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1 Postgraduate Training Ongoing Quality Review and Enhancement Framework Version 1: 2010

2 Contents Contents... 2 PMET Quality Review Framework Introduction... 3 Introduction... 3 Postgraduate Training Quality Governance Framework... 4 PMET Quality Review Framework Diagram Quality Standards for PMET... 6 Scheduled LEP Reviews... 9 Exceptional LEP Reviews Level 1: Exceptional LEP Paper-based Review Level 2: Exceptional LEP Review Visit by School Level 3: Exceptional LEP Trigger Visit by Deanery with Externality Level 4: Exceptional LEP Regulatory Body Trigger Visit Full Programme Reviews Deanery Review Annual Deanery Report Deanery Regulatory Body Review Guidance on Conducting a LEP Review Selection of Panel Members Obtaining and Reviewing Evidence The LEP On-Site Review Meeting Process Development of Findings Report Follow Up of Review Reports and LEP Improvement Action Plans Appendix 1: LEP Review Findings Report Template Appendix 2: On-Site Panel Review Question Form Appendix 3: LEP Improvement Action Plan Template Appendix 5: Form to Request Deanery Quality Review Appendix 5: Level 1 - LEP Paper Based Review Form Appendix 6.a: Letter to LEP Requesting Scheduled Review Appendix 6.b: Letter to LEP Requesting Exceptional Review Appendix 6.c: Letter to LEP Requesting Follow-up Review Appendix 6.d: Letter to LEP Approving Improvement Actions Appendix 7: Standards for Training

3 PMET Quality Review Framework Introduction Introduction Through its structured quality management and enhancement processes, NHS West Midlands Deanery (the Deanery) ensures that the educational outcomes required within the curricula for its vast array of training programmes are achieved by its Local Education Providers (LEPs) and in turn is producing a fit for purpose and highly skilled medical workforce. This quality management and enhancement framework provides the structure to enable robust assurance that quality requirements are being fulfilled and education quality is enhanced for both Foundation and Specialty training, which in turn are utilised to provide assurance to the General Medical Council (which now includes the former Postgraduate Medical Education and Training Board that was responsible for specialty training) as the overall external quality assurance agent for the Deanery. As part of its quality management framework, the Deanery utilises a variety of quality review interventions based on continual review and targeted review dependant on perceived risk to ensure the delivery of the education and training at its LEPs is of a high standard and meets the needs of stakeholders and regulators, enhances the quality of education and in turn improves the quality of patient care. The Deanery recognised the importance of not only reviewing areas where quality may require improvement, but also reviewing areas of enhanced and notable practice. Therefore, in addition, this review framework is also be utilised to review perceived areas of notable practice in order to investigate and share this practice with all educational areas within the Deanery. Where notable practice is identified, the appropriate level of the quality review framework will be invoked. The following diagram illustrates the levels of the quality review framework: 3

4 PMET Quality Review Framework Diagram Framework Description Responsible Scheduled LEP Review Scheduled Review Planned review cycle of LEPs. At least 10% of LEPs are reviewed each year per school, normally through scheduled visits. Head of School and School Quality Lead Exceptional LEP Review Level 1: Exceptional Paper-Based Review Paper based exercise to understand and address an identified low risk quality issue. Level 2: Exceptional Review Visit by School Significant medium risk issue identified requiring a school visit to gather further information and address any identified concerns. Level 3: Exceptional Trigger Visit by Deanery with Externality Significant high level risk identified which requires an extraordinary triggered deanery visit to address these concerns. Level 4: Exceptional Regulatory Body Trigger Visit (i.e. GMC) Significant high level risk identified which requires an extraordinary triggered visit to address these concerns (i.e. GMC) Head of School and School Quality Lead Head of School and School Quality Lead Associate Dean for Quality Postgraduate Dean Programme Review Planned Programme Review Planned programmes reviews are scheduled each year according to identified need (e.g. changes to workforce requirements / identified issue with programme) Associate Dean for Quality / Head of School Deanery Review GMC Deanery Visit and QAFP GMC will visit the deanery on an approximately 3 year cycle to ensure that the local quality framework is operating efficiently. The GMC will also jointly visit the deanery to Quality Assure Foundation Programmes (QAFP) Postgraduate Dean Postgraduate Training Quality Governance Framework In order to ensure robust quality assurance, the Deanery employs a strict quality governance framework where by any quality issues identified are highlighted to an appropriate level, either at LEP, School, Deanery, SHA, or Regulatory Body (i.e. GMC) levels. Quality issues will filter up and be channelled through the governance structure which comprises of; localised LEP educational governance, School Board Meetings, the PMDE Quality Committee, the PMDE Board, and 4

5 LEP Specialty Programme School Deanery Regulator (i.e. GMC) ending in Regulatory Body structures. Any substantial issues regarding patient and/or trainee safety will also be filtered into relevant SHA Governance (i.e. Patient Safety Committee) as a matter of priority. Quality governance is facilitated via quality review processes described within this guidance document (i.e. LEP review, Programme review, Deanery review). In addition to those described within this document, the deanery also employs annual reporting mechanisms starting at LEP level, feeding into School level and finally at Deanery level which in turn get passed onto relevant regulatory bodies e.g. Annual Deanery Report to GMC (see separate Annual Deanery Reporting Guidelines). The following diagram illustrates an overarching approach taken toward education quality governance: Organisational Levels Quality Review Processes Governance Groups Deanery quality review, report and action plan Regulatory Body (i.e. GMC) Royal Colleges SHA Governance / Patient Safety Group PMDE Board Annual Deanery Report PMDE Quality Committee School Annual Report School Boards (i.e. PMDE and FPMB) Programme quality review, report and action Specialty Programme Annual Report Specialty Training Committees LEP quality review, report and action plan LEP Annual Report LEP Local Education Meetings Trainee and Trainer Perception Surveys 5

6 15 Quality Standards for PMET The following are the detailed requirements for doctors and dentists in training posts in the West Midlands Deanery. These standards have been mapped onto the GMC standards for training. They are used in JEST questionnaires for trainees at end of rotation, and also form the basis of all standards assessed when undertaking a quality review and when reporting against for the Annual Deanery Report (ADR): 1. Patient Safety All doctors and dentists in training must make patient safety their prime concern. All of the criteria (standards) below must be understood in terms of this overarching concept of patient safety. 2. Programme Director Each training programme must have a named programme director who accepts responsibility for planning the programme and ensuring that the standards set out below are met within the training programme. 3. Induction At the beginning of each post, all trainees must attend induction programmes designed to familiarise them with both the Trust in general and the specialty department (organisational and educational aspects) in particular. Clinical guidelines used in the department must be explained at the induction. Written information on timetables and other arrangements must be provided. The induction must include details of occupational health services, arrangements in place to deal with bullying and harassment issues, and guidance in place and what to do in terms of whistle blowing in the NHS. 4. Appraisal and Assessment Each trainee must have a named educational supervisor, who meets with him / her privately at the start of each attachment, and then at specified intervals to carry out appraisals, clarify career goals, identify learning needs and plan the education accordingly. Information from the consultant / trainer (if this is a different person from the educational supervisor) about the trainee's progress must be provided for these sessions. Appraisals and assessments must be properly documented using the specified documentation. 5. Feedback The consultant / trainer must give regular helpful constructive feedback on performance in daily clinical supervision. All those involved in training must provide regular informal constructive feedback on both good and poor performance and contribute to appraisal and assessment of the trainees. 6. Protected Teaching There must be a protected teaching programme for all trainees. 6

