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Revalidation and Appraisal Policy for Medical Staff v4.0

Policy Title

Revalidation and Appraisal Policy for Medical Staff

Policy Number

PP33

Version Number

4.0

Ratified By

Human Resources Committee

Date Ratified

08/10/2019

Effective From

17/10/2019

Author(s) (name and designation)

David Elders, Workforce Systems Technical Facilitator

Sponsor

Andy Beeby, Medical Director

Expiry Date

01/10/2022

Withdrawn Date

Unless this copy has been taken directly from Pandora (the Trust’s Sharepoint document management system) there is no assurance that this is the most up to date version This policy supersedes all previous issues

Revalidation and Appraisal Policy for Senior Medical Staff v4.0 2

Version Control

Version Release Author/Reviewer Ratified by/Authorised

by

Date Changes (Please identify page

no.)

1.0

December 2003

Join Consultative Committee Trust Board

Nov 2003

Nov 2003

2.0

18/06/2013 D. Elders, Revalidation and

Clinical Governance Facilitator

Medical Staff Committee

13/06/2013

3.0 15/11/2016 D.Elders HR Committee 11/10/2016

Minor changes to job titles/roles

4.0 17/10/2019 D.Elders Workforce

Systems Technical Facilitator

HR Committee 8/10/2019 Minor changes to job titles/roles

Explicit addition of Locally Employed

Doctors to be covered by the policy


Contents 1 Introduction ...................................................................................................................... 5 2 Scope ................................................................................................................................. 5 3 Aims and objectives of senior medical staff appraisal ...................................................... 5 4 Roles and responsibilities .................................................................................................. 6 5 Definitions ......................................................................................................................... 7 6 The appraisal process ........................................................................................................ 7

6.1 Who will be your appraiser ................................................................................... 8 6.2 Preparing for the appraisal .................................................................................... 8 6.3 What the doctors being appraised must do ......................................................... 9 6.4 What the appraiser must do ................................................................................. 9 6.5 Content of the appraisal process .......................................................................... 9

6.5.1 Delivering a high quality service ............................................................. 10 6.5.2 Developing a high quality service ............................................................ 10 6.5.3 Professional relationships with patients ................................................. 10 6.5.4 Colleagues and team working ................................................................. 11 6.5.5 Teaching and training activities .............................................................. 11 6.5.6 Research activity ..................................................................................... 11 6.5.7 Other matters .......................................................................................... 11 6.5.8 Job plan/working time regulations review ............................................. 12 6.5.9 Personal development plan (PDP) .......................................................... 12

6.6 Peer review ............................................................................................................ 12 6.7 Documentation ...................................................................................................... 13

6.7.1 Formal documents of the appraisal process ........................................... 13 6.8 Deferring an appraisal ........................................................................................... 14

6.8.1 Rescheduling a deferred appraisal .......................................................... 14 6.8.2 Process for deferring an appraisal .......................................................... 14

6.9 Outcomes of the appraisal process ...................................................................... 15 6.9.1 Remediation ............................................................................................ 16

6.10 Implementation of appraisal and training ............................................................ 17 6.11 Clinical academics & senior medical staff working in more than 1 Trust ............. 17 6.12 Standards and quality assurance (QA) .................................................................. 17

6.12.1 The role of an appraiser .......................................................................... 18 6.12.2 Reviewing the performance of an appraiser .......................................... 18 6.12.3 Outcome of the annual appraiser review ............................................... 20

6.13 Probationary review .............................................................................................. 21 6.13.1 Special review .......................................................................................... 21

6.14 Confidentiality ....................................................................................................... 21 7. Training .............................................................................................................................. 22 8. Diversity and Inclusion ...................................................................................................... 22


9. Process for monitoring compliance with the policy ......................................................... 22 10. Consultation and Review................................................................................................... 23 11. Implementation ................................................................................................................. 23 12. References ......................................................................................................................... 23 13. Associated Documentation ............................................................................................... 23 Appendix A – Annual appraisal checklist ..................................................................................... 24 Appendix B – Evidence for an educational / college role ............................................................. 25 Appendix C – Whole scope of work form ..................................................................................... 28 Appendix D – Supporting Information submission timeline ......................................................... 31 Appendix E – Application form for deferment of appraisal .......................................................... 32 Appendix F – Appraiser annual reflection .................................................................................... 34 Appendix G – Rating tool .............................................................................................................. 36 Appendix H – Job description for a medical appraiser ................................................................. 38


1. Introduction This policy sets out the detailed arrangements for the Trust’s local annual appraisal scheme for Trust employed medical staff, which embodies the core principles of the national model scheme as agreed between the NHS Executive and the British Medical Association. The Trust Medical Staff appraisal scheme will underpin the Trust’s approach to clinical governance, productivity and will be the vehicle for the delivery of the GMC’s revalidation and relicensing requirements. The satisfactory completion of five consecutive annual appraisals will be required for revalidation, which will be composed of two elements; GMC annual relicensing and recertification every 5 years.

2. Scope

This policy is for all Senior Medical Staff and Locally Employed Doctors. This policy does not cover doctors in training.

