7th of 14 Core Surgery 14th of 17 15th of 19 General Surgery 16th of 17th 12th of 20 Neurosurgery 12th of 15 9th of 15 Ophthalmology 2nd of 16 5th of 20 Oral-Maxillofacial Surgery 1st of 15 4th of 16 Otolaryngology 10th of 17 12th of 19 Plastic Surgery 8th of 13 6th of 15 Trauma & Orthopaedic Surgery 4th of 17 7th of 21 Urology 8th of 16 13th of 17 Core Surgical Training QRP 2015 The QRP for Core Surgical Training having reviewed all of the available data, information and intelligence relating to Core Surgical Training determined need for the following actions: 4 visits 13 Enquires recommended; 5 APGD enquiries 3 TPD enquiries 5 QIM enquiries 70

73 Higher Surgical Training QRP 2015 The QRP for Higher Surgical Training having reviewed all of the available data, information and intelligence relating to Core Surgical Training determined need for the following actions: 33 visits 2 TPD enquiries; 36 Enquires recommended; 15 APGD enquiries; 2 APGD & QIM enquires; 2 TPD & QIM enquires; 15 QIM enquiries Visits to education providers Site NHS Board Specialty Visit type Queen Elizabeth University Aberdeen Royal Infirmary Glasgow Royal Infirmary Western General Queen Elizabeth University Queen Elizabeth University Western General Western General Hairmyres GG&C General Surgery Triggered Grampian General Surgery Enhanced Monitoring GG&C General Surgery Triggered Lothian General Surgery Triggered GG&C Neurosurgery Triggered GG&C Urology Triggered Lothian Neurosurgery Triggered Lothian Urology Triggered Lanarkshire General Surgery Enhanced Monitoring Trainee cohorts FY CST Higher UG CST Higher FY GPST CST Higher FY CST Higher FY Higher CST Higher FY Higher FY CST Higher FY GPST CST Higher Date of visit 04/11/15 19/11/15 10/12/ /12/ /01/ /01/ /02/ /02/ /03/

74 Site NHS Board Specialty Visit type Hairmyres Monklands Monklands Royal Infirmary Edinburgh Royal Alexandra Queen Elizabeth University Queen Elizabeth University Ninewells Lanarkshire Trauma & Orthopaedics Enhanced Monitoring Lanarkshire General Surgery Enhanced Monitoring Lanarkshire Lothian Trauma & Orthopaedics Vascular Surgery Enhanced Monitoring Enhanced Monitoring GG&C General Surgery Triggered GG&C Trauma & Orthopaedics Triggered Trainee cohorts FY GPST CST Higher FY GPST CST Higher FY GPST CST Higher FY CST Higher FY GPST CST Higher FY GPST Higher Date of visit 04/03/ /03/ /03/ /04/ /04/ /06/2016 GG&C Otolaryngology Triggered TBC 24/06/2016 Tayside Ophthalmology Scheduled TBC 28/06/2016 Governance Under the Chairmanship of Professor William Reid, the Surgical sqmg met 7 times (including the QRP) over the course of the training year and was represented at all DQMGs via highlight papers and formal minutes to ensure transparency and formal oversight. 72

75 Key issues and improvements The sqmg team identified that in many training environments attendance at protected teaching is being lost to the demands of service and that gaps in rotas contribute inevitably to a less satisfactory clinical and educational experience. The team also identified a lack of both emergency and elective theatre opportunities for General Surgery trainees across a number of sites and that opportunities for Core trainees to meet their competencies was limited in a number of sites. The sqmg believes it is important to feedback to departments areas of good practice when identified in order to facilitate discussions within departments and across specialties and supports a more clearly defined process to agree, identify and share good practice. The sqmg team is engaged with and enthusiastic about the quality process and can evidence good engagement with both Foundation and General Practice training with representation on the Surgical sqmg. In relation to future improvement the team aims to take forward the following: 1. To ensure QRPs review more data this year and employ RAG coding of sites using the revised decision making aid. 2. To clearly set out why any visit is being undertaken, making this explicit in the visit notification paperwork 3. To improve 6-week visit report turnaround performance, escalating appropriately when key milestones are missed 4. To develop an exemplar of the best surgical training in Scotland based around 10 key GMC quality indicators (to be agreed), drawing on best practice in each area from across all sites in Scotland. 5. To work with STC, STB and LEPs to help bring surgery in Scotland to a better position in the UK rankings (for overall satisfaction ), using the unique position of the STB to promote and drive improvements in surgical specialties. 6. To identify and record risks in relation to training in surgery. 7. To move Surgical sqmg meetings to the same day as the STB meetings to allow better attendance. 73

76 Scotland Deanery Annual Quality Report The GMC National Training Survey (NTS) 74

77 The GMC National Training Survey (NTS) 1. Overview The NTS reports the experiences of doctors in training against 15 quality indicators: access to educational resources adequate experience clinical supervision clinical supervision out of hours educational supervision feedback handover induction local teaching overall satisfaction regional teaching study leave supportive environment workload reporting systems Through August and September, Scotland Deanery s 8 sqmgs reviewed the performance of each training post in all training programmes in all LEPs in Scotland using the 2016 GMC NTS as well as other sources of data, information and intelligence including the recent outputs from the 2016 NES STS to inform the Deanery s QM-QI visit plan for This complex data review is conducted by sqmgs at their Quality Review Panels. A helpful overview of the state of training in Scotland is gained by reviewing the overall satisfaction rankings of each of Scotland s training programmes (average taken across the 1-4 programmes in Scotland for each specialty) and comparing with the other Deaneries or LETBs across the UK. 2. Patient Safety Concerns raised by doctors in training via 2016 GMC National Training Survey Patient safety concerns that are identified in training environments by doctors in training are sought by the GMC as part of their data collection through their National Training Survey. In order to present the complex content of these concerns (they are often lengthy paragraphs referring to multiple issues) the issues raised have been categorised (by the Deanery) under 4 headings ( patient care, exposure of trainees, medical staffing and other ). Sub-categorisation of the concerns is also undertaken, but this is not presented. Note that a patient safety concern can refer to more than one issue. 77 concerns were submitted, but 2 lacked any content to inform our understanding as to what their authors wished to convey. This analysis is based on the 75 that conveyed concerns. Note that among these 77 patient safety concerns, 25 refer explicitly to concerns about patient care, 4 to exposure of trainees (without appropriate supervision), 44 to medical staffing and 10 refer to other issues. The categorisation is somewhat artificial, though, as inadequate medical staffing often leads to poor care, exposure of trainees and may have other implications too. The GMC seeks responses to each of these concerns from each Health Board and from the Deanery; these responses will be submitted to the GMC (week ending 8th July 2016). Many will trigger further Deanery actions (including some site visits) that will be followedup through the Scotland Deanery Dean s report to the GMC, in the coming months. Of greatest concern is the total number of concerns relating to GG&C and specifically to QEUH, and in particular relating to Medicine in the QEUH. Medicine in QEUH is under enhanced monitoring by the GMC, in part because of this exceptional number of patient safety concerns. 75