7 Educational activity must be based on the relevant Royal College / Faculty curriculum, and separate from clinical work, and must be provided on a regular basis. Trainees must attend a minimum of 70% of these. The programme must be evaluated by the trainees and modified in the light of their feedback. 7. Service Based Teaching There must be opportunities to be taught and to learn during routine work, with appropriate consultant ward rounds, outpatient clinics and operating sessions per week. Handover arrangements must be in place, including arrangements for cross-specialty cover if applicable. 8. Senior Doctor Cover The immediate personal assistance of a senior doctor (normally a consultant or trainer) must always be available to trainees. 9. Clinical Workload All trainees must be exposed to an appropriate level of clinical activity, to develop their clinical knowledge, skills and attitudes appropriate to their stage of educational development, and for the achievement of their educational objectives. 10. Evidence Based Medicine and Audit Written guidelines on the management of common clinical conditions agreed locally in the specialty must be available to the trainees. These should be evidence based and subject to audit involving the trainees. All trainees must take an active part in audit and receive guidance and appropriate support to carry out this work. 11. Inappropriate Tasks No trainee should be expected to perform work for which he / she is inadequately trained, which is of no relevance to his / her educational objectives, or which is prohibited by GMC / GDC guidelines (for example taking consent inappropriately). 12. Rotas The rota must be compliant with current legislation, and monitored regularly to ensure that it remains compliant. Trainees must take part in the monitoring processes, when these occur. 13. Accommodation and Catering The employer is responsible for the provision and maintenance of a safe working environment for the trainees, with accommodation and catering which meet current national standards. 14. Leave 7

8 All trainees must be allowed to undertake annual leave and study leave within their Terms and Conditions of Service. Study leave must be appropriate to their educational objectives, agreed with their educational supervisor in advance, and within the limits set by the regional postgraduate dean. 15. Junior Doctors Forum There must be a junior doctors and dentists forum, which has representation from the employer, the educational supervisors and programme directors, and the trainees. This forum must meet regularly, and the meetings must be documented and minuted, including details of decisions made. 8

9 Scheduled LEP Reviews Scheduled LEP reviews are proactively planned each year to ensure that a random sample of at least 10% (or more) of LEPs associated with a school are reviewed, with the intention that 100% are reviewed over the given period of time. (This may vary between foundation and specialty schools based on their locally agreed reporting arrangements). These reviews are planned and undertaken by Schools, led by the Head of School (HoS) and their deputy / lead for quality. The following illustrates the processes for this: Scheduled LEP Review Process: Foundation and Specialty Training Planning of Yearly Review Schedule by School April Inform Education Development Team of planned review dates School agrees review day programme with LEP via letter Added to central Deanery review calendar School selects panel members for review day ED team may attend random sample of reviews by schools to internally monitor quality of processes Collection and review of LEP background information See Obtaining and reviewing evidence Conduct Review Day See LEP On-Site Review Process Report, action plan and outcome tabled at Quality Committee and Centrally Recorded by Education Development Team Develop Findings Report LEP agrees report and develops action plan which is monitored by school 1 month Report, action plan and outcome sent to Education Development Team for central recording 1 month See Findings Report Development Process If issues are significant, or unable to be resolved, escalation to next appropriate level of review framework Report signed off by HoS and closed via letter to LEP Yes All actions complete? No Monitoring and review of action plan (e.g. follow up review visit planned or paper based review of action plan) 9

10 Typical Review Panel Makeup: 2-4 panel members, made up of the following: HoS, and/or School quality lead, and/or STC lead 1-2 Internal deanery trained panel member(s) Administration (if required) Annual Process Overview: The process starts in April when Schools (i.e. foundation or specialty school) will plan their yearly cycle of visits. The school will also share their planned review cycle with the Associate Dean (Quality) and Education Development Team who will ensure their reviews are added to the central Deanery calendar for use when planning visits to LEPs to avoid duplication. The Education Development Team may also request to sample a random selection of visits each year within each school as a mechanism to audit the quality of processes and act as internal quality control. Schools will then liaise and confirm the review through the Clinical Tutor, Postgraduate Centre Manager, and/or Medical Director through official letter (appendix 6.a). They will then progress to make appropriate arrangements for the review, finalising a timetable and agree appropriate panel members. The School will also collect appropriate pre-review data for use when auditing the LEP and distribute it amongst the review panel (see guidance on conducting LEP review section for further information on this). The review panel will then visit the LEP to review the quality of education. (See LEP on site review process section). They will then develop a findings report (see Findings report development process section and appendix 1) and send it onto the LEP Clinical Tutor, Medical Director and Postgraduate Centre manager within 1 month of the review day. If required, the LEP will develop an improvement action plan within 1 month of receiving the review findings report (appendix 3) and send it back to the School and review panel. This will then be agreed by the School and enter a period of monitoring and review. The School may choose to monitor the action plan either by: 1. Follow up visit (normally if significant issues have been highlighted that need the weight of a visit and a follow up visit letter will need to be sent to the LEP appendix 6.c) 2. Paper based exercise reviewing progress reports on the improvement action plan sent in by the LEP to the School within an agreed timescale. Note: If the School identifies issues that are substantial, or where no progress is being made toward agreed actions within reasonable timescales, the School is able to at any time escalate the issues up to the next most 10

11 appropriate level of the quality framework, and also inform the SHA patient safety or other relevant committee. The visit findings report and LEP improvement action plan must be sent to the Education Development Team for central recording within the Deanery. Following monitoring arrangements agreed within the report, when the actions are agreed and signed off by the HoS via an official letter to the LEP, (appendix 6.d) the School must table the report and closed action plan at the quality committee for final sign off and closing of the quality loop. Reports are then able to be tabled at the relevant Postgraduate Board meeting (i.e. foundation or specialty) for assurance purposes. 11

12 Exceptional LEP Reviews Exceptional LEP reviews are reactionary and undertaken according to need with the intention to gather further information around a perceived issue, address the issue, and/or escalate it where required. These reviews will arise from the ongoing scrutiny of available information presented to schools and the deanery which will include, but not be limited to: LEP self evaluation based on exception reporting GMC (formerly PMETB) Trainee and Trainer Survey results (e.g. red outliers) JEST survey results (e.g. score of 2 or less) Complaints, whistle blowing, or other issues of concern / dissatisfaction raised Critical incidents (e.g. that compromise learning and/or safety) Continual non-compliance to quality standards The exceptional review framework is split into 4 key levels depending on the associated risk and severity of the issue that is raised. In all situations, as with any performance management framework, attempt should be made to address issues at the lowest possible level. Level 1: Exceptional LEP Paper-based Review The first level of the exceptional review framework comprises of a desktop review. The rationale behind this is that often schools identify potential low risk issues that may need to be addressed, however does not warrant the substantial resources required to undertake a physical review visit. This is a more efficient way to ensure that all quality issued identified, no matter how small, are addressed and dealt with appropriately. Examples of when a level 1 review is required include: A small minority of JEST scores of 1 or 2 A small minority of GMC survey red outliers Whistle blowing / concern raised that is perceived to be low risk by the school Typical Review Panel Makeup: 1-2 review members, made up of the following: HoS, and/or School quality lead, and/or STC lead (i.e. as deemed appropriate by HoS) 12

13 Process Overview: The process starts by an issue being highlighted within the school and brought to the HoS or their designated school quality leads attention. They will then make the decision that the issue requires input at level 1 of the exceptional review framework. The school will then send out a standard proforma (appendix 5) to the Clinical Tutor (CT) copying in the Medical Director (MD) at the LEP describing the issue and requesting an update on the issue complete with supportive information or an improvement action plan. The LEP must then respond to this request within 1 month of receiving the report, attaching evidence that the issue has been addressed, or actions being taken to address the issue. The HoS / school quality lead will then review the returned report and supporting information (within 1 month of receiving the returned report) and make a decision as to whether the issue has been addressed, or agree actions to address the issue with timescales. If an action plan has been agreed, the school must monitor this and request updates as required. At the point the school decides that the issue(s) have been resolved, they will sign the report and send the signed report back to the CT and MD at the LEP to indicate this with a covering letter (appendix 6.d). They will also send the report to the Associate Dean (Quality) and Education Development Team for central recording within the deanery, table the report at the next school board meeting, and finally ensure that the report is tabled at the quality committee for information sharing. If at any point the school decides that the issue cannot be resolved through level 1 of the framework, they are able to escalate it to the next appropriate level of the framework. The following diagram illustrates the process for level 1 of the framework: 13

