Revalidation Annual Report
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- Regina Greer
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1 Paper Revalidation Annual Report Purpose of Document: To provide the Board with a report on the first year s experience with medical revalidation in Public Health Wales. Board/Committee to- (Please indicate) To decide- Paper will outline recommendations or issues to be approved by the Board or Committee. To discuss- Board or Committee will be asked to discuss and scrutinise the paper and provide feedback and comments. To inform- Board or Committee will be asked to note the paper for information only Next Steps Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant) Priorities for action include relevant priority for action(s) Align our workforce to priorities and develop and maintain sufficient skills and knowledge Author: Dr Quentin Sandifer, Executive Director of Public Health Services Date: 17 April 2014 Version: 1 Sponsoring Executive Director: Executive Director of Public Health Services Who will present: Executive Director of Public Health Services Documents attached: Revalidation Annual Report Date of meeting: 29 April 2014 Date: 10 January 2014 Version:1 Page: 1 of 26
2 Link to standards for health services Link to risk register Equality impact assessment Financial implications Standard 26: workforce training and organisational development N/A N/A Service engagement user N/A
3 Revalidation Annual Report Author: Dr Quentin Sandifer Date of Meeting: 29 April 2014 Version: 1 Distribution: Public Health Wales Board Purpose and Summary of Document: This purpose of this paper is to provide the Public Health Wales Board with a report on the first year of medical revalidation. Date: 7 April 2014 Version: 1 Page: 3 of 26
4 1 PURPOSE To provide the Board with a report on the first year s experience with medical revalidation in Public Health Wales. 2 BACKGROUND Revalidation for doctors has been introduced in the UK to assure patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practice. Revalidation is based on effective systems of appraisal and governance/quality assurance, the same ones which improve quality and safety. Revalidation is a by-product of these strengthened systems not the intended purpose of these systems. Revalidation went live on 3 December 2012 and the period to the end of March 2013 was described as year 0. In this period specified senior medical leaders underwent revalidation, which in Wales included the Chief Medical Officer and the Responsible Officers (RO s) in the 10 health organisations (designated bodies) in Wales. April 2013-March 2014 was the first full year of revalidation when it was expected that 20% of the medical workforce would undergo revalidation. March 2018 represents the end of the first 5 year cycle when all practising doctors are expected to be revalidated. 3 REVALIDATION PROGRESS In preparation for revalidation organisations were required to complete an ORSA (Organisational Readiness Self Assessment). This includes details of the designated body, information about the RO and the resources to support them, and details about the appraisal system. The ORSA also includes information about the organisational governance in place and identifies priorities for the coming year. The first year-end ORSA for Public Health Wales is appended to this report. The Wales Deanery requires all organisations to submit their first year-end ORSA (revalidation report) by 1 May The Board is asked to receive the report before submission. Public Health Wales is the responsible body for 81 Doctors registered with the GMC. At the end of March doctors (25% of the workforce with a prescribed connection) underwent revalidation. All received a positive recommendation with no deferrals. Date: 7 April 2014 Version: 1 Page: 4 of 26
5 4 APPRAISAL PROGRESS Medical appraisal is a process of facilitated self-review supported by information gathered from the full scope of a doctor s work. It has three primary purposes: 1. To enable doctors to discuss their practice and performance with their appraiser in order to demonstrate that they continue to meet the principles and values set out in Good Medical Practice and thus to inform the ROs revalidation recommendation to the GMC. 2. To enable doctors to enhance the quality of their professional work by planning their professional development. 3. To enable doctors to consider their own needs in planning their professional development The requirements of an appraisal system are to: Ensure all doctors have an annual appraisal. Cover all aspects of the doctor s work. Track appraisees through the system. Ensure sufficient appraiser capacity. Ensure appraisers are trained. Ensure outputs of appraisal are of sufficient quality. Understand reasons for missed or incomplete appraisal The Medical Appraisal and Revalidation System managed by the Wales Deanery is a web-based system that has been adopted in Wales to support medical appraisal. All doctors with a prescribed connection to Public Health Wales are expected to register with and use MARS. At 31 March 2014 all bar 3 doctors had registered with the MARS system. In the year to 31 March /78 (82%) doctors registered on the MARS system had completed a revalidation appraisal during the previous 15 months. Of the remaining 14 doctors, 13 have a revalidation appraisal booked within the next 3 months, the majority earlier rather than later in that period. In many cases there are valid reasons for these delays (only recently joined the organisation, recent consultant appointment, maternity leave, long term sick leave, leave of absence for year sabbatical). One other doctor remains on sick leave. The appended ORSA provides details about the appraisal system in Public Health Wales. 5 RECOMMENDATION The Board is asked to receive and approve this report including the appendix. Date: 7 April 2014 Version: 1 Page: 5 of 26