78 Health Board PS concerns n (% of all) GG&C 37 (49%) Tayside 11 (15%) LEP (n) Specialties (n) Issue Queen Elizabeth University (26) Royal for Children (3) Royal Alexandra (2) Beatson West of Scotland Cancer Centre (1) Glasgow Royal Infirmary (1) Inverclyde Royal (1) Princess Royal Maternity (1) Medicine/Med specialties (22) Surgery/Surg specialties (3) Patient care (12) Medical staffing (21) Trainee exposure (2) Patient care (1) Medical staffing (1) Other (1) O&G (1) Patient care (1) Paediatrics (3) Medicine/Med specialties (1) Surgery/Surg specialties (1) Medicine/Med specialties (1) Medicine/Med specialties (1) Medicine/Med specialties (1) Dykebar (1) Psychiatry (1) Patient care (1) Medical staffing (2) Medical staffing (1) Medical staffing (1) Other (1) O&G (1) Other (1) Stobhill (1) Psychiatry (1) Other (1) Ninewells (9) Murray Royal (1) Royal Victoria (1) Medicine/Med specialties (3) Surgery/Surg specialties (4) O&G (2) Medical staffing (1) Medical staffing (1) Patient care (1) Medical staffing (1) Patient care (2) Medical staffing (1) Patient care (1) Medical staffing (2) Other (1) Medical staffing (1) Other (1) Psychiatry (1) Patient care (1) Medicine/Med specialties (1) Medical staffing (1) 76

79 Health Board Lothian 6 (8%) PS concerns n (% of all) LEP (n) Specialties (n) Issue Royal Infirmary (5) St John s (1) Surgery/Surg specialties (4) Patient care (1) Medical staffing (1) Trainee exposure (1) Other (1) O&G (1) Patient care (1) Medicine/Med specialties (1) Medicine/Med specialties (1) Patient care (1) Medical staffing (1) Highland 5 (7%) Raigmore (4) Paediatrics (2) Emergency Medicine (1) Medical staffing (1) Other (1) Patient care (1) Lanarkshire 5 (7%) Belford (1) Hairmyres Monklands Wishaw General Fife 4 (5%) Victoria (4) Borders 2 (3%) Forth Valley 2 (3%) Grampian 2 (3%) Dumfries & Galloway 1 (1%) Borders General (2) Forth Valley Royal Aberdeen Royal Infirmary Dumfries & Galloway Royal Infirmary Emergency Medicine (1) Medicine/Med specialties (1) Surgery/Surg specialties (1) Medicine/Med specialties (1) Surgery/Surg specialties (1) Medicine/Med specialties (1) Medicine/Med specialties (4) Medicine/Med specialties (2) Medicine/Med specialties (1) Surgery/Surg specialties (1) Surgery/Surg specialties (2) Surgery/Surg specialties (1) Patient care (1) Trainee exposure (1) Patient care (1) Medical staffing (1) Medical staffing (1) Medical staffing (1) Medical staffing (1) Patient care (1) Medical staffing (3) Patient care (1) Trainee exposure (1) Other (1) Trainee exposure (1) Other (1) Medical staffing (2) Medical staffing (1) Other (1) 77

80 3. Undermining Concerns raised by doctors in training via 2016 GMC National Training Survey 19 concerns were submitted. Personal or witnessed experiences of undermining in training environments are sought by the GMC as part of their data collection through their National Training Survey. Undermining concerns can relate to undermining, bullying or harassment from trained staff (including Consultants and Nurses, among others), from other trainees, from non-clinical staff and from patients or their relatives. The GMC seeks responses to each of these concerns from each Health Board and from the Deanery; these responses were submitted to the GMC (week ending 8th July 2016). Many will trigger further Deanery actions (including some site visits) that will be followedup through the Scotland Deanery Dean s report to the GMC, in the coming months. Health Board GG&C 8 (42%) Undermining concerns n (% of all) LEP (n) Queen Elizabeth University (4) Princess Royal Maternity (2) Specialties (n) General Medicine (1) Neurology (1) Surgery (1) Psychiatry (1) O&G (2) Glasgow Royal Infirmary (1) Surgery (1) Gartnavel Royal (1) Psychiatry (1) Tayside 4 (21%) Ninewells (3) Emergency Medicine (1) Trauma & Orthopaedic surgery (1) Urology (1) Royal Victoria (1) Psychiatry (1) Lothian 2 (11%) St John s (2) Psychiatry (2) Lanarkshire 2 (11%) Hairmyres (2) Ayrshire & Arran General Medicine (1) Emergency Medicine (1) 1 (5%) Crosshouse (1) Paediatrics (1) Forth Valley 1 (5%) Forth Valley Royal (1) Trauma & Orthopaedic surgery (1) Grampian 1 (5%) Royal Cornhill (1) Psychiatry (1) 78