3. Aims & objectives

Annual review of an individual’s work and performance, utilising relevant and appropriate comparative performance data from local, regional and national sources; it is anticipated that a formal review of the individual doctors job plan and contribution to service delivery will have taken place prior to appraisal with the appropriate line manager and will be available to inform the appraisal process;

Optimising the use of skills and resources in seeking to achieve the delivery of service priorities;

A consideration of the individual’s contribution to the quality and improvement of services and priorities delivered locally; which will inform the local round of clinical excellence awards;

The identification of both personal and professional development needs and the agreement of plans and resources for these needs to be met;

An opportunity to identify the needs for the working environment to be adequately resourced to enable any service objectives in the agreed job plan to be met;

An opportunity for individuals to discuss and seek support for their participation in activities in the wider NHS;

Whilst relicensing will be an annual GMC function: recertification will depend on specific Royal College criteria and consist of the satisfactory completion of 5 annual appraisals as well as confirmation from the Trust Responsible Officer that there are no unresolved concerns or performance or probity issues;

Appraisal has become structured and moved away from a formative to summative format. Supporting information is now Domain based and increased scrutiny of supporting information, evaluation and Quality Assurance takes place.

Whilst it is not the primary aim of the appraisal process to scrutinise Medical Staff to see if they are performing poorly, it can help to recognise at an early stage any circumstances where there is poor performance or ill health, which may be affecting practice.


4. Roles & responsibilities Chief Executive/Responsible Officer

Ensuring that all Medical Staff undergo an annual appraisal and that there are appropriate trained appraisers in all cases;

Ensuring that the necessary links exist between the appraisal process and other Trust processes concerned with clinical governance, quality and risk management and the achievement of service priorities;

Will have confidential access to any documentation used in the appraisal process. In these circumstances, the individual concerned will be informed;

Accountable to the Trust Board for overseeing the appraisal process and will be required to confirm to the Board on an annual basis that: o Appraisals have been conducted for all Senior Medical Staff and Locally

Employed Doctors; o Any issues arising out of the appraisals are being properly dealt with; o Personal Development Plans for all Senior Medical Staff and Locally

Employed Doctors are in place.

Ensure that responsibility for appraisal processes is allocated to the appropriate accountable Director with ultimate accountability residing with the Responsible Officer.

Individual Doctor

Ensure that they undergo an annual appraisal to comply with contractual requirements and facilitate relicensing and recertification.

Appraisers

Expected to undertake a minimum number of 5 appraisals per annum;

Attend regular update meetings throughout the appraisal year;

Be subject to Quality Assurance procedures. Quality Assurance Support Group

Delegated authority of the Board to ensure the development and approval of the appraisal policy and procedures.

Workforce Systems Team

Administer an electronic system to provide supporting information for the appraisal process.

5. Definitions

Appraisal process - is an annual professional process of constructive dialogue, in which the doctor being appraised has a formal structured opportunity to reflect on his/her work and to consider how his/her effectiveness might be consolidated and improved, aiming towards excellence on a personal, professional, service delivery and Trust performance level. The process is intended to be a positive, forward looking one led by the employer, giving Medical staff regular feedback on their performance, charting their continued progress and identifying educational and development needs.


ARCP Annual Review of Competency Progression

CCT Certificate of Competency of Training

CEA Clinical Excellence Award

CME Continuing Medical Education

CPD Continuing Professional Development

CQC Care Quality Commission

GMC General Medical Council

LNC Local Negotiating Committee

MAG form Medical Appraisal Guidance Form

MSF 3600 Multi source feedback from colleagues and peers

PDP Personal Development Plan

QA Quality Assurance

Senior Medical Staff and Locally Employed Doctors

Consultant, Locum, Associate Specialist, Specialty Doctor, Staff Grade, Clinical Fellow, Teaching Fellow etc.

RO Responsible Officer

SI Supporting Information

SPA Supporting Professional Activities

6. The appraisal process

Preparation for appraisal is included in protected SPA time in job plans (Core 1-1.5 SPA) and appropriate training is made available to appraised doctors and appraisers who will gain an additional 0.25 PAs of SPA time within their job plans, to ensure that the process is fit for purpose; The annual appraisal round is aligned to revalidation dates for all Medical Staff who will be expected to have had their appraisal discussion by no later than three month after the expected date as notified by the Medical Director’s office and in line with NHS England guidance. The Responsible Officer / Medical Director and Chief Executive will follow up any deviations from these timescales. Newly appointed Senior Medical Staff and Locally Employed Doctors will have their annual appraisal date identified to align with their last ARCP or CCT date. The appraised doctor must choose an appropriate appraiser from the list of approved appraisers that is available from the Medical Director’s intranet page (this cannot be a spouse or partner). The appraised doctor must agree a date with the appraiser at least six weeks in advance of the date, submitting supporting information at least 2 weeks before the appraisal.

6.1 Who will be your appraiser

At present Medical Staff have choice from the list of Trust approved appraisers:

For non-consultant grades / Locally Employed Doctors, the appraiser will be the relevant Consultant Supervisor if they are a Trust approved appraiser, if not an individual from the listing can be chosen;


Consultants will get choice of appraiser, however, in specific circumstances, it will be more appropriate for the Clinical Lead or Medical Director to inform the individual Doctor of who their appraiser will be for that appraisal cycle.