14 Level 1: Exceptional LEP Paper-Based Review Process School identify issue with LEP School receives concerns and makes decision that level 1 review required School sends out request to CT at LEP using standard report (appendix 5) indicating identified issue and requesting update on issue accompanied by either an improvement action plan or evidence than issue is dealt with Key Input Process Point Decision End Point LEP sends back report template completed with accompanying evidence and/or associated improvement action plan Within 1 month HoS and school quality lead review returned report and decide if issue has been sufficiently addressed Within 1 month Yes Report signed off by HoS / school quality lead No Action plan monitored and update requested in timely manner Escalation of identified issues within review framework if unresolved Signed report sent back to CT at LEP advising of outcome with covering letter (appendix 6.d) Instantly Report sent to Associate Dean (Quality) and Education Development team for information and central deanery recording Within 1 month Report tabled at School Board for information Next Meeting Report tabled at Quality Committee for information Next Meeting 14

15 Level 2: Exceptional LEP Review Visit by School The second level of the exceptional review framework comprises of an exceptional visit by the relevant School. This level of review would be invoked if a School is made aware of potential issues that require the level of a physical visit to the LEP and may be utilised to address either several issues of concern, or as an exploratory mechanism where a potential issue may have been highlighted which requires further investigation. Examples of when a level 2 review is required include: Concern over potential patient safety / high risk issues that require further investigation. A majority of JEST survey scores of 1 or 2. A majority of GMC (formerly PMETB) survey red outliers. Whistle blowing / concern raised that is perceived to be medium-high risk. LEP annual self assessment indicating issues. When issues identified at level 1 of the framework have not been resolved in reasonable timescales and need escalation. Typical Review Panel Makeup: 2-4 panel members, made up of the following: School Representative (chair/lead) HoS, and/or School quality lead, and/or STC lead 1-2 Internal deanery trained panel member(s) Administration (if required) Process Overview: The process starts with an issue being identified with the LEP and the School making the decision that it needs to be escalated to level 2 of the framework. The school will then liaise with the LEP (normally through the Clinical Tutor, Postgraduate Centre Manager, and/or Medical Director) writing to them utilising the standardised letter template (appendix 6.b) and negotiate the review date and agenda with the LEP as required. The School must also inform the Associate Dean for Quality and Education Development Team that a visit has been arranged, who will then put the visit on the central deanery calendar. They will then progress to make appropriate arrangements for the review and finalising the timetable. The School will also collect appropriate pre-review background data for use when auditing the LEP and distribute it amongst the review panel (see conducting LEP review section for further information on this). 15

16 The review panel will then visit the LEP to review the quality of education, in-particular around the identified quality issues. (See LEP on site review process section). They will then develop a findings report (see appendix 1 and Findings report development process section) and send it onto the LEP Clinical Tutor, Medical Director and Postgraduate Centre manager within 1 month from the review day. If required, the LEP will develop an improvement action plan (appendix 3) within 1 month of receiving the review findings report and send it back to the School and review panel. This will then be agreed by the School and enter a period of monitoring and review. The School may choose to monitor the action plan either by: 1. Planning a follow up visit (normally if significant issues have been highlighted that need the weight of a visit this will require the LEP being advised by a follow up visit letter appendix 6.c) 2. Paper based exercise reviewing progress reports on the action plan sent in by the LEP to the School within an agreed timescale, utilising the improvement action plan (appendix 3) or other agreed format. Note: If the School identifies issues that are substantial, or where no progress is being made toward agreed actions within reasonable timescales, the School is able to at any time escalate the issues up to the next most appropriate level of the quality framework, and also inform the SHA patient safety or other relevant committee. The visit findings report and draft action plan must be sent to the Associate Dean for Quality and Education Development Team for central recording within the Deanery within 1 month of the action plan being developed by the LEP. Following monitoring arrangements agreed within the report, when the actions are agreed and signed off by the HoS, the School must notify the LEP via written letter, (appendix 6.d) table the report and closed action plan at the next Quality Committee meeting for final sign off and closing of the quality loop, and then ensure that both the review report and signed off action plan are presented to the Associate Dean for Quality and Education Development Team for central deanery recording. Reports are then able to be tabled at the next relevant Board (i.e. foundation or specialty) meeting for assurance purposes. 16

17 Level 2: Exceptional School Visit Issue(s) identified (New issue or escalation from lower framework) Schools receives concerns and decision made to escalate to level 2 of framework School sets up School exceptional visit with LEP, utilising internal clinical externality if required (appendix 6.b) Concerns/visit details sent to Associate Dean (Quality) and Education Development team 1 month Added to central Deanery review calendar Collection and review of LEP background information See Obtaining and reviewing evidence Conduct Review Day (School Led) See LEP On-Site Review Process Develop Findings Report 1 month See Findings Report Development Process Report, action plan and outcome tabled at Quality Committee and Centrally Recorded by Education Development Team LEP agrees report and develops action plan which is monitored school ((appendix 3) 1 month Report, action plan and outcome sent to Education Development Team for central deanery recording 1 month If issues are significant, or unable to be resolved, escalation to next appropriate level of review framework (i.e. Deanery Trigger Visit / Trainees removed) Report signed off by HoS and closed via official letter to LEP (appendix 6.d) Yes All actions complete? No Monitoring and review of action plan as required (e.g. follow up review visit or paper-based review of action plan) 17

18 Level 3: Exceptional LEP Trigger Visit by Deanery with Externality The third level of the exceptional review framework is utilised when there are significant issues identified within a LEP and is led by the Deanery. The Deanery will utilise a level of clinical externality / lay membership within this level of review to ensure total impartiality to issues that are identified within the LEP. Examples of when a level 3 review is required include: Majority JEST survey scores of 1 or 2 indicating significant patient safety issues. Majority GMC survey red outliers indicating significant patient safety issues. Whistle blowing / concern raised that has evidence of high risk / patient and trainee safety issues. LEP annual self assessment indicating issues that are high risk or relate to patient and trainee safety. When issues identified in level 2 of the framework, (and in some instances level 1 if seen as significant) have not been resolved in reasonable timescales and need escalation. When issues identified are high risk and require a level of clinical externality outside of the Deanery. Typical Review Panel Makeup: 3-4 panel members, made up of the following: Senior Deanery Representative (chair/lead) Dean, or Associate Dean (Quality), or Head of Education, or Education Development Manager School Representative HoS, or School quality lead, or STC lead Clinical externality, from outside the deanery area College representative, or specialty lead from another deanery Lay membership (from Deanery lay pool, if required following Deanery consideration) Administration (if required) Process Overview: The process starts with an issue being identified with the LEP and the School (or deanery) making the decision that it needs to be escalated to level 3 of the framework. A form requesting a level 3 review visit (appendix 4) must then be completed and sent to the Associate Dean for Quality / Education Development Team at the deanery who will then take control of the review. The Deanery Education Development Team / Associate Dean for Quality will then progress to make appropriate arrangements for the review, drawing together a timetable and agree appropriate panel members, which must include clinical externality. They will then liaise with the LEP (normally through the Clinical Tutor, Postgraduate Centre Manager, and/or Medical Director) writing to them utilising the standardised template (appendix 6.b) and confirm the review date and agenda with the LEP as required. 18

19 The date of the review will also be added to the central deanery visiting calendar. Appropriate pre-review background data will be collected for use when auditing the LEP and distribute it amongst the review panel (see conducting LEP review section for further information on this). The review panel, led by the deanery, will then visit the LEP to review the quality of education, in-particular around the identified quality issues. (See LEP on site review process section). They will then develop a findings report (see appendix 1 and Findings report development process section) and send it onto the LEP Clinical Tutor, Medical Director and Postgraduate Centre manager within 1 month from the review day, ensuring that the relevant School is kept in the loop at all times. If required, the LEP will develop an improvement action plan (appendix 3) within 1 month of receiving the review findings report and send it back to the Associate Dean for Quality / the Dean and review panel. This will then be agreed by the Associate Dean for Quality and the Postgraduate Dean and enter a period of monitoring and review as decided by the original reviewing panel. For this level of review it would be routine to plan a formal follow up visit within a time period that is agreed by the original reviewing panel. This would be facilitated by the deanery Education Development Team / Associate Dean for Quality and utilise a formal letter to the LEP (appendix 6.c). Note: If the deanery identifies issues that are substantial, or where no progress is being made toward agreed actions within reasonable timescales, the deanery is able to at any time escalate the issues up to the next most appropriate level of the quality framework, and also inform the GMC and the SHA patient safety or other relevant committee of required. Following monitoring arrangements agreed within the report, when the actions are agreed and signed off by the Associate Dean for Quality, the Postgraduate Dean, and the Head of School, the LEP will be informed in writing (appendix 6.d). The closed report and action plan must be tabled at the next Quality Committee meeting for final sign off and closing of the quality loop. The Associate Dean for Quality / Education Development Team will ensure that the report and action plan is centrally recorded within the deanery. Reports are then able to be tabled at the next Board (foundation / specialty) meeting for assurance purposes. 19