6 APPENDIX Revalidation Progress Report: 2014 Revalidation is the process by which doctors in the UK will have their licence to practise renewed. The purpose of revalidation is to assure patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practise. The Revalidation Progress Report is designed to enable designated bodies in Wales to report relevant figures relating to , to carry out a self-assessment of the systems and processes they have in place to support medical revalidation and to provide assurances to their boards and to others that appropriate systems are in place. Completed reports will be analysed by the Wales Deanery on behalf of the Wales Revalidation Delivery Board (WRDB). Data relating to achievements in will be reported to the WRDB. Action plans arising from the self-assessment will be analysed at the All-Wales level. Areas where more than one organisation requires further support will be identified and reported to the Revalidation and Appraisal Implementation Group (RAIG). A plan will be developed highlighting areas where action / support at the Wales level may be beneficial. The report is divided into three sections: Section 1: Details of designated body Section 2: Data reporting relating to Section 3: Effective governance to support revalidation: self-assessment The form should be signed off by the responsible officer on behalf of the designated body, though completion of the form may be appropriately delegated. In all cases the responsible officer should confirm that they are happy with the content of the report. The deadline for completion of the report is detailed in the accompanying . Page 6 of 26
7 Following completion of this self-assessment exercise, it is recommended that designated bodies should produce a more detailed action plan to address the development needs identified within their specific organisation. Liaison with RAIG is advised prior to finalising action plans to ensure areas which are already being progressed at an All-Wales level are taken into account. Board-level accountability for the quality and effectiveness of these systems is important and this report, along with the resulting action plan, should be presented to the board, or an equivalent governance or executive group. The self-assessment process will also enable designated bodies to provide assurance to regulators, patients, the public, the profession and other interested bodies, that they are fulfilling their statutory obligations and their systems are sufficiently effective to support the responsible officer s recommendations to the GMC Page 7 of 26
8 Section 1: Details of designated body - Please see guidance notes at the end of this document 1.1 Name of designated body: Name of Responsible Officer: Dr Quentin D Sandifer, GMC # Name of person completing this report: Dr Quentin D Sandifer Job title of person completing this report: Executive Director of Public Health Services and Medical Director Completed report authorised by Responsible Officer: Yes Date: 16 April Type/sector of designated body: (tick one) Local Health Boards Other NHS trust Other NHS organisation Deanery Independent/non- NHS sector (tick one) Independent healthcare provider Locum agency Government Department or executive agency, armed forces, public bodies Other non-nhs (please enter type) x
9 NUMBER OF DOCTORS - Please see guidance notes at the end of this document 1.3 Number of doctors with whom the designated body has a prescribed connection as at 31 March 2014 N= 81 IMPORTANT: ONLY DOCTORS WITH WHOM THE DESIGNATED BODY HAS A PRESCRIBED CONNECTION SHOULD BE INCLUDED IN THIS SECTION. EACH DOCTOR SHOULD BE INCLUDED IN ONLY ONE CATEGORY Consultants (including honorary contract holders) Staff grade, associate specialist, specialty doctor (including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere) General practitioners Trainees: doctor on national postgraduate training scheme (for Deaneries only) Doctors with practising privileges (for independent healthcare providers only; all doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade) Temporary or short-term contract holders (including trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts) Other (including some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc) 4 academics TOTAL 81 Note: Public Health Wales also employs trainee doctors and other medical staff. At 31 March 2014 the total number of these doctors is 36 (18 trainees, 3 specialty doctors, 3 associate specialists, and 12 consultants with a prescribed connection with another designated body). Page 9 of 26