If the Medical Director also undertakes the Trusts Responsible Officer role the individual will undertake their annual appraisal with a Responsible Officer, Level 2 nominated appraiser via NHS England. It will be down to the individual if they wish to combine their clinical appraisal with their management role appraisal. NB. Participation in the appraisal process is a contractual requirement for all medical staff within the NHS and all Medical Staff are expected to participate fully and positively in the process. Refusal to do so is considered a disciplinary matter and will be dealt with under the relevant Trust procedures. The Chief Executive is also required to report the matter to the Discretionary points and Distinction Award Committees and the employee concerned will not be considered for an incremental progression unless and until he/she has agreed to participate fully in the annual appraisal process.

6.2 Preparing for the appraisal

In the month prior to the appraisal discussion, the Workforce Systems Team will prepare a workload summary for the member of staff being appraised. The Clinical Lead and / or Service Line Manager will ensure they have undertaken a formal review of the individual doctor’s job plan and contribution to service delivery which will be made available to inform the appraisal process. It will also serve as the basis of Local CEA application comprising the same domains. Discussion may be required to determine what level of data is sufficient e.g. patient workload, teaching contribution, management contribution and any pertinent internal and external comparative information. The primary purpose of the workload summary is to inform the appraisal and job plan review and to facilitate departmental planning and development. It will also highlight any significant changes which might have arisen over the previous 12 months and which require discussion. The appraisal discussion should be based on accurate, relevant, up-to date and available data. This should be supplemented by any information generated as part of the regular monitoring of organisational performance undertaken by the Trust. Documentation must cover the Doctors whole scope of work.

6.3 What the doctor being appraised must do

Submit all information required (see documentation in appendix A, this is the minimum data set required per year) to the appraiser at least two weeks in advance of the agreed date via the online Appraisal Toolkit. NB. Locally Employed Doctors will use the NHS England Medical Appraisal Guidance (MAG) form;

Identify those issues which he/she wishes to raise with the appraiser; Prepare an outline PDP via the online Appraisal Toolkit (or MAG form);


Submit any additional supporting information, which is considered relevant to the appraisal. This must include sufficient relevant supporting information relating to other work carried out externally to the Trust e.g. in private practice or other third party work.

Change appraiser so that they have only 3 out of 5 appraisals with the same appraiser in any 5-year cycle. Continuity of appraiser for up to 3 years will be encouraged. The appraiser must not be a spouse or partner.

6.4 What the appraiser must do

Receive the relevant minimum data set as specified in appendix A at least

two weeks before the appraisal date via the online Appraisal Toolkit or MAG Form (if a Locally Employed Doctor on a short term placement with prior agreement);

Review the portfolio of evidence as soon as possible after receipt and identify any missing information;

May consult in confidence, where appropriate with the Medical Director, Clinical leads and members of the immediate health care team;

Share with the appraised doctor any perceived deficiencies in the information and paperwork to be used in the appraisal meeting at least 1 week in advance of the appraisal meeting to allow for adequate preparation and validation of supporting information;

Determine whether a peer review process is required (see Section 6.6 for details);

Arrange a confidential venue for the appraisal meeting where there will be no interruptions;

Prepare and agree an agenda of items to be discussed prior to the meeting.

6.5 Content of the appraisal process

The content of the appraisal scheme will cover all of the elements outlined in the GMC’s document “Good medical practice” as well as other relevant local matters:

Good clinical care;

Maintaining good medical practice;

Relationships with patients;

Working with colleagues;

Teaching and training;

Probity;

Health.

6.5.1 Delivering a high quality service This focuses on all clinical aspects of the individual’s work including information on activity undertaken outside the immediate NHS employer and will include:

http://www.gmc-uk.org/guidance/good_medical_practice.asp


Clinical activity via supporting information generated by audit, outcome data and recorded complications, with discussion of factors influencing activity, including the availability of resources and facilities;

Achievements in past year, e.g. as lead or in the form of citations, reviews etc;

Concerns raised by clinical complaints, which have been investigated. (If there are any urgent and serious matters raised by complaints but not yet investigated, these should be noted);

CPD including the updating of relevant clinical skills and knowledge through CME.

6.5.2 Developing a high quality service

Major enhancements, innovations or improvements;

The use and development of any relevant clinical guidelines;

Risk management and adherence to any agreed clinical governance policies of the Trust and suggestions for further developments in the field of clinical governance;

Good uptake of evidence based practice;

Benefits in prevention, diagnosis, treatment or models of care;

Cost efficiency achievements;

Attendance at 50% of Divisional Safecare meetings.

6.5.3 Professional relationships with patients

MSF 3600 from patients to be undertaken within 3 year of an individual’s revalidation date, unless identified otherwise; for a newly appointed consultant this should be undertaken at 18 months and Year 4;

Professional involvement of patients, carers or public groups;

Patient involvement in service design and delivery.

6.5.4 Colleagues and team working

MSF 3600 from Peers to be undertaken within 3 year of an individual’s revalidation date, unless identified otherwise, for a newly appointed consultant this should be undertaken at 18 months and Year 4;

Multidisciplinary working with nursing colleagues and other ancillary professionals;

Successful resolution of problems and challenges;

Chairmanship of Regional or National committees;

Shaping policy and planning at Trust or higher level.

