Equivalence Guidance for GMP Domain 1

Equivalence Guidance for GMP Domain 1 From 1 st August 2011 the new GMC approved curriculum in Intensive Care Medicine (ICM) came into effect. As a result of this new curriculum, all equivalence applications submitted after this date will be assessed against the requirements for a Certificate of Completion of Training (CCT) as defined in the curriculum. This guide has been produced to assist doctors in collating the appropriate evidence for their applications for a Certificate of Eligibility for Specialist Registration (CESR) in ICM in light of these changes. The equivalence assessment by the Faculty judges only the submitted evidence, which should provide sufficient information to cover the four domains needed to achieve a positive recommendation. Multiple sources of evidence for all four domains and their subsections will remain important and enable the assessors to triangulate this evidence. This will strengthen the application and help towards achieving a positive outcome. Despite these changes, the professional judgement of the Faculty assessors remains at the heart of the equivalence process, as is the judgement of educational supervisors and deliverers of training for a CCT in ICM. It is important that applicants accumulate and note the advice available from the General Medical Council and the Faculty of ICM website. The Faculty and the GMC can also be contacted if applicants seek clarification on the written advice, however the Faculty cannot pre-judge evidence outside the formal GMC equivalence process. This document lists the type of evidence needed to populate the application. This evidence will need to be closely allied to the training and experience requirements of the new curriculum in order to achieve the appropriate competencies. Contact Details: The Faculty of Intensive Care Medicine Website: www.ficm.ac.uk Email: ficm@rcoa.ac.uk General Medical Council Website: www.gmc-uk.org Email: certification@gmc-uk.org

Contents Page Introduction... 3 GMP domains for equivalence... 3 General structure of the UK CCT programme... 5 Generic Competencies... 5 Principal learning outcomes of the ICM CCT programme... 7 Curriculum items to be demonstrated for GMP 1A... 10 Demonstration of GMP domains 1b, 2, 3 and 4... 10 Test of knowledge... 11 Evidence of experiential learning... 12 Page 2 of 12

Introduction In April 2011, the GMC approved a new curriculum for a CCT in ICM. This new curriculum was developed from the CoBaTrICE curriculum produced by the ESICM and by consulting with stakeholders to ascertain what was required from the UK training programme. The overall structure of the training programme allows for a variety of core training schemes leading into specialist training in ICM. All trainees must complete at least 1 year of training in each of anaesthesia and general medicine (of which up to 6 months may be emergency medicine). Specialist training consists of 4 years of ICM training (which must include at least 3 months each in cardiac and neuro intensive care, and competence in safe resuscitation stabilisation and transport of children), plus 1 year of a special skill complementary to ICM. It will be necessary to demonstrate competence at level 4 (i.e. expert practice) in most of the competencies in the curriculum including the UK common competencies this is to prepare the trainee for independent practice as a consultant in the NHS. The Certificate of Eligibility for Specialist Registration [CESR] route to the specialist register is awarded after an applicant has been assessed as being equivalent in training and/or experience to a new UK CCT holder. Therefore, applicants for a CESR will have to demonstrate practice and aptitude at this level. GMP domains for equivalence All applications are assessed under the four domains of Good Medical Practice. When compiling evidence for an application, the GMC recommends applicants apportion the evidence provided for the domains according to the pie chart below. Source: General Medical Council, UK Each domain is described below and provides a guide to applicants as to what an assessor is looking for when assessing applications. The evidence provided should answer the questions posed under each sub-section of the four Good Medical Practice domains. Page 3 of 12

Domain 1: Knowledge Skills and Performance A. Has the applicant demonstrated that they have the full range, depth and breadth of experience and skill to the level required? B. Has the applicant demonstrated application of knowledge and experience to practice [e.g. recognising and working within the limits of their competence]. In particular, keeping up to date with CPD, audit, clinical governance, applying the skills and attitudes of a competent teacher/trainer, and making appropriate referrals to colleagues and keeping clear and legible records? Domain 2: Safety and Quality A. Has the applicant demonstrated putting into effect systems to protect patients and improve care [e.g. taking part in and responding to the outcome of audit, appraisals, performance reviews, risk management and clinical governance procedures, and reporting adverse drug reactions or concerns about risks to patients]? B. Has the applicant demonstrated that they monitor and respond to risks to safety and that they safeguard and protect the health and wellbeing of vulnerable people [e.g. responding to risks posed by patients and following infection control procedures]? C. Has the applicant demonstrated that they protect patients and colleagues from any risk posed by their health? Domain 3: Communication, Partnership and Teamwork A. Has the applicant demonstrated that they communicate effectively with:- patients [e.g. keeping them informed about progress of their care] and colleagues [e.g. physician colleagues, nursing staff, allied health professionals, GPs and other appropriate agencies] in both clinical and management situations within and outside the team [e.g. passing on information when patients transfer, encouraging colleagues to contribute to discussions]? B. Has the applicant demonstrated that they work constructively with colleagues by supporting them, delegating effectively, acting as a positive role model and providing effective leadership? C. Has the applicant demonstrated that they establish and maintain partnerships with patients and encourage them to take an interest in their health and obtain appropriate consent to treatment? Domain 4: Maintaining Trust A. Has the applicant demonstrated that they show respect for patients [e.g. polite, considerate and honest with patients and implemented systems to protect patient confidentiality]? B. Has the applicant demonstrated treating patients and colleagues fairly and without discrimination [e.g. being honest and objective when appraising or assessing colleagues and writing references, giving constructive feedback, raising issues of colleagues performance and responding promptly to complaints]? C. Has the applicant demonstrated acting with honesty and integrity [e.g. is honest and accurate in any financial dealings, practice reports, obtains appropriate ethical approval for research projects etc]? Page 4 of 12