20 Level 3: Exceptional LEP Trigger Visit by Deanery with Clinical Externality Significant issue(s) identified (New issue or escalation from lower framework) Schools receives concerns and decision made to escalate to level 3 of framework Concerns raised with Associate Dean (Quality) and Education Development team utilising set proforma requesting deanery trigger visit (appendix 4) Education Development Team sets up Deanery exceptional trigger visit with LEP utilising clinical externality and informs LEP (appendix 6.b) 1 month Added to central Deanery review calendar Collection and review of LEP background information See Obtaining and reviewing evidence Conduct Review Day (Deanery Led) See LEP On-Site Review Process Report, action plan and outcome tabled at Quality Committee and Centrally Recorded by Education Development Team Develop Findings Report (appendix 1) 1 month LEP agrees report and develops action plan which is monitored by deanery and school (appendix 3) 1 month Report, action plan and outcome centrally recorded by Associate Dean (Quality) / Education Development Team See Findings Report Development Process If issues are significant, or unable to be resolved, escalation to next appropriate level of review framework (i.e. PMETB visit / Trainees removed) Report signed off by Postgraduate Dean and closed via official letter to LEP (appendix 6.d) Yes All actions complete? No Monitoring and review of action plan (A follow up review visit would normally planned for level 3) 20

21 Level 4: Exceptional LEP Regulatory Body Trigger Visit The fourth level of the exceptional review framework comprises of a formal LEP quality review from the relevant regulatory body (i.e. GMC). This level of the quality review framework should only be accessed when all other mechanisms to address issues have failed, or extreme issues of concern are identified. Examples of when a level 4 review is required include: When all other efforts to resolve an issue with a LEP have been explored and it is deemed necessary by the Postgraduate Dean, Associate Dean for Quality, and Head of School to inform GMC. When extreme issues of concern are identified within a LEP Process Overview: This level of the framework will only be utilised in extreme circumstances. A formal letter must be addressed to the Postgraduate Dean, who will then make the ultimate decision to access this level of the framework. The Dean will then formally write to the GMC advising them of the issues and requesting them to formally take over reviewing the LEP. The GMC will then formally write back and advise the next stages and the Deanery will hand over control of the review to the GMC. Following the review, any outcomes and actions must then be followed up and monitored with extreme vigilance by the Dean, Associate Dean for Quality and relevant Head of School and signed off with the GMC. 21

22 Full Programme Reviews The Deanery recognises that simply reviewing LEPs is not sufficient to maintain the quality of education and training and that there is the requirement to review an educational programme in its entirety to allow for generic programme wide issues and challenges to be reviewed and addressed. Programme reviews are led by the Postgraduate Dean and Associate Dean for Quality, supported by the Education Development Team and relevant Head of School. Examples of when a Programme Review is required include: The need for a programme review may arise from: Significant issues and themes being identified across the entirety of a programme that is affecting more than one LEP from ongoing Annual Deanery Reporting Mechanisms or ongoing LEP quality reviews. Identification from regulatory or professional bodies of national and local issues within this specialty Significant amounts of low scoring ARCPs within the programme Where a routine programme review has not been undertaken for substantial period of time (5 10 years) Typical Panel Member Make-up: 5-8 panel members, made up of the following: Senior Deanery Representatives Postgraduate Dean, or Associate Dean (Quality) Head of Education or Education Development Manager School Representatives HoS / School quality lead Trained panel members Clinical externality, from outside the deanery area College representative, and/or specialty lead from another deanery Lay membership (from Deanery lay pool) Administration (as required) Process Overview: The process will start with the identification by the Deanery that a programme review is required. The Associate Dean for Quality in liaison with the Postgraduate Dean and associated Head of School will then begin preparations to ensure that the programme in its entirety is reviewed. 22

23 As educational programmes span a variety of LEPs from across the West Midlands area, a programme review is likely to take place in a lead LEP or entirely different location, where required data is reviewed from the variety of LEP sites hosting the programme, and relevant trainees / trainers / college tutors / clinical tutors and other relevant educational staff are transported to this site for consultation with the review panel members. Due to the expanse of a programme review, externality is always utilised on the reviewing panel to maintain transparency of professional, clinical and educational standards. In so, clinical externality and lay representation will be sought. Due to the nature of a programme review, exact arrangements, data to be reviewed and people to interview will be arranged at the discretion of the Dean, Associate Dean for Quality and Head of School, however the level of detail and information processed will be similar to those within any normal LEP quality review. All requirements will be arranged and communicated with relevant stakeholders in advance of the event. The duration of a programme review depends on the size of the programme, amount of data to review and number of LEPs involved in the delivery of education. During the review, the panel will scrutinise available evidence and consult with the relevant stakeholders following the pre-agreed agenda, and develop a programme review findings report which will get presented to all educational programme stakeholders, tabled for discussion at the next available quality committee meeting for review, and subsequent tabling at postgraduate board meeting. If any issues are identified, the Postgraduate Dean, Associate Dean for Quality and associate Head of School will be responsible for drawing up a programme wide improvement action plan which is the responsibility for the programme lead and Head of School to action, and monitoring by the Associate Dean for Quality. The Deanery will also ensure that the GMC is made aware of the findings via inclusion of the findings in the next Annual Deanery Report and share findings with the relevant specialty advisory committee etc. 23

24 Deanery Review The Deanery is formally reviewed under its regulatory body quality framework (formerly PMET, now GMC) in order to regulate the overall quality of how it manages the quality of postgraduate education and training. These quality assurance reviews take place in two forms, both an Annual Deanery Report and also ongoing monitoring meetings to the Deanery itself. Annual Deanery Report The Deanery is required to submit an Annual Deanery Report (ADR) to its regulatory body (GMC, formerly PMETB) which assesses the quality of its education against core standards for training and also standards for deaneries. In order to achieve this, the Deanery will employ a systematic approach to reviewing its Local Education Providers, in turn its Postgraduate Schools, and finally itself through a series of exception reporting and action planning, which if finally sent to the regulatory body for review and sign off. The Deanery will then enter a period where by it ensures agreed improvement actions are addressed to be able to report progress against during the next reporting cycle. > For more information, see separate ADR Guidance and relevant quality frameworks under Deanery Regulatory Body Review As regulatory body, the GMC (formerly PMETB) regulates the quality of postgraduate education at the Deanery, and in so will undertake its own series of quality assurance visits to the Deanery. The GMC will liaise directly with the Postgraduate Dean on this regarding their exact requirements and appropriate arrangements will be made. Following the Deanery visit, similar to local quality processes, a report will be produced indicating findings and any associated improvements which the Deanery is then responsible for developing an improvement action plan against and subsequent reporting to the GMC on this. These actions will then form part of the ADR as time goes on. > See relevant quality frameworks under for further information 24