81 Summary of GMC National Training Survey 2016 UK Picture The NTS ran from 22nd March 11th May (extended from 4th May because the survey period coincided with junior doctors industrial action in England), provides an annual opportunity for all doctors in training in the UK to provide feedback on the quality of their training. 53,577 doctors in training completed the survey (98% of those eligible similar to the 98.6% of 2015) The GMC are reviewing patient safety and bullying and undermining concerns raised via the survey with the relevant LETBs/Deaneries. This year the GMC also ran a national survey of trainers (named educational and clinical supervisors) at the same time as the survey of trainees. 23,154 trainers completed this survey (52.1% of those eligible). Scottish Picture 5062 doctors in training completed the survey (98.7% of those eligible an increase of 1.5% on 2015). 84% of doctors in training rated the quality of their experience as either excellent or good (compares with 82.2% in 2015 and compares with 85% for UK as a whole for 2016). Across all key indicators, Scotland s scores are broadly in line with that of England, Wales and Northern Ireland survey introduced one new reporting indicator: Reporting systems: 91.1% of doctors in training agreed or strongly agreed that have been made aware of how to report patient safety incidents and near misses (cf 90.2% for UK as a whole) 81.1% of doctors in training agreed or strongly agreed that there is a culture of proactively reporting concerns (cf 80.3% for UK as a whole) 85.9% of doctors in training agreed or strongly agreed that there is a culture of learning lessons from concerns raised (cf 84.7% for UK as a whole) 71.2% of doctors in training agreed or strongly agreed that they are confident that concerns are effectively dealt with (cf 68.4% for UK as a whole) 65% of doctors in training agreed or strongly agreed that when concerns are raised, the subsequent actions are fed back appropriately (cf 62.5% for UK as a whole) Patient safety is at the core of the work of the NES quality management team: they will review and act upon all patient safety concerns raised by trainees in the survey in partnership with Health Boards; and work more widely to improve the quality of training and education which has a fundamental effect on patient safety and patient care, now and in the future. The NES quality management team will analyse the NTS results closely and they will compare and triangulate the NTS results with other data collected from a number of sources all year round including NES own Scottish Training Survey. They will work together with the GMC and Health Boards to highlight where the quality of training can be improved and implement change as a result. They will also highlight where the quality of training is excellent, which should be recognised, shared and celebrated. 79

82 Scotland Deanery Annual Quality Report The Scottish Training Survey (STS) 80

83 The Scottish Training Survey (STS) The Scottish Training Survey is a key tool in Scotland Deanery s system for the QM-QI of the training that our trainees receive in Scotland. It complements the GMC s annual NTS in having some domains that are shared, but it has other domains that are unique to the STS. The STS casts additional insights into training, but it will also be used to triangulate against the NTS. The STS gives doctors in training an opportunity to provide confidential feedback on their perceptions of their training in each post and also provides an opportunity to feedback concerns about patient safety issues they have experienced in their post. Trainees in Foundation and Core programmes, who rotate to different posts every 4 months, will each be asked to complete the STS once for each post, three times per year. Trainees who rotate 6 monthly will complete the STS twice, each year; those trainees who are in post for 12 months will complete the STS once per year. The increased frequency of the STS facilitates quality management data collection from small training units that may just have one or two trainees at any one time, although it can still be challenging to get sufficient data from units with very small numbers of trainees. The STS is a key contributor to the data, information and intelligence about training, that are used to inform our understanding around whether training in Scotland meets the GMC s standards for PGMET, and to drive improvements in the quality of training that is provided. The STS is also used to support the quality management of postgraduate training of Dental Core trainees. The STS comprises 29 questions that are grouped under 7 domains or indicators. These indicators are: Team culture The STS requires at least 5 responses to generate a RAG (red and green) report using methodology Teaching developed by the Robertson Centre for Biostatistics Handover at the University of Glasgow; units that are most likely Workload to be examples of best practice (green flag) or have potential concerns requiring further exploration (red Induction flag) that are significantly better (green flag) or worse Clinical supervision (red flag) by more that 5 SEMs from the means of the benchmark groups are identified. Blue and pink flags are Educational environment also generated when units are more than 3 (but less that 5) SEMs from the benchmark groups whereby blue flags signal relatively good, and pink flags signal relatively poor performance. 81

84 Who answered the STS? There were 5635 medical and 106 dental trainees in Scotland Deanery s Turas database (as of 6 June the census date for the June 2016 STS). This number includes 298 OOP trainees (88 of whom are GP trainees) medical trainees were surveyed in June 2016, including 918 GP trainees, 1632 Foundation trainees, 620 Core trainees, 737 ST1 to ST3 trainees and 1346 ST4 to ST8 trainees; 106 Dental Core trainees were also surveyed. The overall response rate in to all runs of the STS was 66%. The response rates overall, and for each category (in posts in GP practice, in hospital training posts and in Dental Core posts) are shown in table 1. Table 1: STS response rates for each run of the survey in the training year , for each cohort of trainees Survey All trainees Sent (n) Response Rate (%) In GP training posts Response Sent (n) Rate (%) In hospital training posts Response Sent (n) Rate (%) Dental Core trainees Response Sent (n) Rate (%) Jun % % % % Mar % % % Feb % % % % Dec % 90 73% % Total % % % % Satisfaction with training Doctors at all stages of training were asked in the STS to reflect their satisfaction with their training experience. In response to the question: Thinking about your development as a doctor, how satisfied or dissatisfied are you overall with the experience you have had in this post, 97% of medical trainees in GP posts recorded varying degrees of satisfaction (rather than dissatisfaction) with their training; this compared with 84% trainees in hospital training posts who recorded varying degrees of satisfaction. 82% of Dental Core trainees recorded varying degrees of satisfaction with their training. Clinical Supervision Good training requires good clinical supervision of doctors in training; good clinical supervision is also necessary to ensure safety of care of patients in training environments. This indicator explores awareness of who is providing clinical supervision within and out of hours as well as their approachability and willingness to help, when asked. It relates to a number of requirements within the GMC s standards Promoting excellence: standards for medical education and training, including: R1.7 Organisations must make sure there are enough staff members who are suitably qualified, so that learners have appropriate clinical supervision, working patterns and workload, for patients to receive care that is safe and of a good standard, while creating the required learning opportunities. R1.8 Organisations must make sure that learners have an appropriate level of clinical supervision at all times by an experienced and competent supervisor, who can advise or attend as needed. The level of supervision must fit the individual learner s competence, confidence and experience. The support and clinical supervision must be clearly outlined to the learner and the supervisor. Foundation doctors must at all 82

