Annual Deanery Report Guidance Version 1: 2010
Contents Contents... 2 ADR Introduction... 3 Postgraduate Training Quality Governance Framework... 4 ADR Process and Documentation... 6 GMC Standards for Training and Deaneries... 9 West Midlands 15 Quality Standards for PMET... 10 2
ADR Introduction Through its structured quality management and enhancement processes, NHS West Midlands 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) through structured training programmes and in turn is producing a fit for purpose and highly skilled medical workforce. The Deanery employs a structured quality management and enhancement review framework which provides the structure to enable robust assurances that quality requirements are being fulfilled and education quality is enhanced for both Foundation and Specialty training through a structured quality review and visiting process (See PMET QA Framework Guidance). The Deanery is also required to produce annual assurance reports in the form of an Annual Deanery Report (ADR) to its regulatory body, the General Medical Council (GMC) which amalgamated with the former Postgraduate Medical Education and Training Board (PMETB) in April 2010. The ADR is an integral part of each postgraduate medical Deanery quality structure, being the main annual process by which the GMC evaluates and re-accredits the Deanery to continue its function as a postgraduate medical training institution. The remainder of this document outlines the West Midlands Deaneries processes for creation of the ADR and responsibilities of all parties involved when developing this report. Please note: ADR reporting is now inclusive of both Foundation and Specialty training in preparation for the PMETB GMC merger. 3
LEP Specialty Programme School Deanery Regulator (i.e. GMC) 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. 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 Training Committees LEP quality review, report and action plan LEP Annual Report LEP Local Education Meetings Trainee and Trainer Perception Surveys 4
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 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 quality review processes, the deanery also employs ADR reporting mechanisms starting at LEP level, feeding into Programme and School level, and finally at Deanery level which in turn get passed onto relevant regulatory bodies e.g. Annual Deanery Report to GMC. 5
ADR Process and Documentation In accordance with the quality governance framework, the Deanery employs a hierarchical approach to the development of the ADR as follows. This is inclusive of both Foundation and Specialty training. ADR Process Responsible Signed off by Deadlines Trainees Annual LEP Reviews Clinical Tutors LEP Medical Director and Clinical Tutor August Contribute Review of Specialty Programme TPDs/STSs Annual School Reviews Heads of School TPDs/STSs School Board October Annual Deanery Review Postgraduate Dean PMET Quality Committee and PMDE Board November GMC GMC Panel December The process starts with each Clinical Tutor assessing the quality of their education provision at their Local Education Provider (LEP) utilising standardised reporting templates which begins in June. The LEP will identify any improvement issues through exception reporting inclusive of each specialty programme that it provides training for. Discrepancies are then documented within an improvement enhancement action plan which must be monitored by the LEP and reported on. LEPs need to send these reports onto the Education Development team at the Deanery, who will then be able to share them centrally with Specialty Training Committees, and Heads of Schools for use with their reporting. Specialty Training Committee s (STCs) and Training Programme Directors (TPDs) through their robust quality management of training programmes will be aware of programme quality issues and notable practice. They 6
will be contacted by their Heads of Schools (HoS) to assist in the development of the overarching school report to ensure that all programmes are represented. LEP self assessments and knowledge from specialty programme TPDs/STCs is then fed into associated schools in September where HoS utilise this information to provide an overall school self assessment inclusive of all of its specialty programmes and their associated LEPs utilising standardised templates. Again, issues discovered should be contained within a school improvement action plan and monitored through school board. In order to assist Royal Colleges with the development of their Annual Specialty Reports, Schools and their faculty are able to share their school reports with colleges. Finally, the Associate Dean for Quality and the Postgraduate Dean at the Deanery utilises school self assessments and other data to develop its Deanery wide ADR self assessment utilising GMC standardised templates which will be sent to the GMC in December in accordance with their quality framework. The ADR is also normally combined with statistical data on the trainees such as ARCP results. The Deanery must also develop a high level improvement enhancement action plan for the following year to describe to the GMC the areas that it wishes to improve or enhance based upon identified issues through LEP, programme and school level exception reporting. They are also required to provide a series of data and statistics to the GMC alongside this which is produced by the information function within the Deanery. The GMC then reviews the Deanery s returned ADR and will write back to ask for further evidence, or if/when it is fully happy with the return, to re-approve the Deanery to continue to provide high quality postgraduate medical education and training. Often, the GMC will reapprove the Deanery with certain conditions. These conditions must then be addressed within the Deanery improvement action plan and reported upon at the next ADR reporting period. The Deanery will then enter a stage of monitoring to ensure that all agreed action plans are actioned accordingly. This takes place through the postgraduate training quality committee and Postgraduate Medical and Dental Education (PMDE) Board. 7