25 Guidance on Conducting a LEP Review Selection of Panel Members Note: Previous sections describing the level of the review framework will provide detailed guidance on a typical panel make up. The constitution of a panel is made up of trained panel members selected on the basis of their objectivity and impartiality. A panel will normally consist of 3-6 members and may include an appropriate level of impartiality/externality (e.g. clinical externality, and/or lay membership). A panel is structured depending on the level of LEP review, however in some cases a larger panel may be required to enable parallel review sessions to take place at the larger LEP sites of in extraordinary circumstances such as combining reviews. It is essential that panel members association with the work being reviewed does not influence their judgement. The panel will therefore consist of members based on their level of impartiality, their level of knowledge of the specialty being reviewed, and also their level of authority within the Deanery depending on the nature of the review. The following general principles relate to review panel members: Ethical conduct: the foundation of professionalism Fair presentation: the obligation to report truthfully and accurately. The findings, conclusions and reports reflect truthfully and accurately the review activities Due professional care: the application of diligence and judgement. Panel members exercise care in accordance with the importance of the task they perform and the confidence placed in them by stakeholders. Having the necessary competence is an important factor. Independence: the basis for the impartiality of the review and objectivity of the conclusions, including the level of externality where appropriate Evidence-based approach: the rational method for reaching reliable and reproducible conclusions in a systematic process. The Deanery continues to recruit and refresh the review panel members to ensure a sufficient number of people are available to take part in reviews. Training sessions are mandatory for new members and will be provided by the Deanery to ensure panel members are familiar with the process and documentation and to ensure a consistent approach to scheduled, exceptional and programme reviews. Refresher training sessions 25

26 are also available to ensure experienced panel members are acquainted with any new documentation and changes in the process. Obtaining and Reviewing Evidence In order to prepare for the day of the review meeting, the review panel will examine a selection of evidence before the meeting. The lead pulling together the review will liaise with appropriate Deanery, School and LEP based colleagues to obtain and collate data. They will then ensure that the review panel has access to this data before the review day. This data will include, where appropriate: Reports from previous review(s) and action plans with update reports where relevant Latest LEP self assessment summary Latest available National Trainee and Trainer Survey results Latest available local JEST survey results Learning Development Agreement (LDA) finance information (MADEL) Any other evidence available to support the nature of the visit On the review day, the LEP must make available any further evidence requested and include information as standard on: Details of the education programme being reviewed Attendance on the training programmes Trainee evaluation results and analyses of the programme Details of the induction programme (Trust and Specialty) MADEL finance budget data sheets update A sample of trainee doctors portfolios made available on the day of the visit as part of a sampling exercise where requested Any available trainee evaluations of formal training sessions Junior doctors facilities summary Junior doctor forum minutes Latest facilities accreditation review Summary of the latest library accreditation review 26

27 The LEP On-Site Review Meeting Process This exploratory meeting is designed to probe the LEP at different levels (i.e. management, trainer, trainee) in order to gain a 360 degree understanding of educational quality within the organisation and any particular issues highlighted to the panel. It utilises agreed standards of which questioning is based around in order to maintain transparency and allow for comparison between each level within the organisation and triangulation of evidence when compared with submitted self assessments and other quality data such as GMC surveys. The review meeting follows the pre-arranged schedule (normally a full day) which is designed to facilitate the following process, and is normally led by a nominated Lead Panel Member (i.e. chair): LEP On-Site Review Process a Panel convene and Review Documentation and Evidence Provided Key Issues Noted for Further Exploration No Complies with Requirements? Yes Process Point Decision Point Formulate specific question areas based on findings add to questioning list b Panel meets with LEP Faculty Management Team (i.e. Clinical Tutor / Centre Manager / Med Director etc) Document Findings (appendix 2) and Triangulation of Evidence c Panel Question Trainees Panel Question Trainers Yes Area(s) to Further Examine? No Prepare Provisional Findings d Panel convene and Conduct Feedback Meeting to LEP Management Team, led by the Lead Visitor See Process for Providing Feedback, and Development of Findings Report for Next Steps 27

28 d. Preparation for Review At the beginning of the review day, the panel initially convene to discuss the background evidence provided to them prior to the review, and note potential areas and issues they wish to review in more detail with the LEP (good practice and cause for concern). They may also develop specific question areas to utilise in addition to the standard questioning areas. These additional questions are documented within the LEP On Site Review Questionnaire (Appendix 2) to be uses later in trainee / trainer questioning sessions. b. Meeting with LEP Management The panel then, led by the Lead Panel Member, officially open the review day by meeting the LEP management team. This normally consists of at least the CT and Centre Manager, however other relevant LEP staff may join (e.g. Medical Director / CEO / Trainers). After the meeting is opened, the LEP management team are then encouraged to provide an overview of the LEP including their identified challenges, achievements and also areas of exemplary practice. The panel will then review perceptions of management in relation to the 15 standards utilising the On-Site Review Questionnaire (Appendix 2). Information is documented by the panel and added to the list of evidence. c. Meeting with Trainee s and Trainer s / Educational Staff The panel then meet with different cohorts of trainees and trainers (and other relevant educational staff) in order to build a holistic picture of quality issues within the LEP. The panel utilise the same standardised set of question areas (Appendix 2) and also the agreed additional specific questions at each interview session in order to ensure consistency and allow for effective comparison between different quality standards, whilst also building a picture of educational quality at the LEP. d. Finalising Outcomes and Providing Feedback to LEP Management Following the investigatory part of the review, the panel convene in order to review findings and share views of the review day. The panel work together to agree final scores for each of the question areas utilised within the questioning period, and also to summarise areas of good practice, potential areas of improvement or enhancement, and general outcomes for feedback. The review panel will then provide feedback to the LEP, chaired by the Lead Panel Member. This meeting is expected to include senior management members of the LEP including representation from the Trust Executive Board (e.g. CEO / Medical Director) in addition to the CT and Centre Manager. 28

29 Process for Providing Feedback for On Site Reviews Panel determines which findings are to be reported Lead visitor prepares formal statement of findings Key Process Point Decision Point End Point Panel classify findings (Good practice or Improvement) Findings agreed? Yes No Further Discussion Convene feedback meeting Lead visitor provides feedback on behalf of review panel Close Meeting See Process for Developing Findings Report 29

30 Development of Findings Report Following the review day, the review panel lead will be responsible for ensuring that a draft Visit Findings Report is developed and ensuring that it is circulated to the visiting team within 5 working days of the visit which is reviewed for factual accuracy. (See appendix 1 for Findings Report template). The review team is required to respond within 5 working days to confirm that either; the report is an accurate reflection of the visit (or) indicate the item(s) that require amendment. Where response is not received within the timescale agreement that the content is accurate will be assumed. Where one or more members of the visiting team are absent on leave, etc., the Lead Visitor is responsible for approving the final report for circulation to the LEP. The draft report is submitted to the LEP Clinical Tutor and Postgraduate Centre Manager to assess factual accuracy within 10 working days of the visit. Response is required within 5 working days to the review panel lead, who will agree weather comments require amendment to the overall report. The report is then finalised and circulated to the Deanery Regional Postgraduate Dean, the Associate Dean for Quality / Education Development Team, and finally the LEP Management Team (Chief Executive, Medical Director, Clinical Tutor and PG Centre Manager). The report outcomes are then tabled for discussion at the next appropriate School Board, the Quality Committee, and if required the PMDE / Foundation Programme Board and Deanery SMT meeting. The results are recorded on the central Deanery database maintained by the Education Development Team. The Education Development Team ensures that formal reports are recorded centrally within the Deanery and are published accordingly. The LEP will then respond with an Improvement Action Plan (appendix 3) as appropriate, which will enter a phase of monitoring by the relevant Deanery/School lead. 30

31 Process for Developing Findings Reports Visiting panel & lead visitor formalise findings within approved documentation and agree scores On day of visit Lead visitor Summarises feedback to trust management representatives On day of visit Significant issues reported to Postgraduate Dean / Associate Dean for Quality Findings report developed in draft (Appendix 1) and circulated to visiting panel members for comment 5 working days of review Review panel review and update draft report 5 working days of review Draft report circulated to the appropriate LEP representative (i.e. CT /Med Director) for factual accuracy only and sent back to lead reviewer 10 working days of review Report updated and published to LEP, and where appropriate are required to respond with action plan (appendix 3) Within 10 working days Report sent to Associate Dean (Quality) and Education Development team for information and central deanery recording Within 1 month Report tabled at School Board for information Next Meeting Report tabled at Quality Committee for information Next Meeting Report tabled at PMDE Board / Deanery SMT for information Next Meeting Follow Up of Review Reports and LEP Improvement Action Plans Where the LEP is requested to submit an Improvement Action Plan (Appendix 3) these must be monitored by the relevant party (e.g. for Scheduled / Level 1 / Level 2 are monitored by the School, and level 3 onwards are monitored by the Deanery). The LEP is required to send updates to this party (i.e. School / Deanery) within the agreed timeframe and forwarded to the original Lead Visitor, Head of School, and Associate Dean for Quality / Education Development Team for records. (The LEP may use space provided on the Improvement Action Plan for this). 31