10 APPRAISALS - Please see guidance notes at the end of this document Section 2: Appraisal / revalidation data reporting relating to April March Numbers of doctors who had completed appraisal between 1 April 2013 and 31 March 2014 (with whom the designated body has a prescribed connection as at 31 March 2014) IMPORTANT: ONLY DOCTORS WITH WHOM THE DESIGNATED BODY HAS A PRESCRIBED CONNECTION SHOULD BE INCLUDED IN THIS SECTION. EACH DOCTOR SHOULD BE INCLUDED IN ONLY ONE CATEGORY NB TRAINEES ARE NOT TO BE INCLUDED IN THIS SECTION NB: Where the answer is nil, please enter Consultants (including honorary contract holders) 59* Staff grade, associate specialist, specialty doctors (including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere) General practitioners Doctors with practising privileges (for independent healthcare providers only; all doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade) Temporary or short-term contract holders (including trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts) Other (including some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc) TOTAL Note 5 doctors last underwent an appraisal between 1 January and 31 March 2013, 14 are due to be appraised before end of June 2014 (most earlier rather than later) and 3 doctors have yet to register on MARS (the RO is in contact with these doctors) 59 Page 10 of 26
11 2.2 An audit has been performed to determine reasons for all missed or incomplete appraisals A missed or incomplete appraisal is an important occurrence which could indicate a problem with the appraisal system or a potential issue with an individual doctor which needs to be addressed. Missed appraisals are those which were due within the appraisal year but not performed or which were performed outside the 9 to 15 month window for annual appraisal. Incomplete appraisals are those where, for example, the appraisal discussion was not completed or where the personal development plan or appraisal summary have not been signed off within 28 days of the appraisal meeting. For this exercise to be valuable every missed or incomplete appraisal should be included in the audit and in a well-managed system this information should be monitored and tracked on a continuous basis. To answer : An audit of all missed or incomplete appraisals for the appraisal year 2013/14 has been completed. Recommendations and improvements are enacted. To answer Amber : Information is available relating to some missed or incomplete appraisals but this is not audited in a systematic way To answer Red : No information is available relating to missed or incomplete appraisals APPRAISERS - Please see guidance notes at the end of this document Amber 2.3 Number of active medical appraisers as at 31 March 2014: Ratio of active medical appraisers to doctors (appraisers: doctors) Ratio to be calculated as total number of doctors divided by number of appraisers i.e doctors divided by 20 appraisers = 1:50 (appraisers : doctors) 1:6.75 Page 11 of 26
12 Section 3: Effective governance to support medial revalidation: self-assessment REVALIDATION RECOMMENDATIONS - Please see guidance notes at the end of this document 2.4 Numbers of doctors with whom the designated body has a prescribed connection as at 31 March 2014 who have had a recommendation made to GMC between 3 December 2012 and 31 March 2014 Responsible officers should ensure recommendations are made to the GMC before the notified due date. This question relates to the number of recommendations completed by the responsible officer between the date revalidation started and the end of the year. Number of recommendations to be split by year (Year 1: December st March Year 2: 1 st April st March 2014) 2012 / / Positive recommendations Deferral requests Notification of non-engagement TOTAL Recommendations which were due between 3 December 2012 and 31 March 2014 but were not completed on time 0 0 The following checklist is provided as an appendix to Effective governance to support medical revalidation: a handbook for boards and governing bodies. The full document can be accessed at (see Governance handbook") The document states that the checklist provides a list of questions that are relevant in the context of ongoing evaluating, demonstrating and reporting on governance of local systems and processes supporting patient safety and medical revalidation. These questions draw on well established principles that support quality improvement Page 12 of 26
13 and medical revalidation objectives. They take account of the clinical governance and appraisal criteria followed in the various assessments of readiness to begin medical revalidation undertaken across the UK, for example the Organisational Readiness Self Assessment. Each designated body should undertake a self assessment against the questions listed, awarding a Red / Amber / rating, outlining the justification for this rating and summarising key actions to be taken to address any issues identified. Red nothing in place Amber working towards meeting criteria criteria met Question R/A/G rating Justification Action plan 1. There is corporate or organisation-wide commitment to creating an environment that fosters good professional practice How does your organisation: know that the governance of systems supporting the provision of quality patient care and medical revalidation An effective communication chain exists between the Responsible Officer, Public Health Wales Appraisal Lead and medical staff. The Responsible Officer works Page 13 of 26