What is meant by Exception Reporting? We use exception reporting when we self assess against the educational standards. Exception reporting simply means reporting on something that is out of the ordinary. In terms of completing this documentation, this would mean that when completing self assessments and action plans, only report on the following: 1. When you are not fully meeting an indicator and associated minimum evidence requirements 2. When you identify notable practice taking place 3. When you have a planned enhancement that takes provision above and beyond the current accepted standard Therefore, if you are simply meeting a standard you do not need to report against this. All standards where exceptions are highlighted should then be commented and reported on within improvement enhancement action plans. Setting SMART Objectives in the Improvement Enhancement Action Plan? In order to ensure that the objectives set within the improvement enhancement action plan are able to be monitored and signed off easily as part of the ADR process, it is important to ensure they have tangible measureable outcomes. It is recommended that SMART objective methodology is considered: Specific Measurable Achievable Realistic Timely Are your objectives specific around exactly what they want to achieve? What is the planned outcome measure for whether you have met the objective or not? Do the objectives have an aim, are achievable, and attainable? Can you realistically achieve the objectives with the resources you have? When do you want to achieve the set objectives - dates? 8
GMC Standards for Training and Deaneries Standards for Training Domain 1 1.The duties, working hours and supervision of trainees must be consistent with the delivery of high quality, safe patient care 2. There must be clear procedures to address immediately any concerns about patient safety arising from the training of doctors Domain 2 3. Specialty including GP training must be quality managed, reviewed and evaluated Domain 3 4. Specialty including GP training must be fair and based on principles of equality Domain 4 5. Processes for recruitment, selection and appointment must be open, fair and effective Domain 5 6. The requirements set out in the approved curriculum must be delivered and assessed 7. The approved assessment system must be fit for purpose Domain 6 8. Trainees must be supported to acquire the necessary skills and experience through induction, effective educational supervision, an appropriate workload, personal support and time to learn 9. Trainers must provide a level of supervision appropriate to the competence and experience of the trainee 10 Trainers must be involved in and contribute to the learning culture in which patient care occurs 11. Trainers must be supported in their role by a postgraduate medical education team and have a suitable job plan with an appropriate workload and time to develop trainees 12. Trainers must understand the structure and purpose of, and their role in, the training programme of their designated trainees Domain 7 13. Education and training must be planned and maintained through transparent processes which show who is responsible at each stage Domain 8 14. The educational facilities, infrastructure and leadership must be adequate to deliver the curriculum Domain 9 15. The impact of the standards must be tracked against trainee outcomes and clear linkages should be reflected in developing standards Standards for Deaneries 1. The postgraduate deanery must adhere to, and comply with, GMC standards and requirements 2. The postgraduate deanery must articulate clearly the rights and responsibilities of the trainees 3. The postgraduate deanery must have structures and processes that enable the GMC standards to be demonstrated for all specialty including GP training, and for the trainees, within the sphere of their responsibility 4. The postgraduate deanery must have a system for use of external advisers 5. The postgraduate deanery must work effectively with others 9
West Midlands 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 Job Evaluation Survey Tool (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. 10
6. Protected Teaching There must be a protected teaching programme for all trainees. 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. 11
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 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. 12
NHS West Midlands St Chads Court 213 Hagley Road Edgbaston Birmingham B16 9RG Tel: 0845 155 1022 Fax: 0121 695 2233 www.westmidlands.nhs.uk