85 times have on-site access to a senior colleague who is suitably qualified to deal with problems that may arise during the session. Medical students on placement must be supervised, with closer supervision when they are at lower levels of competence. In Scotland: 98% of doctors in training in posts in GP, agree that when they ask for advice, senior colleagues are always willing to help. Among doctors in hospital training posts, during the day - 95%, and out of hours 94%, agreed that they always know who to speak to when they need help or advice from a senior colleague. Among Dental Core trainees, 92% agree that when they ask for advice, senior colleagues are always willing to help. During the day - 95%, agree that they always know who to speak to when they need help or advice from a senior colleague. Educational Environment This indicator explores the appropriateness of the patient case-mix to the doctors development, whether there are sufficient opportunities to develop the requisite practical skills and whether the experience will facilitate attainment of the requisite competencies. The availability of on the job informal feedback and their overall satisfaction with the experience in post are also explored. This indicator relates to a number of requirements within the GMC s standards Promoting excellence: standards for medical education and training, including: R1.15 Organisations must make sure that work undertaken by doctors in training provides learning opportunities and feedback on performance, and gives an appropriate breadth of clinical experience. R3.13 Learners must receive regular, constructive and meaningful feedback on their performance, development and progress at appropriate points in their medical course or training programme, and be encouraged to act on it. Feedback should come from educators, other doctors, health and social care professionals and, where possible, patients, families and carers. R5.9 Postgraduate training programmes must give doctors in training: a. training posts that deliver the curriculum and assessment requirements set out in the approved curriculum b. sufficient practical experience to achieve and maintain the clinical or medical competences (or both) required by their curriculum d. the opportunity to develop their clinical, medical and practical skills and generic professional capabilities through technology enhanced learning opportunities, with the support of trainers, before using skills in a clinical situation f. regular, useful meetings with their clinical and educational supervisors g. placements that are long enough to allow them to become members of the multidisciplinary team, and to allow team members to make reliable judgements about their abilities, performance and progress h. a balance between providing services and accessing educational and training opportunities. Services will focus on patient needs, but the work undertaken by doctors in training should support learning opportunities wherever possible. Education and training should not be compromised by the demands of regularly carrying out routine tasks or out-of-hours cover that do not support learning and have little educational or training value. 83

86 In Scotland: 94% of doctors in training in GP posts agree that they get regular feedback on their performance with regard to how they manage patients. 86% of doctors in hospital training posts agree that the experience they are exposed to in this post will enable them to meet the required competencies of this element of the training programme. 81% of Dental Core trainees agree that they get regular feedback on their performance with regard to how they manage patients and 75% agree that they have enough opportunities to develop the procedural (or practical) skills relevant to their stage of training. Handover The STS asks about handover and whether the arrangements ensure that patients are looked after safely out of hours, as well as about the robustness and thoroughness of the handover arrangements, whether there is senior supervision and whether handover could be improved. This indicator relates to requirement R1.14 within the GMC s standards In Scotland: 86% of doctors in hospital training posts agree that the handover arrangements in place in this post ensure that my patients are looked after safely out of hours ; although 49% also agreed that handover could be improved in this post. Promoting excellence: standards for medical education and training : R1.14 Handover of care must be organised and scheduled to provide continuity of care for patients and maximise the learning opportunities for doctors in training in clinical practice. 98% of Dental Core trainees agree that the handover arrangements in place in this post ensure that my patients are looked after safely out of hours. Induction We ask about whether induction enables doctors in training to look after patients safely during the day, and, separately, whether induction also enables doctors in training to look after patients safely out of hours. This indicator relates to requirement R1.13 within the GMC s standards Promoting excellence: standards for medical education and training : R1.13 Organisations must make sure learners have an induction in preparation for each placement that clearly sets out: In Scotland: 94% of doctors in training in GP posts agree that the induction they received in this post enabled them to look after patients safely during the day. 84% of doctors in hospital training posts agree that the induction they received in this post enabled them to look after patients safely during the day. a. their duties and supervision arrangements b. their role in the team c. how to gain support from senior colleagues d. the clinical or medical guidelines and workplace policies they must follow e. how to access clinical and learning resources. 87% of Dental Core trainees agree that the induction they received in this post enabled them to look after patients safely during the day. 84

87 Teaching The STS asks about the quality of teaching that is received by trainees in their place of work and whether it targets what they need to know as well as whether they feel that teaching of trainees and their learning is a priority within their training environment. This indicator relates to requirement R1.16 within the GMC s standards Promoting excellence: standards for medical education and training : In Scotland: 95% of doctors in training in GP posts rate the quality of the teaching they receive in the place in which they work as good. 69% of doctors in hospital training posts agree that the environment in which they work makes them feel R1.16 Doctors in training must have protected time for learning while they are doing clinical or medical work, or during academic training, and for attending organised educational sessions, training days, courses and other learning opportunities to meet the requirements of their curriculum. In timetabled educational sessions, doctors in training must not be interrupted for service unless there is an exceptional and unanticipated clinical need to maintain patient safety. that the teaching of trainees and their learning is a key priority. 84% of Dental Core trainees rate the quality of the teaching they receive in the place in which they work as good. Team Culture This STS indicator explores the trainees experience of team (the extent to which they feel part of a medical or clinical team ), interpersonal dynamics within the multi-professional team ( the role I play in the team is valued by my Consultant/senior colleagues, I am treated with respect by other medical/senior colleagues, I am treated with respect by colleagues from other professions ) whether there is undermining ( is there a culture of undermining in the environment where they work? ) and whether the environment is generally supportive. This indicator relates to a number of requirements within the GMC s standards Promoting excellence: standards for medical education and training : R1.17 Organisations must support every learner to be an effective member of the multiprofessional team by promoting a culture of learning and collaboration between specialties and professions. In Scotland: 95% of doctors in training in GP posts agree that they feel part of a medical team. 88% of doctors in hospital training posts agree that they feel part of a medical team. R3.3 Learners must not be subjected to, or subject others to, behaviour that undermines their professional confidence, performance or self-esteem. R3.10 Doctors in training must have access to systems and information to support less than full-time training. R3.14 Learners whose progress, performance, health or conduct gives rise to concerns must be supported where reasonable to overcome these concerns and, if needed, given advice on alternative career options. R5.9 Postgraduate training programmes must give doctors in training: e. the opportunity to work and learn with other members on the team to support inter-professional multidisciplinary working 93% of Dental Core trainees agree that they feel part of a clinical team. 96% agree that they work in an environment that is generally supportive. 85