14 Question objectives is appropriately supported, managed and assured? ensure the adequacy of resources to support all doctors in fulfilling their professional responsibilities, eg in relation to staff induction, appraisal, Continuing Professional Development (CPD) and revalidation? R/A/G rating Justification closely with the BMA. Public Health Wales appraisal/revalidation coordinator provides administrative support to this process. An effective process exists between the Responsible Officer, Public Health Wales HR division, Professional and Organisational Development Team and appraisal/revalidation coordinator to support Public Health Wales doctors with a prescribed connection. Action plan In what way: 1.1 does the organisation s governance strategy proactively support the provision of quality patient care and medical revalidation objectives? 1.2 might reporting around quality patient care and medical revalidation objectives to the board/governing body be improved? Amber Public Health Wales reports through the Quality and Safety Committee, a subcommittee of the Board, the Executive Group and to informal and formal Board meetings. Public Health Wales recognises that it has to do more to understand service user experience 1.3 How transparent are the board/governing body s governance activities? Policies are available on the Public Health Wales intranet and minutes of the Quality and Safety Committee, formal Executive Page 14 of 26
15 Question R/A/G rating Justification Group meetings and public Board meetings are available on the Public Health Wales internet 1.4 How does the board/governing body regularly review data relating to revalidation and clinical practice? Data relating to revalidation and clinical practice is reported to the Public Health Wales Board on a six monthly basis. Action plan 2. Local governance is in place and monitored How does your organisation ensure: 2.1 all information systems for monitoring the conduct and performance of doctors working in your organisation are operating effectively? Through meetings of a Revalidation Group including the Responsible Officer, members of our Workforce Development/HR and the Lead Appraiser. 2.2 the performance of locums, doctors in training and temporarily appointed doctors is monitored and reported in a way that contributes constructively to their revalidation? 2.3 pre-employment, and other pre-contract checks undertaken in keeping with statutory and other requirements, are comprehensive and accurate? Public Health Wales rarely appoint locums and such appointments directly involve the Responsible Officer and HR. Public Health Wales workforce directorate has in place effective measures to ensure that preemployment, and other precontract checks undertaken are in keeping with statutory and Page 15 of 26
16 Question R/A/G rating Justification other requirements, are comprehensive and accurate. 2.4 quality improvement activities undertaken have been beneficial? Through reports to our Quality and Safety Committee. The Responsible Officer works closely with the Risk Manager and other senior quality and safety managers in the various divisions of the organization. 2.5 it can and does respond quickly when things go wrong? As evidenced by our response to serious incidents, reported to our Quality and Safety Committee Action plan 3. Equality and diversity considerations are integrated into all of the organisation s medical revalidation policies and practices How does your organisation: 3.1 ensure its policies and practices supporting medical revalidation are fair and non-discriminatory, and comply with legal requirements? Policies for equality and diversity exist and staff are required to undertake equality and diversity training. The Responsible Officer last undertook this training in August Page 16 of 26
17 Question R/A/G rating Justification 3.2 keep up to date with equality and diversity issues and policies? Public Health Wales keeps up to date with equality and diversity issues and policies through employees statutory and mandatory training provided by our Workforce and Organisational Development Team. 3.3 approach training in equality and diversity matters? 3.4 How do your organisation s policies and practices supporting quality patient care and medical revalidation promote equality and diversity, eg for people with protected characteristics? 3.5 How does your organisation s board/governance hierarchy engage with equality and diversity issues, and what benefits does this bring? Through employees statutory and mandatory training provided by our Workforce and Organisational Development Team. Through monitoring and support provided by our Workforce and Organisational Development team. Through monitoring and support provided by our Workforce and Organisational Development team. Action plan 4. Ongoing compliance with regulatory requirements and standards creates an environment where professionals can flourish In what ways does your organization: Briefings to the Board by the Page 17 of 26