6.5.5 Teaching and training activities

Review of quantity and quality of teaching activity. This will include:


Junior medical staff;

Medical undergraduates;

Non-medical health professionals;

Postgraduate teaching activity;

Consideration of feedback from those being taught e.g. School visit reports, 3600 feedback;

Involvement in quality assurance of teaching and training;

Invitations to lecture, authorship of educational information, curriculum development, involvement in examinations.

6.5.6 Research activity

Depending on the professional contract of the appraised doctor, academic vs NHS:

Research undertaken in the preceding year, ensuring that all necessary approvals including ethical approval have been followed as collaborator or lead;

Peer reviewed publication record;

Supervision of doctorate/post doctorate fellows;

Roles as principal investigator or major research lead;

Successful peer reviewed grant applications;

National/international lectures or presentations.

6.5.7 Other matters

Discussion of any matters which either the appraiser or appraised doctor may wish to raise, i.e. the individual’s general health and well-being;

Identification of the resources needed to improve personal effectiveness.

6.5.8 Job plan/working time regulations review

The appraisal process should not be the point at which the individual’s job plan is formally considered. This should be discussed before the appraisal takes place and updated on the online Appraisal Toolkit.

There should also be a consideration of the working patterns of the appraisee and how these comply with the Working Time Regulations guidance for Senior Medical Staff.

Any necessary adjustments to working patterns should be discussed and a plan agreed at this point to be included in the summary of discussions in order to move towards full compliance with the regulations.


6.5.9 Personal development plan (PDP) The outcome of the appraisal process should be the agreement of a PDP and summary of discussions, setting out the key educational and development objectives of the individual for the next 12 months and beyond. The PDP must be written in a SMART format so that it is Specific, Measurable, Achievable, Relevant and Timely. Core Skills training must be identified in all PDPs on a yearly basis. Objectives cover any aspect of the appraisal discussion, including personal development needs, training goals, organisational issues, CME and CPD, acquisition of new skills and techniques. The Medical Director will review each PDP to ensure that key areas have been covered.

6.6 Peer review

Where it is apparent that, due to the specialist aspects of a member of staff’s clinical performance, peer review is an essential component of the appraisal process, the appraiser and appraised doctor should plan this into the timetable well in advance of the appraisal meeting. If during the appraisal, it becomes apparent that more detailed discussion would be helpful and important, either the appraiser or appraised doctor will be able to request internal or external peer review. This should normally be completed within 1 month and a further meeting scheduled by no later than a further month to complete the appraisal process. As a matter of routine, the results of any other peer review or external review (e.g. by an educational body, professional body, CQC etc) will need to be considered at the next appraisal meeting.

6.7 Supporting Information The IT system of choice, the Premier IT Appraisal Toolkit, will be used for Trust appraisal embodying the principles of the nationally agreed Supporting Information. As well as feeding the GMC revalidation process, this ensures a standardised, structured and generic process is in place for every Senior Medical Staff appraisal conducted within the Trust. Locally Employed Doctors will use the NHS England Medical Appraisal Guidance (MAG) form due to easier portability between establishments. Please see Appendix A for the generic appraisal checklist. Please also see Appendix B if you have an educational or college tutor role. Please see Appendix C for the whole scope of work form.


Please see Appendix D for the timeline for documentation on the Premier IT appraisal toolkit. 6.7.1 Formal documents of the appraisal process

PDP;

Summary of discussions including ratification of any previous job plan revisions and/or proposed potential changes to working patterns;

Confirmation of the above signed by both appraiser and appraised doctor;

Copies of the completed appraisal documentation held in confidence on the online Appraisal Toolkit or the relevant Trust network drive for Locally Employed Doctors;

Copies of the PDP held on the online Appraisal Toolkit, for the Medical Director / Responsible Officer, to provide relevant information to the Chief Executive and Director with responsibility for Human Resources as well as Specialty Clinical Leads;

Revalidation statements signed by the appraiser for submission to the RO for collation over the five-year revalidation cycle;

Appraised doctor and appraiser feedback forms reviewed by the Appraisal Support / Quality Assurance Reference Group.

In addition, the Medical Director must submit an annual report on the process and operation of the appraisal scheme to the Trust Board as part of the annual Clinical Governance update report. This information will also be shared and discussed with the Human Resources Committee and Local Negotiating Committee . The report will be completely anonymised and will not refer in any way, either explicitly or implicitly, to specific individuals. Rather, the report will highlight any Trust-wide issues and action arising out if the appraisal process e.g. educational development. Although the appraisal process is intended to be conducted on an annual basis, there may be occasions where a follow-up meeting is required before the next annual appraisal is due. When this is considered necessary, appraisers are responsible for ensuring this occurs.

6.8 Deferring an appraisal Annual appraisal for Medical Staff is a contractual requirement and essential for recertification and revalidation. Under normal circumstances, the successful completion of five annual appraisals will be required to fulfil adequate SI of CPD for the purpose of revalidation. Certain circumstances may arise when a practitioner may need to request a deferment of appraisal. An appraisal may be postponed beyond the end of the normal appraisal year i.e. no appraisal undertaken between 1st April and 31st March the following year, due to the following request:


Imposition of sanctions on practice;

Longer term sickness absence;

Maternity leave;

Prolonged study leave;

Sabbaticals.