88 Workload Having a workload that is conducive to learning is essential in a training environment. In the STS we ask trainees to reflect the extent to which they agree or disagree with statements about their workload: I have the time I need to spend with patients to ensure I investigate issues thoroughly, a) when admitting patients to the hospital, b) during my normal working day, and c) when working out of hours. We also ask whether their workload is so heavy that it impacts on the safety of patient care. This indicator relates to requirement R1.12 within the GMC s standards Promoting excellence: standards for medical education and training : In Scotland: 85% of doctors in training in GP posts agree that they have the time they need to spend with patients to ensure they investigate issues thoroughly during their normal working day. 25% of doctors in hospital training posts agree that their workload is so heavy that it impacts on the safety of patient care R1.12 Organisations must design rotas to: a. make sure doctors in training have appropriate clinical supervision b. support doctors in training to develop the professional values, knowledge, skills and behaviours required of all doctors working in the UK c. provide learning opportunities that allow doctors in training to meet the requirements of their curriculum and training programme d. give doctors in training access to educational supervisors e minimise the adverse effects of fatigue and workload. 97% of Dental Core trainees agree that they have the time they need to spend with patients to ensure they investigate issues thoroughly during their normal working day STS free text comments The STS invites trainees to submit free text comments allowing us to identify and follow-up any patient safety and undermining concerns. These comments are routinely, also, made available as part of the pre-visit data packs that are available to panel members on QM-QI visits undertaken by each sqmg. STS Thematic Review The STS invites trainees to submit free text comments allowing us to identify and follow-up any patient safety and undermining concerns. These comments are The trainees are asked 4 qualitative free text questions, namely: Please describe the most memorable experience that occurred in this post Please describe the most positive aspects of this post Please describe the most negative aspects of this post Are there any areas which you feel are important to the quality of your training which are not currently covered by the survey? routinely, also, made available as part of the pre-visit data packs that are available to panel members on QM-QI visits undertaken by each sqmg. This section of the report focusses on the June 2016 data and only the responses from Medical trainees (not Dental). The STS questionnaire was sent to all 5286 trainees who completed a placement in June (77.9%) completed questionnaires were received, of whom 3133 (76%, n3133/n4117) added material to at least one free-text comments box, which equates to 59% of all trainees (n3133/n5286). After separating out all the individual comments, into the 4 questions, 9836 individual comments were identified. 86

89 Demographics of respondents Table 1, below provides the demographic details of trainees who both responded to the questionnaire and provided comments in at least one of the free text boxes. For the purposes of this report, the level Higher refers to Specialty trainees who are in ST1 and above. Table: Number of respondents by level, specialty training board and region. Level Region National East North South East West Total Foundation Higher Core GP Other Total Specialty Training Board Anaesthesia, Intensive Care and Emergency Medicine Diagnostics Foundation General Practice, Public Health and Occupational Medicine Medical Specialties Mental Health Specialties Obstetrics & Gynaecology and Paediatrics Surgical Total The number of participants writing about a particular theme are not seen as representative of the views of the sample as a whole as they reflect what trainees chose to write. Nevertheless, simple counts are used to illustrate the proportion of comments that addressed particular themes, and when an issue was raised frequently, weight was attributed to this as reflecting an important element of experience. The comments were classified under the six main themes and 39 subthemes. The themes are across all trainees in all regions/specialties/levels, and therefore some may be less applicable to certain groups of trainees than others. The majority of the subthemes were additionally coded as positive, neutral/mixed or negative, however a few of the subthemes were just coded as Yes if the code was present, and for four of 87

90 the subthemes different additional codes were used. Table 2 provides a list of the six themes, corresponding subthemes, the GMC requirements the themes map on to and the additional codes used. Table: List of themes and subthemes Theme Subtheme GMC Requirements Working conditions Experience/ development Trainee role Rota design/management R1.7, 1.12 Hours worked R1.7, 1.12 Workload R1.7, 1.12 Staffing levels Location of placement Ward rounds Handover R1.14 Induction R1.6, 1.13, 5.9 Isolation Opportunities to develop skills R1.16, 1.18, 5.9 Provision of protected time for learning Becoming an independent practitioner R3.12 Access to study leave Case mix Balance between training and service provision Volume of non-medical/mundane work/administration R1.15, 5.9 R5.9 Clarity of role R5.9 Cross-covering R5.9 Continuity of post/patient care R5.9 Working across sites Not specific to chosen speciality R5.9 Emotional Effects Level of competency/responsibility R1.7, 1.9, 1.10, 1.11 Patient interactions Patient care 88

91 Theme Subtheme GMC Requirements Atmosphere Ward/practice culture Trainee support Staff attitude R3.3 Teamworking R1.17, 5.9 Interaction with other specialties R1.17, 5.9 Communication with other staff/ seniors Supportive environment Staff support Colleague support Level of support R3.1 Teaching Senior support Supervision R1.8, 1.19, 1.21, 2.11, 5.9 Feedback R3.13 Attitude R3.3 Resources R1.20 Infrastructure Bed Management /practice management issues Staff facilities R5.9 89

92 Scotland Deanery Annual Quality Report The Task Force to Improve Medical Education and training in Scotland (TIQME) 90