18 Question 4.1 ensure ongoing familiarity with the organisational and professional responsibilities set down in regulations and guidance? 4.2 take patient and public views, complaints and compliments into account to support governance and quality improvement? 4.3 know that relevant data are collected and distributed to doctors, including for doctors working in a range of, or remote, practice settings, in a way that supports their revalidation? 4.4 monitor the quality of data supporting your RO in their role, including making revalidation recommendations to the GMC? R/A/G rating Amber Justification Responsible Officer. The Responsible Officer attends RAIG, Revalidation Remediation and Responsible Officer Network meetings. Similarly the Lead Appraiser maintains his knowledge and experience through his active involvement in Faculty of Public Health affairs. Public Health Wales take patient and public views, complaints and compliments seriously and these are reported to the Quality and Safety and Executive Team. The Responsible Officer has oversight responsibilities for complaints working closely with the Risk Manager. However, further work is required on service user experience. The Responsible Officer communicates directly with all doctors with a prescribed connection to Public Health Wales. Through regular meetings of the Revalidation Group. Action plan Page 18 of 26
19 Question R/A/G rating Justification 4.5 What was the outcome of your last review of data needs to support quality improvement and monitoring? Amber Further work required to strengthen appraisal assurance and checks on medical professional registration. Action plan How does your organisation: 4.6 ensure the identity, qualifications, references and experience of your doctors? 4.7 monitor the conduct and performance of doctors, including temporarily appointed doctors, locums and doctors in training, and ensure any issues arising are addressed? Amber The HR Medical Workforce lead continuously reviews the GMC list of doctors to assure the Responsible Officer that doctors with a prescribed connection do not have conditions or other restrictions on their practice. Doctors are required to make specific declarations at each appraisal. Before a doctor is revalidated a check is undertaken that the doctor has no complaints and is not subject to any inquiries or investigations. The HR Medical Workforce lead continuously reviews the GMC list of doctors to assure the Responsible Officer that doctors with a prescribed connection do not have conditions or other restrictions on their practice. Doctors are required to make specific declarations at each appraisal. Page 19 of 26
20 Question 4.8 manage admission to the performers list, if relevant? R/A/G rating Justification Not relevant to Public Health Wales 4.9 know that the arrangements to grant and monitor practising privileges for medical practitioners are robust? The directors of the divisions that offer such practicing privileges undertake pre-employment checks with HR input. Action plan 5. Medical appraisal takes place in accordance with GMC guidance and organisational requirements 5.1 What is the practical effect of the integration of your organisation s appraisal policy with other governance arrangements? Amber This is still being evaluated. How does your organisation: 5.2 know that all doctors requiring annual appraisal have participated? Reference to MARS. Direct communication with the very few doctors that have yet to register. 5.3 manage the situation where doctors requiring appraisal have not been appraised? By direct communication from the Lead Appraiser and Responsible Officer. 5.4 know all doctors are familiar with your organisation s appraisal policy and system? The Responsible Officer and The Wales Deanery and the Appraisal Lead communicate regularly with our Designated Doctors to ensure understanding and familiarity is maintained. Page 20 of 26
21 Question R/A/G rating Justification Action plan How does your organisation ensure: 5.5 the focus of appraisal is on the GMC s Good Medical Practice and other relevant guidance? The structure of the MARS appraisal is consistent with the GMC s Good Medical Practice and other relevant guidance 5.6 appraisers are appropriately trained to conduct appraisals? All Public Health Wales Appraisers are required to complete The Wales Deanery Appraisal skills training module. 5.7 medical appraisers are supported in the role through leadership and peer support? The Lead Appraiser liaises closely with medical appraisers and the Responsible Officer supports as necessary. 5.8 adequate resources are available to support doctors appraisal, revalidation and CPD? Amber Public Health Wales has managed to this date within existing resources but this could be challenged in year 2 as the number of doctors presenting for revalidation increases. 5.9 the quality and completeness of information supporting appraisal? Monitored by the Lead Appraiser and Responsible Officer. How does your organisation: 5.10 manage and monitor the performance of its appraisers in their role? Through the Lead Appraiser and Responsible Officer roles monitor the quality and robustness of appraisals and appraisal outputs? Amber Through the Lead Appraiser and Page 21 of 26
