Rayvathi John, Revalidation Support Manager

Produced by

Mr Declan Flanagan. Responsible Officer

Rayvathi John, Revalidation support manager

Michael Ferguson Revalidation Administrator

Emral Jarrold, acting Revalidation Support Manager

Annual Board Report for Medical Revalidation

2013-2014

1.Executive summary

As of the 31st March 2014, 256 doctors were attached to Moorfields Eye hospital for the purpose of revalidation. This is referred to as having a prescribed connection with the trust. It is relevant that the approximately 55 Specialist Registrars in the Trust do not have a prescribed connection with the Trust for appraisal and revalidation purposes. Annual appraisal of SpR’s [ARCP] is the responsibility of the London Deanery though Moorfields consultants who are clinical or educational supervisors have an active role in this process.

Of the 256 doctors thenumbers of completed appraisals within the appraisal year 2013-2014 were 207 [80.9%]. This included all Consultants, SAS, Trust fellows, Locum and honorary doctors.

The Trust submitted a mandatory Revalidation Annual Organisational Audit (AOA) to NHS England [NHS E] covering the period April 2013 – March 2014. The Trust received comments on this audit in late July 2014 from NHS England. The report compares Moorfields performance with the rest of London. 80.9% of all Moorfields doctors had an appraisal with the reporting period. This compares with 79.5% for the rest of London and 83.8% for the whole of NHS England. See Appendix C for a breakdown of this data. The full organisational audit report from NHS England is available on request.

One hundred doctors have now been successfully revalidated by the Trust.

2.Purpose of the Paper

As part of the framework for quality assurance and for the purpose of revalidation, NHS England has requested thisAnnual Report to cover the period of 2013-2014together with the compliance statement (Annex D). This follows the completion of the Annual organisation Audit (AOA) exercise which was submitted in May 2014.

The paper is intended to provide assurance to the Board that, in line with a number of self- and external assessments during the course of the year, the trust is fulfilling all the requirements for revalidation.

3.Background

Medical Revalidation was launched nationwide in December 2012. The purpose of the implementation of Revalidation was to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system.

The trust has assigned a Responsible Officer, Declan Flanagan, Medical Director and Clinical Revalidation lead, Miss Alison Davis, Consultant Ophthalmologist to lead on the implementation and delivery of the Revalidationrequirements. With effect from June 2014, Miss Poornima Rai, Locum Consultant Ophthalmologist has replaced Miss Davis as Clinical Revalidation lead.

Moorfields Eye Hospital has a statutory duty to support the Responsible Officer in discharging their duties under the Responsible Officer Regulations[1] and it is expected that provider executive teams (Trust Management Board) will oversee compliance by:

• monitoring the frequency and quality of medical appraisals in their organisations;
• checking that there are effective systems in place for monitoring the conduct and performance of their doctors;
• confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and
• Ensuring that appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the role undertaken.

The trust submitted an annual Organisational Readiness Self-Assessment (ORSA) in May 2013;to The NHS Revalidation Support Team (RST).Under the RAG rating system (Red, Amber, Green) this report received a green rating. This rating reflected the efforts of the Revalidation team and progress made in implementing actions which had previously been identified earlier in the revalidation preparation process.

4.Governance Arrangements and Quality Assurance

A revalidation group had already been established which was made up of the Medical Director, Clinical Revalidation Lead, Revalidation/HR Advisor and Recruitment/Revalidation Assistant. In addition the revalidation group is supported by Trust Audit team.

In October 2012 the Clinical Revalidation lead presented a paper to the Quality and Safety Committee with an update on the trust’s progress in ensuring readiness for Revalidation.

An audit was undertaken in March 2013 through our internal audit programme, KPMG, the outcomes of which has been presented to the Audit Committee in May 2013.

Thisauditidentified the need to procure a centralised Revalidation Management System (RMS) to audit, monitor and capture accurate data for appraisal and revalidation. The Trust undertook an evaluation of commercially available RMS systems. A bespoke system from Premier IT was then purchased and has been in use since 1st April 2014. Training for the RMS was organised over 12sessions of 1.30 hours per session. In addition support was also provided to cover the individual appraisal needs for doctors.

The audit also identified the need to confirm that if doctors worked for other institutions as well as Moorfields that evidence of this work was considered at their annual appraisal. Doctors are now required to produce this evidence. This evidence is usually in the form of a letter from the Chief Executive or Medical Director of the other institution.

In the past year the Trust introduced an electronic incident reporting system. This gives the Responsible Officer and individual doctor’s access to all incidents in which they have been named. There is a similar system for complaints.

An internal audit was conducted on the Model Appraisal Guide (MAG) by the revalidation group in 2013-2014 to ensure the quality assurance of appraisal. The aim of the audit was to determine whether the medical appraisal process was fit for purpose. In addition it also aimed to identify the number of doctors who had completed an appraisal between 1st December 2012 and 1st June 2013.

The outcomes of this Audit will be reported to the Trust Management Board in August 2014.The revalidation team will in the second cycle address the outcome of the audit which will be submitted to Audit team or Quality and safety committee in the last quarter of 2014-2015.