93 The Task Force to Improve Medical Education and training in Scotland(TIQME) Excellence in medical education requires partnership and collaborative working at all levels within the NHS. At the strategic leadership level TIQME brings together the NES Medical Executive Team, the Medical Directors of each territorial Health Board and their Directors of Medical Education and Associate Directors. The inaugural meeting of this group took place in Perth on 5th November 2015 under the banner NHS Scotland working together to support and deliver excellence in Medical Education Topics tackled and debated included the new Scotland Deanery QM-QI framework, the new GMC standards for medical education and training and the Scottish single system to implement the GMC Recognition of Trainers guidance. Further meetings have looked at the GMC regional visiting process and the engagement of the service at Health Board level with medical education. Although TIQME sits outside the Scotland Deanery Quality Workstream governance arrangements, the opportunity it provides to look at the educational culture and environments from different perspectives is considered a powerful tool to drive improvement. Networking and keeping channels of communications open are key aims of this group. The strategic work of TIQME is supported by a new operational partnership between the Deanery s Quality Improvement Managers/Administrators and Quality Education Managers based in Scotland s Health Boards. The new partnership forum is tasked with improving the range of communications and arrangements that underpin shared work around the Quality Improvement Framework. The group is seeking to develop common approaches to visit arrangements, communication standards and meeting room layout requirements together with better understanding of new and existing reporting formats. The partnership group meets on a six-month cycle. Dr Iain Wallace Medical Director NHS Lanarkshire Dr Morwenna Woods Chair of Scottish DME Group TIQME has been an extremely useful forum for taking forward a range of actions to improve the quality of medical education in Scotland. Bringing together Directors of Postgraduate Medical Education, Undergraduate Deans, Directors of Medical Education and Medical Directors has provided an excellent opportunity to share innovation and best practice across sectors. As a result of the improvement activities that are already underway NHS Scotland should be better prepared for the GMC visit in

94 Professor Alastair McLellan Postgraduate Dean Professor David Bruce GP Director TIQME is the most important driver of improvements in the quality of medical education and training in Scotland. The impact is being seen already. 92

95 Scotland Deanery Annual Quality Report The Sharing Intelligence for Health & Care Group 93

96 The Sharing Intelligence for Health & Care Group In response to the National Information & Intelligence Framework for Health and Social Care in Scotland which states that a key priority for Scotland must be to maximise intelligence use and impact by sharing information across sectors, and the recommendation by the Mid-Staffordshire NHS Foundation Trust Public inquiry that there should be better sharing of all intelligence between regulators which, when pieced together, would raise the level of concern ; the Sharing Intelligence for Health and Care Group was established. This brings together six national organisations; Audit Scotland, Care Inspectorate, Healthcare Improvement Scotland, Mental Welfare Commission for Scotland, NHS Education for Scotland, and Public Health and Intelligence. The aims of this group are to: provide a forum to identify potential or actual risks to the quality of health and social care and, where necessary, initiate further action in response to these risks, and promote co-ordination of activity between these partner organisations, respecting the statutory responsibilities of each The Quality workstream provides this group with data from the GMC National Training Survey, the Scottish Training Survey, reports from visits to Local Education Providers including Enhanced Monitoring visits and concerns raised by doctors in training about their training environment. This data is provided at Health Board level, covering all sites where medical education is delivered. When these data are added to that of the partner organisations, a rich picture of quality of patient care is built. For each Health Board a report is then complied which is shared with senior colleagues from the relevant NHS Board, feeding back the conclusions of the group and exploring how providers of care, regulators and other national organisations can best work together to make best use of this shared data. All Health Boards in Scotland have now been reviewed by the group and the second cycle of review is now underway. The information above is largely drawn from the Sharing Intelligence for Health & Care Group Annual Report. NES Deputy Chief Executive and Medical Director Professor Stewart Irvine summarised the NES role NES is the education and training body for NHS Scotland and is very aware that education and training is patient safety for the next 30 years. We are responsible for managing large numbers of health professionals in training across the professions, working and learning in clinical environments. The feedback we gather from these staff provides valuable insight into the quality of care our patients and their families receive. 94

97 Scotland Deanery Annual Quality Report Our Working Groups 95

98 Our working groups Our 6 working groups are the Quality Workstream s engines of change and improvement, intended to develop and implement new ways of working. Drawing on experience from within the Workstream itself and experience and expertise of partners the Working Groups are principally charged with leading innovation and driving-out inconsistency. The section below set out the aims of each group and what they have achieved to date. Group 1. STC Engagement Working Group Aims and Objectives To develop a robust system for 2-way communication to and from the trainer front line so that those who are doing well, and those who are doing less well receive timely feedback based on the QM data & information that is processed by QRPs & sqmgs. This communication system must link sqmgs-stbs- STCs-Trainers. To develop a template to capture intelligence around quality of training within the scope of the STC and a process to ensure that this is accessible to the sqmg and actioned appropriately. To develop the STB highlights reports to ensure that it is fit for the purposes of supporting promotion of good practice and supports discouragement of poorer practices, and to support dissemination thereafter to STCs and to trainers. In line with the group s objectives, it was agreed that one of the most important links to the front line was via the annual Training Programme Director report. The group agreed to redevelop the report template to encourage greater provision of information relevant to the QRP process. The group also agreed that this report should be shared with the relevant STC and that the TPD response should reflect the intelligence and input of the whole STC. This redeveloped report was launched via a workshop at the NES Medical Education Conference A large number of TPDs and STC Chairs attended the workshop and welcomed the work of the group in trying to simplify the template and increase the opportunity to make local intelligence available to QRP panels. The group received feedback at the workshop that TPDs felt they did not receive advice of the outcomes of the QRP to which they were contributing and they were unsure whether their report had been helpful as no feedback on its content was provided. As a result of this feedback, the group developed a template to capture QRP outcomes on the day of the event and share these, in a simplified format, with TPDs following the events. This activity is currently underway and is being led by APGDs for Quality across all specialty groupings. During the 2016 QRPs a tool to assess the TPD report was also piloted. It is hoped that in future years this will allow specific feedback to be provided on each TPD report, highlighting information which the panel found particularly useful and noting areas where additional detail would be appreciated. This was not fully rolled out in 2016 as the group were aware that TPDs were working with a new report template and shortened completion time. The STB highlights report is working well and STC agendas now contain a specific section on training quality matters. Moving forward, the group will concentrate on maximising the value from these activities and improving the flow of information outlined in the objectives above. 96