32 Nonconformities are monitored for corrective and preventive action until such time that they can be fully closed. Where a follow up visit has been identified, this must be arranged in a timely manner between the LEP and the review lead using formal Deanery letter (appendix 6.c) and an appropriate report will be generated. Schools are responsible for sending signed reports and closed Improvement Action Plans to the Associate Dean for Quality / Education Development Team for central records and monitoring. These must also be tabled at relevant School Board meetings, and always tabled at the next relevant Quality Committee to ensure progress against actions identified are appropriately performance managed. See the Quality Governance Framework section at the start of this guide for how issues are escalated for further details. 32

33 Appendix 1: LEP Review Findings Report Template PMET Review Findings Report Summary SECTION 1: Visit Overview and Executive Summary Type of Visit: (Include Reasoning) Specialty: LEP Visited: Site and Address: Clinical Tutor: Centre Manager: Review Date: Scheduled Review / Level 1 / Level 2 / Level 3 / Follow Up Review Panel: Name Title Organisation LEP Feedback Attendance: (Name, Title) Executive Summary: Name Notable Practice: Title Areas for Improvement or Enhancement: Recommendations Follow up arrangements: i.e. plan follow up review visit, action plan, dates of review etc. Programme approved to run at LEP site: Action plan to address concerns required: Progress report against action plan required to be submitted to Head of School: Follow up review visit required: Patient safety issues and/or serious concerns highlighted: Further Comments: Yes - Without conditions Yes - With the following conditions No Not Required 4/8/12 weeks from date of review visit Not Required 3/6/12 months from date of review visit to XXX Not Required 3/6/12 Months from date of review visit to XXX Yes / Potential / No 33

34 Scoring Key: 1 Standard not met - Unsatisfactory (serious concerns) 2 Standard not met - Needs Attention 3 Standard met - Acceptable 4 Standard met Good 5 Standard met - Excellent (potential best practice) SECTION 2: Findings from Discussion with Educational Staff and Trainees (Exceptions Only) Domain Score Findings Summary 1. Patient Safety All criteria below must be understood in terms of this overarching concept of patient safety 2. Programme Director s Planning Named programme director who accepts responsibility for planning the programme and ensuring that the standards set out below are met 3. Induction to post Clinical guidelines, written information on timetables etc, occupational health services, bullying and harassment issues, and whistle blowing in the NHS. 4. Appraisal and assessment A named educational supervisor, initial and interval appraisals and assessments and feedback - all properly documented 5. Feedback on Junior Doctors Work Regular helpful constructive feedback on performance in daily clinical supervision, including both good and poor performance. 6. Protected teaching (bleep free) Based on relevant Royal College curriculum, on a regular basis, evaluated by trainees 70% attendance at minimum. 34

35 SECTION 2: Findings from Discussion with Educational Staff and Trainees (Exceptions Only) Domain Score Findings Summary 7. Service based teaching Teaching and learning in routine work, with appropriate consultant ward rounds, outpatient clinics, operating sessions per week. Handovers. 8. Senior doctor cover The immediate personal assistance of a senior doctor (normally a consultant or trainer) must always be available to trainees. 9. Clinical workload Exposure to an appropriate level of clinical activity, to develop their clinical knowledge, skills and attitudes and achievement of educational objectives. 10. EBM and audit Local written EBM guidelines for common clinical conditions. Audit involving trainees, who receive guidance and support for audit. 11. Inappropriate tasks No work for which the trainee is inadequately trained, or of no relevance to educational objectives, or which is prohibited by GMC / GDC guidelines. 12. Rota compliance Rota is compliant with current legislation, and monitored regularly to ensure that it remains compliant. Trainees must take part in monitoring processes. 13. Accommodation and catering The employer is responsible for a safe working environment, and accommodation and catering to current national standards. 35

36 SECTION 2: Findings from Discussion with Educational Staff and Trainees (Exceptions Only) Domain Score Findings Summary 14. Leave Allowed to undertake annual leave and study leave within their Terms and Conditions of Service. Study leave must be appropriate to educational objectives. 15. Junior doctors forum This forum must meet regularly, and the meetings must be documented and minuted, including details of decisions made. Overall Satisfaction Recommendation of post? (Summary): In attendance as part of the day: (Summary): Trust and Senior Education Staff: Education Supervisors: Trainees (overview - no names): SECTION 3: Any other comments 36

37 Appendix 2: On-Site Panel Review Question Form On-Site LEP Review Panel Question Form This form should be completed by each individual panel member when on site conducting a LEP review for each interview. Indicate the target audience of the interview, comment on key points identified, and then give a score to each domain area. Any further comments / questions asked should also be indicated toward the end of the form. Hand the form into the lead visitor at the end. Panel Member Name: LEP Name: Date: Specialty: General comments / observations / questions asked during interview: Question Area Standard 1. Patient Safety All criteria must be understood in terms of this overarching concept of patient safety continually ask and re-investigate throughout and at end of review meeting Score Comments and Outcomes from Discussions 5 Excellent 4 Good 3 Acceptable 2 Needs attention 1 Concern Target audience interviewed during discussion ( ): Clinical Tutor: Trainees: Trainers: Other (detail below) Other Details: 2. Programme director s planning Named programme director who accepts responsibility for planning the programme and ensuring that the standards set out below are met 3. Induction to this post Clinical guidelines, written information on timetables etc, occupational health services, bullying and harassment issues, and whistle blowing in the NHS 4. Appraisal and assessment A named educational supervisor, initial and interval appraisals and assessments and feedback - all properly documented 37

38 Question Area Score Comments and Outcomes from Discussions 5. Feedback on your work Regular helpful constructive feedback on performance in daily clinical supervision, including both good and poor performance 6. Protected teaching (bleep free) Based on relevant Royal College curriculum, on a regular basis, evaluated by trainees 70% attendance at minimum 7. Service based teaching Teaching and learning in routine work, with appropriate consultant ward rounds, outpatient clinics, operating sessions per week, handovers etc. 8. Senior doctor cover The immediate personal assistance of a senior doctor (normally a consultant or trainer) must always be available to trainees 9. Clinical workload Exposure to an appropriate level of clinical activity, to develop their clinical knowledge, skills and attitudes and achievement of educational objectives 10. EBM and audit Written EBM local guidelines for common clinical conditions. Audit involving these by the trainees, who receive guidance and support for audit 11. Inappropriate tasks No work for which the trainee is inadequately trained, or of no relevance to educational objectives, or which is prohibited by GMC / GDC guidelines 12. Rota compliance Rota is compliant with current legislation, and monitored regularly to ensure that it remains compliant. Trainees must take part in monitoring processes 13. Accommodation and catering The employer is responsible for a safe working environment and accommodation and catering to current national standards 14. Leave Allowed to undertake annual leave and study leave within their Terms and Conditions of Service. Study leave must be appropriate to educational objectives 15. Junior doctors forum This forum must meet regularly, and the meetings must be documented and minuted, including details of decisions made Would interviewees recommend the LEP? Yes No Please hand completed form to the lead visitor at the end of the review day for records 38

39 Appendix 3: LEP Improvement Action Plan Template LEP Improvement Action Plan This improvement action plan is to be used following actions identified as part of a LEP quality review. The action plan is to be completed by the designated lead at the LEP (e.g. Clinical Tutor) agreed with the relevant lead at the Deanery (i.e. Lead reviewer / Head of School / Associate Dean for Quality / Dean) and then signed off and monitored as appropriate by all parties. The LEP is required to send in progress reports at agreed intervals. LEP Site Name: Site Address: Specialty relating to: Clinical Tutor Name: Clinical Tutor Identified Issue Actions planned to address issue Lead Date due by Progress Updates Date of action plan agreed: Date to review action plan: LEP Lead Name: Position: Signature: Deanery Lead Name: Position: Signature: 39