6.8.1 Rescheduling a deferred appraisal A member of staff who has been absent from clinical practice for a substantial period will face some difficulties obtaining suitable SI for their appraisal. Although an appraisal early after a return to work may be useful for planning development needs and reinstating confidence, it will be more challenging to meet the minimum standards for gathering SI. The Workforce Systems Technical Facilitator, and where appropriate, the Responsible Officer / Medical Director will use their judgement and discretion to agree a suitable appraisal date with the doctor who has been deferred.

For breaks shorter than 6 months, the next appraisal must take place no longer than 18 month after returning to work. The aim is to avoid missing an appraisal year altogether (if possible);

For breaks longer than 6 months, the next appraisal must take place within 6 months of returning to work.

6.8.2 Process for deferring an appraisal

Where a doctor feels that they need to request a deferment the following process must be followed:

The doctor must make a written request, as soon as possible, to the Workforce Systems Technical Facilitator. NB. Under normal circumstances, doctors will be expected to apply no later than 3 month before their expected appraisal date.

The Workforce Systems Technical Facilitator will flag the requested deferment to the Medical Director;

The doctor will be informed in writing if the request has been granted;

Guidance regarding the expected date of the deferred appraisal will be provided. Each case will be judged on an individual basis and no one will be disadvantaged by factors such as sickness, incapacity or pregnancy and maternity leave. The following factors will be taken into account:


Whether performance concerns have been raised;

Whether there have been issues with incomplete or inadequate supporting information in earlier appraisals;

Whether the doctor is receiving remedial support or training;

How many appraisal have, or potentially will have been, missed in a given 5-year revalidation cycle;

If any further breaks are anticipated. The Trust has the right to impose sanctions if the doctor concerned fails to undergo an annual appraisal without good reason. In all cases, there must be adequate consideration of individual circumstances. The deferment process aims to ensure that such circumstances are dealt with in a manner that is appropriate, consistent, fair, robust and timely. If required, informal advice can be obtained from the:

Workforce Systems Technical Facilitator;

Regional Revalidation Support Team. 6.9 Outcomes of the appraisal process

Maximum benefit from the appraisal process can only be realised where there is openness between the appraiser and appraised doctor. Where, there is disagreement, which cannot be resolved at the appraisal discussion between the appraiser and appraised doctor, this should be formally recorded and a meeting will take place in the presence of the Medical Director to discuss the specific points of disagreement. Where the disagreement involves the Medical Director and the disagreement is of a professional nature, the Chief Executive will consult with the respective Regional Specialty Advisor on the issues involved. Where the disagreement involves the Medical Director and the disagreement is of an executive nature, the matter will be referred to the Chairman of the Trust. Where it becomes apparent during the appraisal process that there is a potentially serious performance issue which requires further discussion or examination, the matter must be referred by the appraiser immediately to the Medical Director and Chief Executive to take appropriate action in line with local Trust policies and procedures. It is important to note that the appraisal process must not attempt to investigate or deal with any matters, which are properly the business of other procedures e.g. disciplinary procedures.


Where it becomes apparent during the appraisal process that there is a potentially serious performance issue (that has not been previously identified) the appraisal meeting or process should be adjourned pending advice from the Medical Director. 6.9.1 Remediation

Remediation includes all activities from providing help and support to simple advice or referral to occupational health or through formal mentoring, further training, re-skilling and rehabilitation. An appraiser has the role of a facilitator and is not responsible for providing remediation. The responsibility is with the individual doctor to recognise the need for remediation rather than the appraiser. When concerns do arise through the appraisal process either:

The doctor will recognise during their preparation, that their performance may give cause for concern or that they are unable to provide suitable/satisfactory evidence to support Revalidation and/or

The appraiser will form a view during the appraisal discussion and raise any concerns at this point.

Where a performance issue is identified, the doctor and appraiser should discuss and agree an action plan. This discussion should include the Clinical Lead/Business Unit Head of Service. A referral to occupational health for an assessment should be an early consideration. The Clinical Lead/Business Unit Head of Service enables the early identification of performance issues through the bringing together of information from annual appraisals, adverse events, routine performance data, identifying trends, and/or complaints and concerns raised directly in a structured way. The collation of data should enable clinical management to take an informed review. Once an issue is uncovered, it must be dealt with using the appropriate mechanisms and not ignored. The Clinical Lead/Business Unit Head of Service will respond initially with an informal 1:1 meeting with the individual – regardless of the nature of the problem. There may be a mixture of responses and proposed resolution outcomes in keeping with the mixed nature of problems, agreeing an action plan. If this meeting has an unsatisfactory outcome or if the matter is of a more serious nature, the matter will be referred to the Medical Director. Where concerns are raised about patient safety the matter will always be referred to the Medical Director.