The principles of the UK CCT in Intensive Care Medicine training programme are that it: Is outcome based Is planned and managed Promotes safe practice Is delivered by appropriately trained and appointed trainers Allows time for study Includes those core professional aspects of medical practice that are essential in the training of all doctors Meets the service needs of the NHS Respects the rights and needs of patients Is prepared with input from the representatives of patients Accommodates the specific career needs of the individual trainee Is evaluated Is subject to review and revision General structure of the UK CCT programme 3.2.1 Duration of training The minimum indicative duration of training in the UK in ICM is seven years, undertaken in three stages. Applicants for equivalence will need to demonstrate sufficient periods of time spent in the necessary component parts of ICM training to develop competence. Stages of ICM training (i) Stage 1 ICM (CT1-ST4) training consists of an initial four year block of training Stage 1 contains minimum training times of 12 months each in anaesthesia, medicine and ICM across the minimum four year training Stage. (ii) Stage 2 ICM (ST5-6) covers ICM training in a variety of special areas including paediatric, neurosurgical and cardiothoracic ICM. It also allows trainees to develop a special skill or area of expertise that will benefit patients and the service in general. (iii) Stage 3 ICM consists of the final year of training (ST7), which must be spent in Intensive Care Units consolidating the trainee s competencies and acquiring high level management and administrative skills, progressively achieving autonomy so that they are competent to take up a consultant post in ICM. Generic Competencies The applicant must also demonstrate general professional knowledge, skills, attitudes and behaviors required of all doctors. The common competencies are core aspects of medical practice. Page 5 of 12

Principal learning outcomes of the ICM CCT programme Core Common learning outcomes Take a focused history from patients with complex presentations Conduct a focused examination on patients with complex presentations Organise and prioritise clinical duties Formulate a diagnostic and treatment plan Prioritise the patient s wishes Prioritise patient safety Work well as a team member Promote quality and safety in the workplace Promote infection control in the workplace Promote patient self care and management Be an effective and sympathetic communicator Be able to communicate bad news with sympathy Be able to deal with complaints and medical error Be able to communicate effectively with all health care professionals Promote public health Apply the principles of medical ethics and law Obtain valid consent Understand the legal framework for practice Ensure that medical research is conducted within a correct ethical and legal framework Systematically appraise and apply evidence to medical practice Perform audit Teach and train Develop positive personal attributes that contribute to clinical effectiveness Participate in the management of the health care system Core Anaesthesia as applied to the Severely Ill learning outcomes Knowledge and skills in areas of anaesthetic practice are essential for a competent intensivist. Whilst these skills can be learnt in the intensive care environment the volume of cases is such that expertise will be difficult to achieve. The applicant must have undertaken an attachment of no less than 12 months in anaesthesia (normally in blocks of 6 months but no less than 3 months) to develop the necessary skills of induction of anaesthesia, airway control, management of acutely unwell patients, care of the unconscious patient and understanding of surgery and its physiological impact on the patient. These skills are core to the safe practice of Intensive Care Medicine and applicants will be expected to demonstrate maintenance of these skills.. Will be able to manage the perioperative care of the acutely ill emergency patient to Level 2 standard Will be able to manage emergency anaesthesia for stable patients under local supervision to Level 2 standard Will understand the principles of advanced cardiorespiratory resuscitation for the unstable critically ill patient undergoing surgery Will recognise and have knowledge of and manage potential airway problems to Level 2 standard Will successfully manage a CICV (can t intubate; can t ventilate) situation in a simulated environment Page 6 of 12