22 Question R/A/G rating Justification Responsible Officer roles. Need for further work on appraisal assurance acknowledged review the annual appraisal process and put consequential learning into effect? Through the Lead Appraiser and Responsible Officer roles and in internal revalidation meetings monitor the outcomes of doctors participation in CPD? Through the Lead Appraiser and Responsible Officer roles How does your governance hierarchy oversee appraisal, and consider whether it is delivering anticipated benefits? Through briefings to the Executive Group and Board by the Responsible Officer. Action plan GUIDANCE NOTES NUMBER OF DOCTORS 1.3 Number of doctors with whom the designated body has a prescribed connection as at 31 March 2014 The responsible officer should keep an accurate record of all doctors with whom the designated body has a prescribed connection. The prescribed connection is defined in detail in the RO regulations and the responsible officer must be satisfied that the doctor has correctly identified their designated body. To do this the Page 22 of 26
23 responsible officer will need to understand this section of the regulations and will need to know the other roles the doctor performs. A number of doctors, including locums, other employed or contracted doctors and doctors in wholly independent practice may not be included in these categories and should be entered under other. All general practitioners (GPs) including principals, salaried and locum GPs on the medical performers list should be entered under general practitioner. Trainees on national training schemes, including GP trainees, have a prescribed connection to the Deanery; trainees on independent schemes may have a prescribed connection to the employing trust. Academics with honorary clinical contracts will usually have their responsible officer in the Health Board or Trust where they perform their clinical work. Depending on their contractual status, secondary care locums may have a prescribed connection to a locum agency or an employer. Doctors with practising privileges may have a prescribed connection with the independent sector hospital depending on their other roles. The categories relate to current roles and job titles rather than qualifications or previous roles. The number of individual doctors in each category should be entered. APPRAISALS Section 2: Appraisal / revalidation data reporting relating to April March 2014 The appraisal system is one of the cornerstones of revalidation and good quality appraisal is essential for the responsible officer to be assured that each medical practitioner is up to date and fit to practise. Appraisal must also provide a safe environment for personal development needs to be discussed and agreed. A good appraisal system is dependent on effective leadership and management, the quality of the supporting information and the quality and professionalism of the appraisers. For revalidation to fulfil its primary objectives it is essential that information from all the doctor s roles is available at appraisal. The appraisal system must be set up to deliver annual appraisal for all the doctors who have a prescribed connection with the designated body. In order to ensure all doctors have an annual appraisal, it is necessary for the responsible officers to establish the reasons for missed or incomplete appraisals, to satisfy themselves that the appraisal system is functioning effectively and also that doctors are fulfilling their professional and contractual obligations. The responsible officer is responsible for the quality and effectiveness of the appraisal Page 23 of 26
24 system even if this has been commissioned from an external provider organisation. In these circumstances, it is advisable for a service agreement to be drawn up defining the required quality standards and key indicators. For the purposes of this guidance the organisational appraisal year runs from 1 April to 31 March. The appraisal year is defined in this way to assist the management and monitoring of the appraisal system and to allow comparison and benchmarking between organisations and sectors. A completed annual appraisal is one where the appraisal meeting has taken place between 9 and 15 months of the date of the last appraisal and the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting. It is not suggested that these definitions, required for managing an effective organisational appraisal system, should be applied to revalidation recommendations for individual doctors. The audit will give a detailed understanding of what has happened in all missed or incomplete appraisals and the responsible officer will exercise judgement on a case by case basis if an