Multi-Professional Deanery SCHOOL VISIT REPORT Visiting School Date visited Medicine April 18 th 2013 Local Education Provider (LEP) visited Princess Alexandra Hospital NHS Trust Visiting team Ian Barton, Head of School of Medicine Ian Fellows, Chairman of Core Medicine Training Committee Sue Agger, Senior Deanery Quality and Academic Training Manager LEP team Melanie Walker, CEO Radha Rajendram, Associate Medical Director Yvonne Barlow, Clinical Director Jonathan Refson, Clinical Tutor Alice Dain, College Tutor Margaret Short, Medical Education Manager Summary (including recommendation of posts by trainees) This visit was carried out to assess whether the improvements in the quality of medical education identified in the previous School of Medicine visit in January 2011 are being maintained and built upon and also to follow up on the concerns about undermining and poor handover in the Department of Medicine identified in the Deanery Performance and Quality Review in October 2012 The visiting team was extremely impressed by the clear evidence of continued progress which has occurred since the last visit: The trainers are generally accessible, friendly and supportive, particularly in the cardiology, gastroenterology and orthogeriatrics departments The content of and attendance at the CMTs formal teaching programme has improved; PACES teaching is more structured There is good access to simulation training The processes for handover have improved and have been shown to work in practice when led by motivated consultants Undermining in the respiratory and gastroenterology departments is no longer a problem; no other evidence of undermining by consultants was identified All the ST3+s met confirmed that their speciality training was of a high standard and felt that the medical take was more manageable than in many of the other Trusts in which they had worked. 1 of 9
The two main areas where improvements need to be made are: Handover: The new processes have not yet been adopted consistently by all consultants and admitting teams Undermining: There are poor relationships between some of the junior doctors and some (but not all) of the matrons and other staff tasked with expediting discharges and meeting other targets. Similar difficulties occur in many Trusts, but it is not usual for these difficulties to be described as undermining by the majority of trainees Over 90% of the trainees met would be happy to have a relative admitted to the Trust provided they were being managed by one of the better firms, such as cardiology, gastroenterology and orthogeriatrics Approximately 50% of the CMTs met would recommend their posts. All the ST3+s met would recommend their posts. The School of Medicine is prepared to recommend continued approval of the posts conditional upon receipt to HEEoE [formerly the Deanery] of a satisfactory action plan to address the requirements outlined below within 3 months of the date of this visit report. Examples of Good Practice The commitment of the new RCP College Tutor, Dr Alice Dain The high quality of the work of Margaret Short and her team in the education centres The active role taken by a senior nurse in taking calls from referring GPs Actions required by visiting team and timeframe The Trust must provide a written action plan to meet the following requirements by 26 th July 2013 A programme of work must be put in place to improve the relationships between junior and middle grade medical staff and the matrons and other staff tasked with expediting discharges and meeting targets. This should change behaviours in a way that leads to a cessation of reports of undermining. It is equally important that the trainees should understand their duties to act professionally and to not behave in an antagonistic way towards the matrons and other staff tasked with expediting discharges and meeting targets. The reported friction is a clear indication that the present arrangements are unsatisfactory. The timing of Discharge Facilitation Meetings should be reviewed. CMTs (or other trainees) should not be expected to attend these if it means them missing consultant ward rounds or delaying urgent clinical work. The Clinical Tutor s suggestion that they should occur at the end of the working day in order to plan for the following day s discharges seems a good solution 2 of 9
Recommendations of visiting team The Trust should enlist the help of the trainees in seeking solutions to the concerns that they have identified, for example, as Quality Improvement Projects; a forum should be set up to facilitate trainee engagement The outliers placement should be removed from the CMT rotation The current level of senior support in the stroke placement should be maintained and if there is evidence to confirm this, consideration should be given to allocating an F1 to the stroke team Consideration should be given to creating CMT placements in ITU and haematology & oncology Processes should be put in place which facilitate CMTs attendance in OPD clinics Planned re-visit date Approximately eighteen months 3 of 9
RELATED EVIDENCE Previous School of Medicine visits (dates and summaries) 6 th January 2011 Generally a very supportive report with only minor concerns Previous DPQR (date and summary for Medicine) 24 th January 2013 Generally a very supportive report. However, there were concerns about undermining and handover in the Department of Medicine 2012 GMC Trainee Survey outliers 2012 trainee survey: Specialty Red outliers Green Outliers CMT Handover, Undermining by consultant 2012 GMC Trainee Survey patient safety concerns and free text comments from Medicine Understaffing, high workload, poor feedback, lack of opportunities to perform practical procedures, high administrative workload and poor handover were all highlighted Areas of >20% poor/unsatisfactory in 2012 End of Post survey Specialty Cardiology CMT Geriatric Medicine Opportunities for practical procedures (based on only one response) Attending OPD, Opportunities for practical procedures, Attending training days, Taking study leave, Performing tasks of no educational value Attending Regional Training Days (based on only two responses) Amber/Red RAG Scores in Deanery GMC Report Amber: Concerns about patient safety have been raised by the local CCG 4 of 9