99 Group 2. Trainee Engagement Working Group Aims and Objectives To develop a process, with involvement of a SCLF, to engage trainees in the activities (QRP, QMG & visits) of the NES QM-QI of framework for PGMET. To support engagement of trainees as representatives of the wider trainee cohort, to ensure that trainees gain greater appreciation of the commitment of Scotland Deanery to QM & QI of PGMET. To develop a process to recruit and train trainees for these activities. To identify a process that will enable release of doctors in training from their posts to engage in QM-QI processes. Guided by the above aims, there is a clear vision of what the Group wishes to achieve with the Group identifying at an early stage that the GMC had recruited Associates who are involved in GMC visits and had developed a person specification for recruitment of the Associates. Accordingly, the Group made reference to the GMC documents (with permission from the GMC) and constructed a recruitment frame work and outline paper on trainee appointments. The Group have estimated that 30 trainees of all grades from across Scotland will be required to participate each year in the QM-QI process. This has been based on the assumption of 80 QM visits per year. It is anticipated that each trainee recruited will participate in a minimum of 3 QM visits per year along with at least 1 QRP. It is also envisaged that they will attend SQMG/DQMG meetings. The Group identified many advantages not only to the QM-QI process of trainee involvement but also for trainees who choose to become involved. This will include insight into Quality Management which can be linked to development of Leadership and Management skills, a requirement of virtually all specialty curricula. Time for trainee involvement in QM-QI, as agreed at DQMG, is to be identified from within their existing study leave allocation and trainees will have travel and subsistence expenses paid. Trainees currently engaged in their respective STCs across the regions of the Scottish Deanery are likely to be most knowledgeable about QM-QI issues. The Group therefore sought the approval of STB Chairs to approach TPDs and Trainees. Recruitment of 30 trainees is now under way, with appointments expected from November

100 Group 3. Training Working Group Aims and Objectives To ensure that all those involved in work of the quality workstream including QIAs, QIMs, QLs, Leads, lay participants and trainees are trained to effect the roles they are required to deliver for the workstream including training for QRPs, visit panels (& for leading visits, where appropriate). To maintain an up to date log of all training undertaken. To ensure that E& D training is undertaken by all quality workstream staff involved in our processes & that the training is up to date. To manage calibration meetings annually as a forum for sharing and learning from the team s experience of engagement in key roles and activities to subserve the purposes of refresher training and to support standardisation of approach. To develop training programme content fit for the roles that are intended. To commission PD & other workstreams or others within NES to support development & delivery of training where feasible (as currently being explored for training for visits). QRP QRP training had preceded the formation of the workgroup. The need for further QRP training was scoped and this demonstrated that only 3 of those involved requested training/further training. It was felt that for the small numbers involved this could be achieved via support and experiential learning through participation in the process. Equality & Diversity The QM Team responsible for a visit will record E&D training status of visit panel members as part of the organisational arrangements. This information will then be logged as a shared resource. It is the individual s responsibility to complete available training resources. Training for Panel Visit Chairs Enquiries were made regarding resources for the training of Panel Visit chairs by the group. Information was sought from GMC, HIS, Royal Colleges and other Deaneries/LETBS. No existing training material exists apart from an e-module on the visit process by Health Education England KSS. In order to take this project forward the group developed a novel training package outlining the visit process, preparation for a visit including the pre-visit teleconference, briefing materials and construction of recommendations based on GMC standards. A substantial part of the programme focused on skills development in giving feedback and dealing with difficult interview scenarios. The first training day was held on delegates attended and subsequent feedback received from participants was very positive. 100% agreed that the aims of the workshop were achieved with delegates overall ratings being good (19%), very good (31%) or excellent (50%). [Appendix 1] For the other 18 potential Lead Visitors unable to attend, the event was be repeated on

101 Training for Panel members To ensure the success of the visiting process there will be a requirement to train those who will act as panel members. The potential number of postgraduate trainer panel visitors is large. Trainee visitor representatives will also need to be included in this group as well as visitors nominated by Undergraduate Medical Schools as part of the joint visiting pilot. Trainee visit representatives are to be recruited by the Trainee Engagement workgroup. This will require significant resource in terms of time for the production of new training materials and also for training delivery. The first training day for panel members was held in Glasgow on with further events held in Perth on and Edinburgh on There has been positive engagement by all groups to attend these training events. Group 4. QI of Workstream Processes Working Group Aims and Objectives To create a framework for continuous, controlled, systematic improvement of the processes within the QM- QI framework including QRPs, sqmgs, QM-QI visits and reports, DR and associated processes based upon use of informative performance metrics and informed by feedback. To lead on the development of the TURAS quality module. To foster a culture of QI in relation to all activities undertaken by and within the quality workstream. To create a generic reporting template and to populate it with performance indicators for each sqmg s annual report. To ensure that workstream processes deliver to the expected standards but also to improve performance through refining these standards to ensure that they remain challenging. Over the course of the last year the group has organised and facilitated a series of national workshops and seminars that have informed change and refinement of the Deanery s processes and procedures including events for the visit process, the QRP process and the new GMC Deanery Report process. Feedback from these events and other sources resulted in a data base of over 160 individual improvement actions that has resulted in many individual improvements and new standard operating procedures for: Priorities for 2017 are: Development of a Version Control SOP Development of a house report writing style Launch of the new Turas Quality Management module Full launch of visit tracker data base QRPs Visits Enhanced monitoring Identification of good/best practice Calibration of standards 99