The Responsible Officer has discussed revalidation of doctors employed by Moorfields Dubai [MEHD]. The GMC have confirmed that as these doctors are responsible to the Medical Director of Moorfields Eye Hospital and as they work only for MEHD that they can be revalidated by the Moorfields Responsible Officer. The previous Medical Director received training in appraisal to GMC standards to support this process. Another consultant has recently been trained to fulfil this role until the new Medical Director is appointed. The Quality and Safety structure in MEHD recently been strengthened with the appointment of a Quality and Safety officer responsible for collection of clinical outcome data for clinical audits.This will strengthen the annual appraisal process. This officer has recently spent a week working with the Quality and Safety team in London to ensure that clinical quality assurance is performed to the same standard in MEHD as in London. A member of the Quality and Safety team will also spend a short period of time in MEHD in August 2014

The Revalidation and Quality & Safety team is providing support to ensure that all medical staff in the new Moorfields Croydon satellite have training in appraisal and clinical audit to ensure that they fulfil all the requirements for revalidation.

The Revalidation group are currently in the process of scheduling an Independent audit by a third party (yet to be agreed) to assess the quality assurance of the internal Revalidation process adopted by the trust. It is hoped that the findings of this audit will be presented to the Audit Committee by December 2014. In additionan internal audit is to be arranged to look at the appraisal process currently used by the trust.

Weekly meetings are undertaken within the Revalidation group to address any adhocissues and concerns that may arise of the Revalidation and appraisal process.

The Trust Responsible Officer is appraised by an external appraiser nominated by NHS England and his Responsible Officer is Dr Andrew Mitchell of NHS England.

The Responsible Officer {RO] and the Trust Revalidation lead attend regular external Responsible Officer Network meetings with other RO’s, representatives from the GMC as well as NHS England.

a.Policy and Guidance

There is a Medical Revalidation and Appraisal policy as well as a Back on Track Policy in place these polices wasratified by the Board in March and October 2012 respectively. These policies were drafted in accordance with the guidance issued by the GMC and NCAS. The Back on Track Policy was amended in May 2012 to reflect changes made by the GMC.

Doctors are able to access the polices under

5.Medical Appraisal

a.Appraisal and Revalidation Performance Data

For 2013-2014, the Trust recorded that out of 256 doctors 207 appraisals were completed.

Collation of data for audit and reporting during 2013-2014 has been a major challenge for the team in the absence of any IT Revalidation management system. Until the system is fully embedded, the Trust is currently monitoring the appraisal data using a manual process. Prior to the implementation of the Revalidation management system and during this report period, the Trust has used various systems to manage the appraisal and revalidation process. For example the doctors used a PDF version of the appraisal form called Model Appraisal guide (MAG) which after completion was stored either on the Trust appraisal system or on the individual’s local drive.The Trust was also engaged with 2 different providers for the purpose of obtaining colleague and patient feedback, which through a manual process were updated on an internal database (standard excel spreadsheet).This experience with different providers was helpful in deciding what comprehensive RMS to purchase. The spreadsheet also requires regular audit to ensure they are aligned with all current starters and leaver in the trust(which is sourced from the Trust HR system).

The manual process alsorelies heavilyon the available resource (both internal and external)to update the information on a regular basis. This arrangement also, has a restricted functionality on producing details on appraisal information or being able to produce a report to identify reasons for incomplete appraisal, appraisals output not signed, etc.

The new revalidation management system in use since May 2014 willmake it much easier to manage the appraisal process and audit the quality of the process.

SeeExtract from AOA report-Appendix Asubmitted to NHS England in May 2014 on the appraisal undertaken in the trust.

b.Appraisers

Additional appraisers have been recruited to ensure that each appraiser has a manageable workload. Training by accredited external providers has been provided for all new appraisers and refresher training for some of the existing trainers.

As of March 2014, 46 trained appraisers were engaged in the process of Medical appraisal up to revalidation standard.

The trust also organised top-up training for existing appraisers on the 15th October 2013 to 16th December 2013 and 23 appraisers in total attended these session. This training was organised to ensure the knowledge and skills remain up-to-date within the GMC’s requirement.

The trust has been continuously recruiting new Medical appraisers to balance the proportion of the appraiser and appraise ratio and ensure that the workload for each appraiser remains manageable..Further training has been organised in July 2014 and although outside the period covered by this report a total of 56 appraisers have now been trained.

The revalidation group intends to set up an appraiser network to offer ongoing support to appraisersand the details of this network are yet to be finalised.

c.Access, security and confidentiality

The trusthas an implemented framework of Information Governance to ensure all the information held on staff members are complaint with the Data protection and confidentiality, information security and information quality on an annual basis.

d.Clinical Governance

The trust has an established team and system to record all incidents and complaints through Risk and safety team.The report and details are available if requested to all staff so that they are able to provide the data at the time of their appraisal.

The trust also has a dedicated Audit team to assist the doctors and contribute to their clinical performance by auditing to the revalidation standards.