MEETINGS WITH TRAINEES (1 OF 2) Trainee Group CMTs Number of trainees met 4 CMT1s, 2 CMT2s Domain 1: Patient safety Adequacy of clinical supervision: No concerns Safety of rota patterns and effectiveness of handover: Handover is of variable quality; it is very good when motivated consultants, such as Dr Dain, are on call Discharge Facilitation Meetings: These are occurring at a time which coincides with consultant ward rounds and management of urgent clinical problems; the CMTs are expected to attend them even though they may not know many of the patients being discussed. Preventing CMTs from attending ward rounds may adversely affect patient safety because they will not hear first-hand what has been decided about individual patients Domain 5: Delivery of approved curriculum Adequacy of clinical (including outpatient) experience: There are difficulties attending OPD in most placements, particularly when the clinics are off site Adequacy of content of individual programmes: The cardiology, gastroenterology and orthogeriatrics placements are particularly good. The recent changes in the stroke placement have improved its quality; it would benefit from having more junior support and the CMTs feel that it is now a suitable training environment for an F1; it would be further improved by attendance at TIA clinics, attendance on neurology ward rounds and more exposure to thrombolysis. The outliers placement is of poor educational value. Placements in ITU and haematology & oncology would improve the balance of the rotations Quality of internal formal teaching: CMT teaching has improved considerably and PACES teaching is more structured Ability to attend internal and external training courses etc. including accessibility of study leave: No problems identified Accessibility of assessments including WPBAs: Generally good Adequacy of feedback: No concerns identified Domain 6: Support and development of trainees, trainers and local faculty Arrangements for Trust induction (including for intermediate starters): No concerns identified Arrangements for departmental induction (including for intermediate starters): No concerns identified 5 of 9
Quality of educational supervision (including appropriate use of eportfolio): No concerns identified Quality of careers support: Not discussed Intensity and educational content of work and adequacy of learning opportunities (including audit): No concerns identified Experience of bullying and harassment, awareness of whistle-blowing policy: There were no reports of undermining by consultants. There were, however, consistent reports from all of the CMTs of difficult relationships with some (but not all) of the matrons and some others involved in facilitating discharges and meeting targets. All of the trainees met reported feeling undermined Support from postgraduate education team and pastoral support: This is clearly very good. Domain 7: Management of education and training Awareness of how to access additional support: Not discussed; trainees should be reminded that they can approach their TPD, college tutor and/or clinical tutor. Domain 9: Outcomes Trainee progression and examination achievements: All were progressing well 6 of 9
MEETINGS WITH TRAINEES (2 OF 3) Trainee Group ST3+s Number of trainees met 3 from a range of specialities Domain 1: Patient safety Adequacy of clinical supervision: Consultant supervision is very good. Safety of rota patterns and effectiveness of handover: The presence of a ward cover ST3+ at weekends improves patient safety. There are three trainees on call overnight who may be stretched on occasions; however, the relatively small size of the acute medical take at PAH makes this rare. Handover does not occur to a high standard consistently Domain 5: Delivery of approved curriculum Adequacy of clinical (including outpatient) experience: This is good Adequacy of content of individual programmes: No concerns identified. Quality of internal formal teaching: No concerns identified Ability to attend internal and external training courses etc. and accessibility of study leave: No concerns identified Accessibility of assessments including WPBAs: No concerns identified Adequacy of feedback: No concerns identified Domain 6: Support and development of trainees, trainers and local faculty Arrangements for Trust induction (including for intermediate starters): No concerns identified Arrangements for departmental induction (including for intermediate starters): No concerns identified Quality of educational supervision (including appropriate use of eportfolio): No concerns identified Intensity and educational content of work and adequacy of learning opportunities: The respiratory posts are busier than the others in the Trust Experience of bullying and harassment, awareness of whistle-blowing policy: No examples of consultant undermining. The ST3+s supported the perceptions of undermining expressed by the CMTs Opportunities for academic training: Not discussed Support from postgraduate education team and pastoral support: This is excellent. 7 of 9
Domain 7: Management of education and training Awareness of how to access additional support: Not discussed, but trainees should be reminded that they can approach their TPD, college tutor and/or clinical tutor. Domain 9: Outcomes Trainee progression and examination achievements: Not discussed 8 of 9
MEETINGS WITH TRAINERS AND LEP TEAM Domain 1: Patient safety Processes for clinical supervision: There is good consultant presence on site in the twilight period and at weekends Design of rota patterns and handover processes: New processes for handover have been introduced but they are not yet embedded Work intensity: This is lower than in most other Trusts in the Region. Domain 2: Quality Management Provision of information for Deanery Quality Management Processes: Not discussed Domain 5: Delivery of approved curriculum including assessment Knowledge of curriculum, training in use of portfolio and training in completing assessments including WPBAs objectively: Not discussed Teaching programmes: Not discussed Outpatient attendance: Not discussed Domain 6: Support and development of trainees, trainers and local faculty Arrangements for Trust and departmental induction (including for intermediate starters): Not discussed Training for clinical and educational supervisors: There is a local programme for CS training; ES training is largely delivered off-site Careers support: Not discussed Identification of time for educational activities in job plans: Consultants should be allocated 0.125 PA per trainee for educational supervision from within their SPA time. Job plans should state clearly the sessional commitment to educational supervision. Support from postgraduate education team: This is clearly very good Domain 7: Management of education and training Support at Trust Board level: Not discussed Support at Departmental Level: Not discussed 9 of 9