appraisal falls outside the appraisal year for acceptable reasons. For doctors in training it has been agreed that revalidation recommendations will be based on the process of annual review of competence progression and therefore Deaneries do not need to complete this section. The role of medical appraiser is an important professional role and effective selection processes and structured initial training programmes are needed. Ongoing performance review, development and support of appraisers will also be necessary to maintain the skills of the appraiser and to assure the quality and consistency of appraisal. It has been agreed by the Wales Revalidation Delivery Board that, in order to further support revalidation, all NHS doctors will be required to access their appraisal via MARS from 1 April Therefore it is anticipated that NHS designated bodies will be taking steps to ensure this happens. 2.1 Numbers of doctors who had completed appraisal between 1 April 2013 and 31 March 2014 (with whom the designated body has a prescribed connection as at 31 March 2014) For the purposes of this guidance, a completed annual appraisal is one where the appraisal meeting has taken place between 9 and 15 months of the date of the last appraisal and the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting. In most circumstances Page 24 of 26
25 the final sign-off of the appraisal should occur within a few days of the appraisal meeting. Some organisations may require additional sign-off from a medical manager, clinical director or medical director. These additional processes should be described in the organisation s appraisal policy with any necessary deadlines but the principle that should apply in all situations is that the appraiser and doctor should sign the agreed outputs within 28 days. The 28-day period is to allow for holidays and other absences and should be sufficient for agreement and signoff in almost all circumstances. For example, an appraisal meeting taking place on 31 March would need to be signed off on 27 April for it to be included in the year. An appraisal that has not been signed-off within this period should be regarded as incomplete and included in the audit of missed/incomplete appraisals so the reason for the delay can be explored. In completing this self-assessment it is important to distinguish between the responsible officer s responsibility to manage the quality and effectiveness of the appraisal system and their responsibility to make revalidation recommendations on individual doctors. To manage the system the responsible officer needs to know that every doctor has had an appraisal meeting and the sign-off has been completed. In making recommendations on individual doctors the responsible officer can use their judgement to allow flexibility for appraisals delayed by holidays, sickness absence, study leave, etc. There is no suggestion that an individual appraisal will be invalidated by delays, but in managing the appraisal system the organisation needs to set a reasonable expectation, track what s happening and understand the reasons for delays. It would be unusual for a designated body to complete appraisals on all the doctors for whom it has responsibility within the appraisal year. There are many potential reasons for this and the main purpose of this section is to help the designated body establish the reasons for missed or incomplete appraisals so that the management of the appraisal system can be optimised. The same categories of doctors in section 1.3 are used in this section to identify those doctors who have had a completed appraisal in the year 2013/14. Comparing the numbers in sections 1.3 and will give an indication of the additional organisational capacity and training required. APPRAISERS Page 25 of 26
26 Number of active medical appraisers as at 31 March 2014: Active appraisers are those who have performed at least one appraisal in the appraisal year and undertaken revalidation ready training, as described in the Appraisal Policy and Operating Standards, should include: Understanding of the purpose of appraisal and revalidation and the links between these processes and other systems for improving the quality of medical practice in the organisation and the wider healthcare system Competency in assessing supporting information that informs the appraisal and revalidation process, speciality aspects of appraisal Skills to conduct an effective appraisal discussion, including all the elements needed for revalidation Ability to produce consistently high quality appraisal documentation, sufficient to inform the revalidation recommendation as well as inform personal development Wales Medical Appraisal Policy in particular ethos of appraisal in Wales, integration with other quality improvement and patient safety processes, principles of delivery Wales Whole Practice Appraisal policy Wales Quality Indicators of Supporting Information policy Concept of agreement at appraisal and processes for resolving disputes Quality criteria for appraisal summary and PDP For those using MARS, managing the above through MARS Page 26 of 26
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