Will manage Anaesthetic critical incidents to Level 2 standards Core Medicine as applied to the Severely Ill learning outcomes The applicant must demonstrate the ability to rapidly assess, investigate and manage a wide range of acute medical and surgical problems Knowledge and experience of the management of acutely ill patients outside critical care is required, including a range of presentations relevant to critical care practice. Whilst all these competencies can be acquired in an ICU environment the volume of cases is such that expertise will be difficult to achieve; an attachment of no less than 12 months (normally in blocks of 6 months but no less than 3 months) to an acute medical unit admitting a broad range of unselected medical take is required to facilitate the development of diagnostic, investigational and patient management skills. Up to 6 months within this period can be spent in Emergency Departments. The trainee will be able to manage the following common presentations to at least Level 2 competency: Cardio-respiratory arrest Shocked patient Unconscious patient Anaphylaxis Abdominal pain Blackout/collapse Breathlessness Chest pain Confusion/Delirium Fever Fits/seizures GI bleeding upper and lower tract Palpitations Poisoning Weakness and paralysis Medical problems following surgery Medical problems in pregnancy ICM learning outcomes The trainee will progressively assess, diagnose and manage a wide range of problems both within and outside the Intensive Care Unit. This will involve an attachment of at least 24 months experience in intensive care units with a sufficient number of admissions and case mix. Applicants should demonstrate that they are capable of becoming an independent practitioner. They must include evidence of education of others, management and leadership skills. Initiate and continue the resuscitation of the severely ill patient in a variety of hospital environments Assemble and integrate data relevant to the management of the severely ill Manage a wide range of medical and surgical patients presenting with severe illness and developing organ dysfunction and failure Initiate and manage organ specific support including mechanical ventilation, renal support, cardiovascular support and nutritional support Perform a range of practical procedures including the placement of intravascular access devices and chest drains Perform a variety of advanced airway techniques including bronchoscopy and tracheostomy techniques Page 7 of 12

Be familiar with ultrasound techniques to identify vessels and basic investigation of body cavities Have a detailed knowledge of the majority of conditions presenting to intensive care Have a wide experience of ICM in varied situations Be able to manage initial resuscitation and stabilisation of any acutely ill patient, adult or child, prior to transfer to an appropriate specialist centre Be able to work unsupervised and take on a management and leadership role in an ICU. Be able to supervise trainees in ICM Special ICM Cardiothoracic learning outcomes: Be able to manage cardiac failure following an acute cardiac event Be able to manage post operative cardiac patients following both elective and emergency cardiac surgery Be aware of the indications for discussion and transfer of critically ill patients to Regional Cardiothoracic units Be able to stabilise and transfer patients with acute cardio-respiratory conditions requiring cardiothoracic intensive care Neurosurgical Intensive Care learning outcomes: Be able to manage patients with severe acute brain injury Be able to manage post operative neurosurgical patients following both elective and emergency neurosurgery Be able to manage common neurological disorders not requiring neurosurgery Be aware of the indications for discussion and transfer of critically ill patients to Regional Neurosurgical units Be able to care for and manage the potential organ donor and their families Be able to stabilise and transfer patients with acute neurosurgical conditions Paediatric Intensive Care learning outcomes: Specialists in ICM will often obtain consultant posts in district general hospitals without paediatric services and expertise immediately available on site. They must therefore be able to contribute with other disciplines to the stabilisation and initial management of the critically ill child before and during transfer to a paediatric centre. Be able to resuscitate, stabilise and transfer an acutely ill child Understand the fundamentals of paediatric intensive care including post operative care following surgery Be aware of the indications for discussion and transfer of critically ill children to Regional Paediatric Intensive Care units These outcomes may be achieved in a variety of situations which facilitate familiarity with children and allow development of knowledge of the physiological differences seen in babies and children and competence in management of for example small airways, lungs, veins, and circulation. Situations could include paediatric anaesthesia, a paediatric unit admitting acutely unwell children and babies as well as a PICU. Some but not all skills may be practised in simulation. Structured visits to a PICU to become aware of the particular problems faced by children will be necessary if a formal attachment to a PICU has not been included in the training programme. Special Skills Applicants could for example have competence in: Additional Medicine, Anaesthesia or Emergency Medicine Page 8 of 12

Advanced ultrasound imaging techniques Academic training as part of an Academic training programme Augmented learning outcomes in specialist Intensive Care including Paediatrics, Cardiothoracic or Neurosurgical Intensive Care Medical Education and Teaching Management training Research methods training to be unit lead in CLRN portfolio study research A period of research aimed at obtaining pilot data to underpin a research training fellowship Rehabilitation Medicine to equip clinicians with a special interest in chronic critical care (e.g. chronic ventilatory support), or critical care follow up. Quality Improvement Curriculum items to be demonstrated for GMP 1A Applicants for the CESR will have to demonstrate equivalence in the following areas as defined in the GMC approved CCT in ICM [August 2011]. Please refer to the curriculum document. 1. Test of knowledge; the test of knowledge must cover the advanced sciences and be equivalent to the UK FFICM exam. 2. Common competencies History taking Clinical Examination Therapeutics and safe prescribing Clinical reasoning and Decision making Managing long term conditions 3. Basic level anaesthesia including an Initial Assessment of Anaesthetic Competence including, competence level equivalent to at least 1 year training in anaesthesia. Control of infection Preoperative Assessment Premedication Induction of General Anaesthesia Intra-operative Care Postoperative care Anaesthesia of Emergency Surgery ALS adults and children Airway management Critical Incidents General surgery Non theatre including transfer Trauma and stabilisation 4. Basic competence as acquired during at least 1 year training in general medicine including ALS Shocked patient Unconscious patient Page 9 of 12