6.10 Implementation of appraisal and training To be successful the appraisal scheme must be introduced with an adequate level of support and training for both appraisers and appraised doctors. Key issues include:

The allocation of adequate time for both the preparation stage and formal appraisal meeting – for both appraisers and appraised doctors;

The ready availability of up-to-date and relevant data to inform the appraisal process (as outlined in Section 6 above);

The provision of appropriate training for both appraisers and appraised doctors – before beginning the process for the first time.

A training programme to support the appraisal process has been developed locally and this will be used within the Trust to support both appraisers and appraised doctors in the process. An appraiser’s support group has been established to ensure information and experience sharing to facilitate development and improvement of the appraisal process. Additional support will be available initially from the Trust Revalidation Support Team via the Workforce Systems Technical Facilitator on [email protected]

6.11 Clinical academics and medical staff working in more than one Trust

Clinical Academics employed by the University with an honorary contract with the Trust should usually have one appraisal process and one appraiser. This will be agreed, in the case of each Clinical Academic, between the University employer, the Trust and the individual themselves with information contributed by all parties. For individuals working in more than one Trust, the Workforce Systems Technical Facilitator will identify who is the Designated Body/Responsible Officer for that Doctor. Agreement will also include appropriate discussion prior to the appraisal between Clinical Lead/Business Unit Head of Service to ensure key issues are considered systems for accessing, sharing data are agreed, and arrangements for actions arising out of the appraisal are determined.

6.12 Standards and Quality Assurance (QA)

Quality Assurance of appraisal comprises the QA of appraiser work and the QA of appraisal systems. The QA of appraiser work is delivered through 3 processes:

Review of appraiser performance by members of an Appraiser Support and Quality Assurance Reference Group comprising the Appraisal Lead and support group (linked to appraiser reaccreditation or de-selection);

Appraiser updates (formal training, information sharing and appraiser support);

Recruitment and selection.

mailto:[email protected]


6.12.1 The role of an appraiser

An appraiser will:

Have completed an acceptable appraiser training course, which includes a summative assessment of competence as an appraiser;

Carry out a minimum 5 appraisals a year and a maximum of 10;

Attend at least 50% of appraiser learning set meetings and appraiser update sessions per year (or appropriate alternatives);

Take part in an annual performance review with a member of the appraisal QA group.

6.12.2 Reviewing the performance of an appraiser

Based on review of documentation by a member of the QA group (acting as ‘QA Reviewer’):

Review of 3 anonymised appraisal portfolios using a standardised rating tool, with assessment of individual sections, overall standards and constructive comments linked to explicit, accepted standards;

Review of accumulated appraised doctor feedback from all appraisals carried out over the past year;

The appraiser’s reflective account of his or her own performance, development and learning needs.

NB. In addition to this documentation review, the appraiser and QA Reviewer will have a face-to-face meeting at least once every 3 years. A face-to-face review would also be necessary if the appraiser requests one or the QA Reviewer requests one, usually in light of any concerns arising from anonymised documentation, appraised doctor feedback, or the Annual Reflection form. Following the annual QA Review (including documentation review and interview if the latter has taken place), the summary sheet will be completed by both parties, giving an overall assessment of the appraiser’s performance over the previous year and identifying any development needs. Once agreed by both parties, the document will be submitted in confidence to the Appraisal Lead and the Workforce Systems Technical Facilitator. The appraiser is also to retain a copy.


6.12.3 Outcome of the annual appraiser review

Satisfactory – the appraiser may continue working, with a further review in 1 year;

Needs supervision and close follow up – this usually will apply to the next 2 appraisals. Draft summaries of these subsequent appraisals need to be shared with a QA member who will assess these to ensure that standards improve. Most of these appraisers are expected to proceed to approval for a further year; however, a few will need to proceed to ‘special review’.


6.13 Probationary review This will involve feedback from a QA group member to an appraiser by e-mail, telephone or meeting after their first 2 – 3 appraisals, looking at summary standards. It will also be the preferred option for supporting an appraiser returning to appraisal work after a break from appraising (e.g. maternity leave, prolonged sickness, or a break from appraising which does not coincide with a break in other clinical work). Each of these cases will be taken on merit after referral to the QA group. Appraisers who do not engage or respond to 3 invitations to have performance reviews will be in breach of contract and recommended for de-selection. In the unlikely event that appraisers who are de-selected would wish to re-apply to become appraisers they would need to apply for re-entry. 6.13.1 Special review

This will involve 2 members of the QA group, who will assess all output forms (for the whole of the last year and the most recent 2 – up to a maximum of 10. This would be undertaken for appraisers failing to demonstrate improvement following a period of supervision by a QA group member, or for an appraiser about whom serious performance concerns have arisen, e.g. through an appraise complaint, or concerns of appraiser underperformance from a member of the QA group about the appraiser either as a doctor or in the appraiser role. The outcome of this special review may be:

Recommend de-selection;

Further supervision of the next 3 appraisals, following which the appraiser will be reviewed by the Appraisal Group member, when a final decision will be made.

