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Clinical governance peer review scheme
Process of clinical governance peer review visitto a cardiology department
- Objectives of the BCS peer review scheme
- To ensure that cardiac departments have sufficient facilities and staffing to provide a safe and comprehensive service to their emergency and referral population.
- To ensure that arrangements and protocols are in existence to meet specific objectives identified by the National Service Framework for coronary heart disease applied to England, the Clinical Standards Board in Scotland, by British Cardiovascular Society Council and its affiliated groups, and Royal College of Physicians.
- To ensure trusts’ participation in local, regional and national audits, and that data collection is sufficiently robust to identify all relevant complications and unfavourable outcomes. To ensure that they are adhering to national guidelines and meeting audit standards.
- To promote discussion and the exchange of ideas between the reviewers and the reviewed, to offer adviceon solutions to problems, and generally to support trusts to improve their cardiac services.
- To reassure the public and the government that cardiology is being practiced to a high standard and to assist with the promotion of equitable access to cardiac services.
- Organisation of peer review visits
The BCS will only undertake a peer review at the invitation of the chief executive of an NHS trust or other organisation. The President of the British Cardiovascular Society will formally write to the chief executive of those trusts with a cardiac unit offering to undertake a peer review for clinical governance. Alternatively, the chief executive of a trust may directly request the President of the British Cardiovascular Society for a peer review visit to the cardiology department.
After the chief executive has accepted the invitation for the British Cardiovascular Society to review the cardiac unit, the BCS Development Manager will establish links with the trust and cardiac unit. He/she will identify the lead clinician and the trust contact delegated by the chief executive.
- Appointment of and responsibilities of the review team
The President of the BCS will appoint the review chairman before the review takes place. The review chairman will be a senior cardiologist with experience of running a cardiac or cardio-thoracic unit. He/she will fulfil the person specification for chairmen of peer reviews.
All members of the review team must fulfil the person specification. They should have expertise from relevant subspecialties, affiliated groups, linked societies and organisations. The British Cardiovascular Society provides training for peer reviewers. The review team must treat as confidential the review visit and all information obtained during the visit. They will sign a confidentiality agreement with the British Cardiovascular Society. The team will generally comprise:
The chairman (consultant cardiologist); two other cardiologists; a senior cardiac clinical physiologist; a senior cardiac nurse; the BCS Development Manager or delegated BCS staff member. In specific cases, additional professional colleagues of specific disciplines (including a senior manager) may be required for a peer review visit, or a patient or carer nominated by Heart Care Partnership (UK).
All reviewers should be from outside the region of the trust being reviewed.
- Information from cardiac unit to be reviewed
The BCS Development Manager sendsa questionnaire to the lead clinician of the reviewed cardiac unit at the beginning of the process. The BCS questionnaire will include medical, nursing and cardiac clinical physiologist questions. The lead clinician should complete the questionnaire in conjunction with the trust contact, senior cardiac clinical physiologist and nurse manager.
The cardiac unit to be reviewed should also provide an information pack to the BCS Development Manager not later than one month before the date of the review. This includes data on results from national statutory audits and audit results of unit; protocols, guidelines and care pathways; description of services and clinics, number of beds, inpatient and outpatient data; waiting list times for procedures and investigations; profile of trust including workforce and demographic data for the trust and health authority catchment and referral population; mortality and morbidity data for the unit, trust and health authority/board.
- Programme for review
The trust and Society will agree the scope of the planned peer review eg whether it will be limited to a single hospital in a multi-hospital trust or will be a trust-wide review of more than one hospital and department. The peer review visit may take one or two days.
On the day of the review, reviewers visit the cardiac unit and other facilities used. They will meet and discuss resources, staffing and facilities with appropriate staff (eg clinical physiologists, nurses, managerial, and other staff and patients). Reviewers will then interview the chief executive, medical director, director of nursing and others to discuss trust-wide clinical governance issues. Smaller groups of reviewers will interview colleagues in their own discipline to review and discuss specific issues.
The reviewers will have a short feedback session at the end of the review with the lead clinician, senior cardiac clinical physiologist, unit/directorate nurse or manager, and trust chief executive and medical director. The reviewers will give them their initial findings, commendations and concerns.
- Peer review report
The final report will be signed by the President of the BCS and the chairman of the review team. The President will send the final report to the chief executive of the trust, with copies to the medical director and to the lead clinician of the reviewed unit. The process should be completed within three months of the review.
There should be a section in the report for praise of excellence, commendation of good practice and achievement of high clinical standards as identified in specific areas of the reviewed unit. There should also be a section in the report where the reviewers may express concerns about the reviewed unit. The report should indicate whether these concerns are critical, major or minor. There should be a section in the report for specific recommendations arising from the review.
There will be two stages to feedback from the reviewed trust, using a pro-forma. The first should be immediately after the peer review visit, the second 4 - 6 weeks after the President has sent the final report to the Trust. The President will send a further letter to the chief executive and the senior clinicians one year after the visit to ask what action the Trust and cardiac department has taken to implement the review team’s recommendations.
The British Cardiovascular Society (BCS) expects that most peer review visits and reports will result in findings that do not endanger patient safety. Where the clinical governance review indicates a major cause of concern, the reviewers in consultation with the President of the British Cardiovascular Society may decide to issue an urgent preliminary report. This will be done within two weeks of the visit.
If there are more serious issues of real or potential threats to patient safety, the Society will invoke the BCS reporting system for adverse findings of a peer review visit. This outlines the mechanisms of referring concerns to the Trust, and, if appropriate, to statutory agencies.