40 Appendix 5: Form to Request Deanery Quality Review Request for Deanery Quality Review How to Complete this Form This form is used to request the central Deanery to set up a LEP quality review. In accordance to the Quality Review Framework, the Deanery is responsible for leading on Level 3 and program reviews, and Schools are normally responsible for leading on Scheduled Reviews, Level 1 and Level 2 reviews. (However, under some circumstances this form can be used by a school to request Deanery support to set up a review on their behalf if they require support). When fully completed the form must be mailed to the Education Development Team at the Deanery, and/or ed to deanery.review@westmidlands.nhs.uk incomplete forms will be sent back to the lead requesting the review. 1. Who is Requesting the Review Please provide details of who is requesting the review and how to contact them Lead requesting review Position address 2. Site to be Reviewed Organisation Phone no. Please use the following area to detail the site to be visited and which specialty it belongs to School Name Proposed date of review Trust/site to be reviewed and address Main contact at Trust/site (phone / ) Sub-Specialty Name Proposed timing 3. Level of Review Please indicate the level of review visit requested (see review framework guide book for details, normally scheduled reviews, Level 1 and Level 2 would be led by the relevant School) Level 3: Deanery Led Trigger Visit with Externality Level 4: Regulatory body visit (i.e. GMC) Program Review Other (please state and describe reasoning) If other please describe reasoning for requesting deanery to set visit up: 40

41 4. Reason for Review and Evidence Available Please provide an overview of the main reason(s) for the visit. The paragraph below will be reviewed by the Deanery used to inform the Trust/PCT, including Medical Director of the reason for the visit. Do you have any supporting evidence? ( ) If so please attach and describe below: Yes: No: Do you require any supporting information from the LEP prior to review? ( ) If so please list below: Yes: No: 5. Panel Members Required Please use the following area to detail your potential panel members for the review. These will be contacted to confirm attendance. (Note, Level 3 reviews require a level of externality within the visiting panel and will have Deanery level representation as standard) 1. Name Position Organisation Contact Details (phone & ) Any Other Information Please utilise the space below to inform of any further information or requirements 7. Signatures Name requesting review Signature Position Date When fully completed please mail the form to the Education Development Team at the Deanery, and/or it to deanery.review@westmidlands.nhs.uk incomplete forms will be sent back to the lead requesting the review. 41

42 Appendix 5: Level 1 - LEP Paper Based Review Form Level 1: LEP Paper Based Review This template is utilised to send out to a LEP for use with level 1 of the quality review framework requesting a paper based review of quality issues highlighted. When a LEP receives this review report request they must respond to the School utilising this form with progress update and improvement action plan within 1 month of the initial request date. LEP Site Name: Specialty relating to: Name requesting review: LEP Clinical Tutor Name: Date of Initial Request: Sub-Specialty: Requestor Clinical Tutor 1. Description of Issues / Concern Identified (Completed by School lead requesting review) 42

43 2. Update on Issues / Concern Identified with appropriate evidence(completed in response by lead at LEP e.g. Clinical Tutor / Medical Director) Check: Appropriate supporting evidence attached to validate update ( ) 3. Any Improvement Actions Identified (Completed in response by lead at LEP and agreed with lead requesting review) Issue identified Actions planned to mitigate issue Lead Date due by Progress Updates (list & attach appropriate evidence) Date to review report: Date report closed / actions completed: LEP Lead Name: Position: Signature: Deanery Lead Name: Position: Signature: 43

44 Appendix 6.a: Letter to LEP Requesting Scheduled Review St Chad s Court 213 Hagley Road Edgbaston Birmingham B16 9RG {Date} DX Birmingham 25 Tel: {College Tutor Name} {LEP Address} Dear {College Tutor Name} Re: Scheduled Review of {Specialty Name} Specialty at {LEP Name and Site} Date: {planned date} It is the GMCs requirement that 10% of training programmes within the Deanery are inspected every year. Following this, the school of {school name} has identified that a review of the {specialty name} at {LEP name and Site name} is now required. A review date has been planned for {planned date}. Scheduled reviews are proactively planned each year to ensure that a random sample of at least 10% (or more) of Local Education Providers associated with a school are reviewed, with the intention that 100% are reviewed over the given period of time. The visiting panel members scheduled to attend your visit are listed as follows; Name, Position, Organisation Lead Visitor Name, Position, Organisation Name, Position, Organisation Chairman: Elisabeth Buggins CBE DL Chief Executive: Ian Cumming OBE West Midlands Strategic Health Authority 44

45 The agenda is proposed as follows (however subject to change following consultation): Delete times if AM or PM meeting: Times Agenda Items Attendees 9.30am Or 12.30pm Review Team Convenes for briefing by Lead Visitor and reviews LEP evidence pack Refreshments to be made available (Deanery review team only) 10.00am Or 1.00pm Review Team meets with Senior Training Team Clinical Director, Medical Director, College Tutor, Postgraduate Centre Manager, Clinical Tutor 10.45am Or 1.45pm 11.30am Or 2.30pm 12.15pm Or 3.15pm 12.45pm Or 3.45pm Review Team meets with Educational Supervisors associated with specialty being reviewed Review Team meets with Specialty Trainees Review Team prepares feedback summary Refreshments to be made available Feedback and Findings Meeting from Deanery Educational Supervisors Specialty Trainees (NHSWM review team only) Chief Executive Officer and/or Medical Director, Clinical Director, Postgraduate Clinical Tutor, College Tutor, Educational Supervisors, Senior Medical Staffing Representative, Postgraduate Centre Manager Can you please start planning for the visit to ensure that: 1. Sufficient numbers of Educational Supervisors are available to be interviewed within your specialty. 2. Sufficient numbers of Trainees are available to be interviewed within your specialty. 3. Ensure the relevant senior staff (i.e. Chief Executive Officer, Medical Director, Clinical Director, Postgraduate Clinical Tutor, College Tutor, Educational Supervisors, Postgraduate Centre Manager and Senior Medical Staffing Representative) for your specialty are available for the feedback session. You are welcome to invite anyone else you feel should attend. 4. Provide an evidence pack on the day which includes information on the following: Reports from previous review(s) and action plans with update reports where relevant Latest LEP self assessment summary Details of the education programme being reviewed Latest available National Trainee and Trainer Survey results Latest available local JEST survey results (if available) Trainee evaluation results and analyses of the programme Details of the induction programme (Trust and Specialty) MADEL finance budget data sheets update A sample of trainee doctors portfolios made available (if authorised) Any available trainee evaluations of formal training sessions Junior doctor forum minutes Latest facilities accreditation review Summary of the latest library accreditation review Please confirm receipt of this Scheduled Review notice by contacting the administrator below by {date} (2 weeks from letter date) 45

46 For any other queries in regards to your visit please liaise with the Lead Visitor or their administrator. We also ask for you to provide us with room and parking arrangements and directions at least 4 weeks before the visit. Lead Visitor Contact Details: Administrator Contact Details: {lead visitor and phone number} {administrator and phone number} Yours sincerely, {Head of School Name or designated quality lead} Head of School for {school name} CC. Medical Director: {Name / } Clinical Tutor: {Name / } Education Centre Manager: {Name / } Deanery Associate Dean (Quality): {Name / } Deanery Education Development Manager: {Name / } 46

47 Appendix 6.b: Letter to LEP Requesting Exceptional Review St Chad s Court 213 Hagley Road Edgbaston Birmingham B16 9RG {Date} DX Birmingham 25 Tel: {College Tutor Name} {LEP Address} Dear {College Tutor Name} Re: Exceptional Review of {Specialty Name} Specialty at {LEP Name and Site} Date: {planned date} The Deanery operates within a robust quality assurance framework for postgraduate training to which it is responsible to the GMC as regulatory body. As part of ongoing quality management and enhancement processes, it has been identified that an exceptional review of the {specialty name} at {LEP name and Site name} is now due and scheduled to take place on {date} for the following reasons: Level of review (see Deanery Quality Management Guide for more information on the QA framework) Level 1: Exceptional paper based review by school (see attached paper review template) Level 2: Exceptional review visit by school Level 3: Exceptional Deanery led trigger review visit with externality Level 4: Regulatory body visit (the regulatory body will write out separately regarding this) Brief reasoning for the review requirement: Chairman: Elisabeth Buggins CBE DL Chief Executive: Ian Cumming OBE West Midlands Strategic Health Authority 47