6.14 Confidentiality

Appraisal must be a confidential process between appraiser and the appraised doctor. National guidelines referred to in medical regulation publications stipulate that there would be an explicit link between successful participation in annual appraisal, relicensing and revalidation. There is now a shift in emphasis in appraisal, from a purely formative toward a summative process. This is linked to clinical governance and performance management. The result of this is that disclosure of the output form / MAG form and summary of discussions may be necessary in certain well-defined circumstances. Gateshead processes which link appraisal and clinical governance, particularly with regard to management of performance concerns, have been developed. The appraisal process serves a number of purposes, which influence the circumstances in which


appraisal documentation, may be viewed by individuals other the appraiser and the appraised doctor. Namely:

Providing an accurate record for those involved (appraiser and appraised doctor);

QA of an appraiser’s work;

Addressing concerns highlighted in the appraisal interview;

Capacity to highlight CPD concerns that may need to be addressed by the Trust as well as issues relating to facilities and support services etc, which need to be brought to the attention of the RO.

The Workforce Systems Techncial Facilitator will hold a summary of discussions in electronic format. The appraisal interview should not take place without the previous year’s documentation being available to the appraiser prior to the meeting. Documentation on the electronic system must be available automatically to the appraiser.

7. Training

Senior Medical Staff and Locally Employed Doctors will receive information about this policy when they commence employment, as part of their induction process. The HR Department is responsible for issuing briefings and communications to remind staff how they can access information about the policy. They are also responsible for providing support to managers and members of staff who have questions or concerns about all employment policies. Appraiser training and top-up training courses will be advertised and delivered on an ad-hoc basis as and when required on the intranet.

8. Diversity and Inclusion

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we treat members of staff and patients reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act). An Equality Analysis has been undertaken as part of the development of this policy.

9. Process for monitoring compliance with the policy

Standard / process / issue

Monitoring and audit

Method By Committee Frequency

Quality Assurance Audit and review of appraisal

Senior medical appraisers

Appraiser support / Quality Assurance Reference Group.

Quarterly


10. Consultation and review This policy has been reviewed in consultation with the LNC.

11. Implementation of policy (including raising awareness) This policy will be circulated by the Trust Secretary as detailed in OP27 Policy for the development, management and authorisation of policies.

12. References Advance Letter (MD) 6/00

GMC’s document “Good medical practice”

13. Associated Documentation

Information and published documents relating to revalidation and medical appraisal for Senior Medical Staff are available on the Trust intranet. This policy is to be read in connection with the relevant mini user guides on how to use the Appraisal Toolkit (Premier IT) for:

Appraisee (The Doctor)

Appraiser

Responsible Officer

The Trust remediation policy PP45.

http://www.gmc-uk.org/guidance/good_medical_practice.asp


Appendix A – Annual appraisal checklist Division: Directorate:

Doctor: (include GMC no)

Date:

Appraiser Venue:

Yes No N/A

Continuing Professional Development

Clinical

Academic (A) or Educational (Teaching) (E) Under Yes/no add A, E or both

Professional (including managerial)

Context:

Internal

External

Personal

Quality Improvement Activity

Clinical Audit

Review of Clinical Outcomes

Case review or discussion

Significant events and reflections

Clinical incidents, Significant Untoward Incidents (SUIs) NB. Summary of at least 2 clinical incidents per year or declaration OR self-declaration that you have not been involved in any events.

Feedback from colleagues

Feedback from patients

Feedback from clinical supervision, teaching and training

Complaints, compliments etc

Formal complaints NB. Self declaration if no formal complaints.

Summary of compliments

Other

Mandatory Training – to be completed on a yearly basis.

Medical Device Training - you must attain the necessary level of competency to use medical devices safely and effectively, prior to using them unsupervised.

Signed off probity self-declaration

Signed off health self declaration

Summary documentation

PDP

Job Plan – must be up-to-date at the point of appraisal and agreed with your line manager.

Tutor role – Post Grad (PG), Foundation (F), College (C) under Yes/No add PG, F or C or N/A

Private practice

The Nuffield, Newcastle

The Spire, Washington

Other i.e. sports clubs etc.


APPENDIX B – Evidence for an Educational / College role To be included under Supporting Information as evidence in your Premier IT appraisal toolkit portfolio:

1. How long have you been: Clinical supervisor Educational supervisor Other educational roles i.e. college tutor.

2. Please list the trainees you have supervised over the last 12 months:

Trainee initials

Grade FT/CT/ST

Role CS/ES

Dates From - To

Any Challenges / Issues / Reflections

3. Which of the following Education & Training activities are you involved with? Would you

like some further training in this activity?

Activity Brief description of your achievements this year. Any challenges/issues? Any supporting information submitted?

Further training? Yes / No

Teaching (informal and formal)

Work Based Assessments / Observation

Appraisal / Careers advice / Coaching

Organising / Managing training processes

Evaluation of education / training

Programme / Course review and development

Undergraduate Activity

Other Activity

4. What training in any aspects of education and training have you received in the previous 12

months?