Clinical Governance and Clinical Audit meetings are held on a regular basis to offer support, training and updates to doctors. This is to enhance their professional development and ensure compliance with the requirements of the trust and professional bodies.

There were 57 doctors that required Revalidation during the reporting year 2013-20414. 100% Revalidation Recommendations were completed on time and below is the split:

Positive recommendations - 55

Deferrals requests - 2

Non engagement notifications –N/A

Reasons for all missed or late recommendations-N/A

SeeAudit of revalidation recommendation-Appendix B

Although outside the period covered by this report a total of 102 doctors have now been revalidatedas of 26th August 2014. 43 more have dates to revalidate by the end of March 2015.

6.Recruitment and engagement background checks

The Trust has a dedicated Human Resources team to ensure the Recruitment and Pre-employment checks are in place before the employee commences with the Trust.These checks also ensure collection of revalidation information if appropriate from previous employers.

The Trust HR team ensures that all staff areonly appointed to the post once the following pre-employment checks are undertaken.

Identity check
Qualification check
Occupational Health Clearance
DBS
3 recent references
Right to work in the the UK
Information Governance Training
Name of last responsible officer
Reference from last responsible officer
Revalidation due date

7.Monitoring Performance

The performance of each clinical service is monitored against 3 core clinical outcomes which are benched marked against published external outcomes.

Doctors are required to produce at least oneaudit annually to recognised standards of their clinical outcomes covering a key area of their practicefor their appraisal.

8.Responding to Concerns and Remediation

The trust has a Back on Track policy which is based on the guidelines provided by GMC and National Clinical Assessment Service (NCAS). The guidelines from the policy are used when required when responding to concerns about a doctor or when remediating a doctor.

The trust used the Back on Track policy for guidance in January 2013 to help a doctor return in an honorary capacity and worked closely with the GMC to support the doctor. However upon advice of the GMC this doctor’s honorary contract was terminated.

9.Risk and Issues

The recorded average medical appraisalsundertaken within secondary care during 2013-14 is 80%. Moorfields for the same period has recorded 81% which is marginally above the NHS average for appraisal.

The Revalidation team are continually tasked with identifying those doctors who have not yet had their appraisals due to maternity leave, illness, appraisal dates not set and leave dates imminent. During the last quarter of 2013-2014, some such caseswere identified and postponementsof theirrevalidation or appraisal were agreed by the Responsible officer.

The Revalidation team identified that most of the doctors who had not yet identified an appraisal date were temporary or short term contract holders. These were mostly trust Fellows who are employed for approximately 1 year from outside UK and do not wish to undertake an appraisal or be revalidated as there are no implications for them to practise in their home country after the termination of contract.

The Trust employs over 90 Clinical Fellows. These are either UK ophthalmologists who have completed their SpR training or have come from abroad for further subspecialty training. The Revalidation team has stressed the importance of annual appraisal to GMC standards to this group and provided additional training and support for them.

Associate Specialists are recognised nationally as a group that have had a low rate of annual appraisal in the past. For this reason the Responsible Officer and the revalidation team have supported them in preparing for appraisal. In addition 2 Associate Specialists from Moorfields attended a training day for them run by the London Deanery.

Moorfields has a substantial number of consultants with research roles and responsibilities with the Institute of Ophthalmology and other institutions. They are required to have annual joint clinical and research appraisals with clinical and research appraisers. The Revalidation Management system is being modified to facilitate this.

The trust creates awareness of the requirements and support in place for annual appraisal and revalidation during medical induction. Continuous support is also offered to all staff particularly clinical fellows and associate specialistsby their services and the Revalidation team to ensure that they are all appraised to revalidation standards.

Temporarily appointed fellows, i.e. those on fixed term contracts shouldbe listed on the Trust risk register for the purpose of annual appraisal and revalidation.

10.Corrective Actions, Improvement Plan and Next Steps

As mentioned above within the Revalidation group there has been an appointment of a new Clinical Revalidation lead Mrs Poornima Rai, Locum ConsultantOphthalmologistcommenced these additional duties in June 2014. The new RMS system Premier IT was introduced in April and went live in May 2014,appropriate training has and iscontinually being provided.

Future Plans

• To continue to develop and improve the new RMS by introducing additional features to replace the current manual formswhich are used (Clinical declaration of practice elsewhere and appraisal form) .

• The Clinical Revalidation lead will identify ‘Revalidation representatives’ from individual services and satellites to ensure the smooth operation of revalidation within the serviceand address queries and support revalidation.

• A new support network system for all trained appraisers will be created to keep appraisers up to datewith changes in revalidation, RMS improvements. The objective of this network is also to ensure that appraisers are supported and offered assistance where needed.

• Modify the RMS system to facilitate joint clinical and research appraisals for clinicians with research roles in the Institute of Ophthalmology and other research institutions.

• All the doctors who have not had appraisals or who have missed appraisal dates have now been identified using the RMS system. This will allow close monitoring of the appraisal progress of all doctors and provision of support if nay doctors are missing their appraisals.

11.Conclusion and recommendation