48 The visiting panel members scheduled to attend your visit are listed as follows; Name, Position, Organisation Lead Visitor Name, Position, Organisation Name, Position, Organisation The agenda is proposed as follows (however subject to change following consultation): Delete times if AM or PM meeting: Times Agenda Items Attendees 9.30am Or 12.30pm Review Team Convenes for briefing by Lead Visitor and reviews LEP evidence pack Refreshments to be made available (Deanery review team only) 10.00am Or 1.00pm Review Team meets with Senior Training Team Clinical Director, Medical Director, College Tutor, Postgraduate Centre Manager, Clinical Tutor 10.45am Or 1.45pm 11.30am Or 2.30pm 12.15pm Or 3.15pm 12.45pm Or 3.45pm Review Team meets with Educational Supervisors associated with specialty being reviewed Review Team meets with Specialty Trainees Review Team prepares feedback summary Refreshments to be made available Feedback and Findings Meeting from Deanery Educational Supervisors Specialty Trainees (NHSWM review team only) Chief Executive Officer and/or Medical Director, Clinical Director, Postgraduate Clinical Tutor, College Tutor, Educational Supervisors, Senior Medical Staffing Representative, Postgraduate Centre Manager Can you please start planning for the visit to ensure that: 1. Sufficient numbers of Educational Supervisors are available to be interviewed within your specialty. 2. Sufficient numbers of Trainees are available to be interviewed within your specialty. 3. Ensure the relevant senior staff (i.e. Chief Executive Officer, Medical Director, Clinical Director, Postgraduate Clinical Tutor, College Tutor, Educational Supervisors, Postgraduate Centre Manager and Senior Medical Staffing Representative) for your specialty are available for the feedback session. You are welcome to invite anyone else you feel should attend. 4. Provide an evidence pack on the day which includes information on the following: Reports from previous review(s) and action plans with update reports where relevant Latest LEP self assessment summary Details of the education programme being reviewed Latest available National Trainee and Trainer Survey results Latest available local JEST survey results (if available) Trainee evaluation results and analyses of the programme Details of the induction programme (Trust and Specialty) MADEL finance budget data sheets update A sample of trainee doctors portfolios made available (if authorised) Any available trainee evaluations of formal training sessions Junior doctor forum minutes Latest facilities accreditation review Summary of the latest library accreditation review 48

49 Please confirm receipt of this Scheduled Review notice by contacting the administrator below by {date} (2 weeks from letter date) For any other queries in regards to your visit please liaise with the Lead Visitor or their administrator. We also ask for you to provide us with room and parking arrangements and directions at least 4 weeks before the visit. Lead Visitor Contact Details: Administrator Contact Details: {lead visitor and phone number} {administrator and phone number} Yours sincerely, {Head of School Name or designated quality lead} Head of School for {school name} CC. Medical Director: {Name / } Clinical Tutor: {Name / } Education Centre Manager: {Name / } Deanery Associate Dean (Quality): {Name / } Deanery Education Development Manager: {Name / } 49

50 Appendix 6.c: Letter to LEP Requesting Follow-up Review St Chad s Court 213 Hagley Road Edgbaston Birmingham B16 9RG {Date} DX Birmingham 25 Tel: {College Tutor Name} {LEP Address} Dear {College Tutor Name} Re: Follow Up Review of {Specialty Name} Specialty at {LEP Name and Site} Date: {planned date} Following your review on {original review date} for {specialty name} at {LEP name and Site name} and the outcomes of your improvement action plan, it has been identified that a follow up review is now due to monitor the progress toward agreed actions resultant from this. This review has been scheduled for {planned date}. The visiting panel members scheduled to attend your visit are listed as follows; Name, Position, Organisation Lead Visitor Name, Position, Organisation Name, Position, Organisation Chairman: Elisabeth Buggins CBE DL Chief Executive: Ian Cumming OBE West Midlands Strategic Health Authority 50

51 The agenda is proposed as follows (however subject to change following consultation): Delete times if AM or PM meeting: Times Agenda Items Attendees 9.30am Or 12.30pm Review Team Convenes for briefing by Lead Visitor and reviews LEP evidence pack Refreshments to be made available (Deanery review team only) 10.00am Or 1.00pm Review Team meets with Senior Training Team Clinical Director, Medical Director, College Tutor, Postgraduate Centre Manager, Clinical Tutor 10.45am Or 1.45pm 11.30am Or 2.30pm 12.15pm Or 3.15pm 12.45pm Or 3.45pm Review Team meets with Educational Supervisors associated with specialty being reviewed Review Team meets with Specialty Trainees Review Team prepares feedback summary Refreshments to be made available Feedback and Findings Meeting from Deanery Educational Supervisors Specialty Trainees (NHSWM review team only) Chief Executive Officer and/or Medical Director, Clinical Director, Postgraduate Clinical Tutor, College Tutor, Educational Supervisors, Senior Medical Staffing Representative, Postgraduate Centre Manager Can you please start planning for the visit to ensure that: 1. Sufficient numbers of Educational Supervisors are available to be interviewed within your specialty. 2. Sufficient numbers of Trainees are available to be interviewed within your specialty. 3. Ensure the relevant senior staff (i.e. Chief Executive Officer, Medical Director, Clinical Director, Postgraduate Clinical Tutor, College Tutor, Educational Supervisors, Postgraduate Centre Manager and Senior Medical Staffing Representative) for your specialty are available for the feedback session. You are welcome to invite anyone else you feel should attend. 4. Provide an evidence pack on the day which includes information on the following: Reports from previous review(s) and action plans with update reports where relevant Latest LEP self assessment summary Details of the education programme being reviewed Latest available National Trainee and Trainer Survey results Latest available local JEST survey results (if available) Trainee evaluation results and analyses of the programme Details of the induction programme (Trust and Specialty) MADEL finance budget data sheets update A sample of trainee doctors portfolios made available (if authorised) Any available trainee evaluations of formal training sessions Junior doctor forum minutes Latest facilities accreditation review Summary of the latest library accreditation review Please confirm receipt of this Scheduled Review notice by contacting the administrator below by {date} (2 weeks from letter date) 51

52 For any other queries in regards to your visit please liaise with the Lead Visitor or their administrator. We also ask for you to provide us with room and parking arrangements and directions at least 4 weeks before the visit. Lead Visitor Contact Details: Administrator Contact Details: {lead visitor and phone number} {administrator and phone number} Yours sincerely, {Head of School Name or designated quality lead} Head of School for {school name} CC. Medical Director: {Name / } Clinical Tutor: {Name / } Education Centre Manager: {Name / } Deanery Associate Dean (Quality): {Name / } Deanery Education Development Manager: {Name / } 52

53 Appendix 6.d: Letter to LEP Approving Improvement Actions St Chad s Court 213 Hagley Road Edgbaston Birmingham B16 9RG {Date} DX Birmingham 25 Tel: {Clinical Tutor and Postgrad Centre Manager Names} {LEP Address} Dear {Clinical Tutor and Postgrad Centre Manager Names} Re: Approval of improvement actions from the review of {Specialty Name} at {LEP Name and Site} on {review date} Following the review on {original review date} for {specialty name} at {LEP name and Site name} and our review of outcomes against your improvement action plan, it has been decided by the School of {school name} that sufficient progress has been made. Please accept this letter as acknowledgement that the review of you local education provision in this area is now closed and your programme will now enter the normal cycle of routine visiting. We wish to thank you for your continued efforts to maintain and enhance the quality of postgraduate education. Yours sincerely, {Head of School Name or designated quality lead} Head of School for {school name} CC. Medical Director: {Name / } College Tutor: {Name / } Deanery Associate Dean (Quality): {Name / } Deanery Education Development Manager: {Name / } Chairman: Elisabeth Buggins CBE DL Chief Executive: Ian Cumming OBE West Midlands Strategic Health Authority 53

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