Anaphylaxis Abdominal pain Blackout/collapse Breathlessness Chest pain Confusion/delirium Fever Fits /seizure Haematemesis and melaena Palpitations Poisoning Weakness and paralysis Medical complications of surgery Medical problems in pregnancy 5. Applicants must demonstrate expert level clinical skills and knowledge commensurate with consultant practice in; Resuscitation and initial management of the acutely ill patient Diagnosis, Assessment, Investigation, Monitoring, and Data Interpretation Disease Management Therapeutic Interventions including Organ Support in multi-organ failure Practical Procedures relevant to ICM Perioperative Care for all major specialties Comfort and recovery End of Life care Paediatric care Transport 6. Applicants must demonstrate skills and knowledge for all the essential specialist critical care areas: Cardiothoracic critical care; Neurocritical care; Paediatric resuscitation stabilisation and transfer A Special Skill* *The special skill can be experience in a partner specialty to ICM e.g. anaesthesia, medicine or emergency medicine (where a higher level of competence to that gained during core training must be achieved) or a skill such as ultrasound practice, research or education when a detailed portfolio of experience and evidence must be produced. Demonstration of GMP domains 1b, 2, 3 and 4 The GMC generic guidance for CESR applications provides good advice on the types of evidence required for GMP domains 1b, 2, 3 and 4. The evidence required for the demonstration of research, teaching and management will also assist in the demonstration of GMP 1b and 2a. Areas which must be covered include elements of Common Competencies and ICM curriculum including: Page 10 of 12

Time management Patient as focus of care Prioritisation of patient safety Team working Principles of quality and safety Communication and relationship with patients Communication with Colleagues Breaking bad news Managing Complaints and medical error Public Health Ethics and confidentiality Consent UK legal framework for practice (recognising this may not be the same in all 4 countries) Research Evidence and guidelines Audit Teaching and Training Leadership Health systems and unit management How to demonstrate equivalence The applicant must demonstrate equivalence by providing evidence. For each unit of training, there are defined core clinical learning outcomes. These outcomes define the minimum standard required of a trainee for that unit of training at each level. The following tables specify the core clinical learning outcomes and provide guidance on the type of evidence that should be provided in support of the application. There are also tables for the test of knowledge and the non-clinical units. The core clinical learning outcomes are guidance as to the level of practice required. Applicants should also look at the competencies for each unit of training to ensure that they can demonstrate the full range of skill and knowledge that underpin the learning outcomes. The sources of evidence suggested below and in the tables are not an exhaustive list but provides guidance on the types of evidence that would assist in triangulating the evidence to prove equivalence. The more useful evidence provided in support of the application, the easier it is to assess equivalence. Test of knowledge Sources of evidence should include the following provided by the institution: Curriculum Method of assessment Method used for standard setting Pass rate Method of quality assurance A letter from institution confirming the above and signed by at least the head of faculty or equivalent Page 11 of 12

Refer to the Syllabus for a list of All Basic Science competencies that are tested within the FFICM examination. Some examples of acceptable tests of knowledge include: Australia and New Zealand The Fellowship of the College of Intensive Care Medicine (FCICM) Evidence of experiential learning Applicants need to provide evidence that they have achieved an equivalent level of competence as defined in the curriculum assessment system. The list of sources of evidence below covers most of the areas required to demonstrate equivalence. Sources of evidence can include: Logbooks [electronic, theatre records, critical care logs, ward/em logs] Structured references References Letters of support Appraisals [e.g. 360, team assessment behaviour] Theatre lists/rotas Job description/job plan Critical Care Unit case mix or audit reports Training certificates/assessments [e.g. ACLS/ATLS] Equality and diversity training certificate from deanery or equivalent type training course Training programme curriculum Courses and meetings attended certificates Case diaries Record of procedures learnt Educational qualifications Train the trainer type course Audit [Evidence of involvement, contribution and presentation of results] Appraisal of their research placement by their academic supervisor A review article to a standard suitable for publication A research project Published or unpublished articles Feedback from trainees Management course attendance certificate/s Management qualifications [e.g. diploma, degree] Page 12 of 12