102 Group 5. QI of PGMET Working Group Aims and Objectives To change the culture surrounding PGMET within NHS Scotland through promotion of understanding that improvement in the quality of training is key to improving the quality and safety of patient care and to recruitment of trainees and trained doctors. To support trainers, trainees and other stakeholders in effecting improvements in the quality of PGMET that is provided in Scotland. To engage with the existing network of those trained in QI methodology such as the Improvement Advisor network and with trainers and trainees in projects featuring small tests of change in aspects of delivery of training. To agree 4-6 themes in PGMET e.g. feedback, to prioritise as targets for improvement activity. To engage the whole cohort of QLs as PGMET QI champions. If funding becomes available to support targeted improvement campaigns to develop a process to manage and evaluate use and impact of the funding. To identify, support and promote good practice in PGMET through SHARE and other resources. The working group has considered the engagement of those involved in medical education across Scotland in the Quality Improvement of Medical Education and Training and is now taking forward the following objectives and actions. In a further refinement of the aims and objectives above the group are seeking to 1. To enable educational providers to have a clear understanding of what is necessary to meet national standards and what would be regarded as current best practice. 2. To enable educational providers to exchange new ideas on measures that enhance educational delivery, and to celebrate the achievement of new advances in such delivery. 3. To provide a means whereby trainees, students and organisations can support educators through positive feedback. 4. To support educational units in their identification of areas for development. 5. To foster an educational culture across Scotland that promotes team- working and learning. The following actions are now happening. Sharing definers of required & good practice for each educational domain with education providers Developing and piloting educational improvement toolkits for each standard domain that support a review of the elements defined in E.1 and provide examples of tools and practices that have supported delivery at a local level and related references Facilitating opportunities for educators and learners to exchange examples of innovative and excellent practice Identifying routes through which students and trainees can be encouraged to feedback to educators at a local level 100

103 The SHARE Quality Improvement website is a key output of the working group. Launch During the launch of the SHARE website in May 2015, a total of 13 case studies were submitted and subsequently published on the site. The quality team worked with website development team over the summer months to resolve technical issues that were preventing satisfactory publishing of cases. Work to prompt case entry to SHARE QRP cases: Following the Quality Review Panels in August/September 2015, the administrative team for SHARE contacted all specialty groups and obtained a summary of all Good Practice Recognition QRP outcomes. The team liaised with all specialty groups to obtain further information on the potential good practice items and requested invites be sent out to the relevant sites and departments inviting them to complete and submit a case study to the SHARE website. These actions resulted in a further 10 case studies being received and subsequently published on SHARE. Visit cases: As part of the current Deanery visits process, visit reports have the ability to identify areas of good practice. In order to obtain further information Use of SHARE There are currently 24 case studies published on the website with a further 1 case study to be reviewed at the next QI of PGMET working group meeting. Despite the relatively small number of cases there has been a high level of user engagement with cases. Users have the opportunity to rate cases. 3 cases have received over 11,000 ratings. The average rating for a case is 2444 rates. The group plans to develop SHARE further by 1) Encouraging SHARE case entry: DQMG will be invited to consider other ways that stakeholders could be encouraged to use SHARE e.g. asking DMEs to note entries in the DME report; creating an automatic to all those accepted to the next Scottish Medical Education Conference, sending an annual report to DMEs and STBs showing number and ratings of cases per board and discipline on these areas and to invite submission of case studies the SHARE administrative team recently developed an invite template which is available for distribution by visit chairs/ldds/qims. Also, to ensure an up-to-date record of all areas of good practice identified at visits the administrative team developed a Good Practice Visit Log which was recently distributed to specialty QIMs for update. This log details the areas of good practice identified at visits and who within the relevant specialty has ownership of ensuring wider circulation of the information. The SHARE administrative team plans to work with all specialty groups to update this log every two months and report via the QI of PGMET working group. 2) SHARE case study review, themes and highlighting: Any case studies submitted to SHARE will also be reviewed at the QI of PGMET working group prior to publication on the website will see the development of a SHARE newsletter highlighting particular themes or key cases 101

104 Group 6. Working Group on Joint UG-PG visit processes Aims and Objectives To work with Scottish Dean Medical Education Group (SDMEG) and to develop, further, a single joint system for QM & QI for undergraduate and postgraduate medical education & training. To support further development of the UG QRP by the SDMEG, in particular to extend the range of data and information relating to UG MET reviewed by the UG QRP. To support the joint development of a single system for QM-QI visits (scheduled, triggered & immediate triggered) and for reporting on these visits to ensure that the UG & PG needs from these processes are fully achieved. To support refinement of the joint processes through learning from doing. From the outset, the Scotland Deanery Quality workstream and the Scottish Deans Medical Education Group (that has oversight of the delivery of undergraduate medical training in Scotland) have had the shared vision of working together to craft a single QM-QI process for training environments that train medical undergraduates and postgraduates. This aspiration reflects the approach that has been embedded in the GMC s standards for medical education and training, namely, a single set of standards that applies to medical education and training whether for undergraduates or postgraduates. Professor Alastair McLellan In , the 5 Scottish Medical Schools introduced and engaged in a QRP for undergraduate medical training. This QRP was the first of the QRP season (the rest being postgraduate QRPs), and involved representatives of all 5 Medical Schools as well as an LDD and the APDG-quality for Foundation. Among the data reviewed was the Scottish Undergraduate Survey. A number of LEPs have undergraduates from more than one medical School, and for the first time, there was an opportunity to review survey feedback on undergraduate training of undergraduates in the same location but from different Medical Schools. Output from the undergraduate QRP was fed into the Foundation QRP and to the subsequent postgraduate QRPs including GP, Core and Higher training QRPs. This achieved, for the first time, oversight of the span of experience of training from undergraduate through foundation, GP, Core to Higher training for those sites that have all of these cohorts of learners. Professor Gary Mires Chair of the Scottish Deans Medical Education Group As the approach to QM-QI visiting in a postgraduate training context was itself a new process, and as the approaches of the individual Medical Schools also differed, we have undertaken a series of pilot, joint scheduled and triggered QM-QI visits, that have incorporated variants of structure, administrative support and of reporting, to inform our development of a single approach to QM-QI visiting, that will emerge from a joint workshop in October in We, whether with responsibility for QM-QI in an undergraduate context or in a postgraduate context, remain committed to the development of a single approach to undergraduatepostgraduate QM-QI visiting in the training year. 102