5. PDP – please add this to your final PDP.


Appraisal for Educational / College Role Any clinician undergoing their NHS appraisal is encouraged to review their educational roles and include this in their overall documentation. Many will have more defined roles, however, and so will need to expand this part of the appraisal. GMC Definitions Clinical Supervisor: ‘A trainer who is selected and appropriately trained to be responsible for overseeing a specified trainee’s clinical work and providing constructive feedback during a training placement. Some training schemes appoint an educational supervisor for each placement. The roles of clinical and educational supervisor may be merged.’ Educational Supervisor: ‘A trainer who is selected and appropriately trained for the overall supervision and management of a specified trainee’s educational progress during a training placement or series of placements. The educational supervisor is responsible for the trainee’s educational agreement.’ Now that the GMC has taken over the regulation of training and education, we have much more explicit definitions of supervisory roles. Good appraisal of consultant trainer roles is part of the GMC requirements, but also allows us to maintain and further develop our skills within these areas. It is becoming increasingly apparent that, for medico-legal reasons, those of us involved in helping develop trainees need to have regular, demonstrable appraisal of our roles, resulting in professional development. How it fits into the NHS appraisal process Under the medical revalidation process, your appraisal must cover your Whole scope of practice. Personal Development Plan (PDP) Your educational role(s) is also to form part of you PDP. This will be shared with the clinical tutor for Medical Education. This will allows the Postgraduate Medical Education lead to provide the evidence required by the GMC and the Deanery via the PGME Annual report and also inform the Trust Training the Trainer programme (Scones & Roles), making it more relevant to trainers within the Trust. Attempts should be made to produce an educational PDP for each annual appraisal. This may be ongoing from the previous year, but should be SMART. If advice is required please contact the post graduate medical education team. Evidence that may be included in Consultant Trainers Appraisal Portfolio The following are examples of evidence which could be included in an individual’s appraisal portfolio to support their role as clinical/educational supervisor and /or tutor


Delivering Educational Role:

Description of role and trainees supervised;

Log of teaching sessions delivered;

Teaching feedback summaries;

Trainee feedback documentation: o Deanery visits GMC reports; o Speciality audit; o Trust audit.

Trainee ARCP outcomes / exam success;

Trainee logbook data;

Record of trainee / training problems encountered and resolved (with subsequent reflection);

Peer review (eg observed episode of giving trainee feedback);

Evidence from Trust Specialty/College Tutor and/or FP Tutor;

Evidence should also be recorded that time, recognition of role in job plan;

and supporting resources (eg PC & office space) are available to enable you

to deliver your educational role. Maintaining educational role:

Evidence of meeting Northern Deanery CS and ES knowledge & skills

requirements;

Other evidence of meeting GMC standards for trainers;

Training course attendance certificates;

Log of education related CPD;

Evidence of reflective practice. Relationship with trainees:

Example of educational meeting with trainee;

Description of your approach to giving feedback;

Trainee satisfaction surveys;

Trainee feedback from teaching;

Audit of training MSF;

Trainee thank you’s. Relationship with colleagues in education e.g. Trust College Tutor / FP Tutor / other educational & clinical supervisors:

A description of the team structure within which you deliver education;

Record of joint education / teaching sessions;

Record of relevant meeting attendance;

MSF;

Record of any formal peer review. Probity:

Evidence of equitable treatment of trainees, based on seniority, previous level of performance, flexible working and any disabilities.

K Brown Oct11 Developed from NW Deanery Documentation


Appendix C – Whole Scope of Work Form Your appraisal will need to cover the whole of your professional practice. If you practice in more than one organisation, you will need to describe the other work you do in your Supporting Information documentation) that covers your practice in each place of work. Forms are provided below for your completion and inclusion within your appraisal portfolio to ensure your whole scope of practice is captured. Part 1) Whole Work Declaration Form You are required to complete the attached declaration form to confirm you have sought and included supporting information that includes all areas of your professional practice. Part 2) Appraisal supporting information form For each area of professional practice outside your designated body you will need to ask for completion of a supporting information form. A template is provided below. Part 1) Whole WorkDeclaration Form

Name

GMC Number

Appraisal Date

Appraiser

Declarations I confirm that all my clinical activity in the independent sector and elsewhere, including the numbers and nature of any procedures/investigations performed, has been included as part of my appraisal. I confirm that I have performed only activities that are within my scope of practice as reviewed at my last appraisal. I confirm that I will perform techniques new to me only after appropriate training and governance approval.

Print Name

Signature

Date completed


Part 2) Appraisal supporting information form To be completed by doctor

Name

GMC Number

Designated Body

Appraisal Date

Appraiser

To be completed by organisation where additional professional activity is undertake. This Doctor undertakes clinical or other professional activity in our organisation. To assist their annual appraisal I should be grateful if you would complete the below template and return it to the doctor above, to be included within their appraisal portfolio.

Please confirm all aspects of practice the doctor undertakes within your organisation, and the frequency of such work

Scope of Work Frequency

Are there any limitations on the doctor’s practice?

Yes No

If yes, please give details (including is these limitations are voluntary or imposed)

Are there any specific training requirements for this post?

Yes No

If yes, what training and why?

Has this training been carried out?

If yes, what was the outcome?

If no, why not?

Does the Doctor require any regular updates in this area?

Yes No

If yes, why and what are they?


Are you aware of any complaints/compliments?

Yes No

If yes, what were they and in what context?

Have there been any clinical incidents or other significant events?

Yes No

If yes, what are they and what was the outcome, current status?

Have there been any concerns over probity?

Yes No

If yes, what were they and what was the outcome, current status?

Have there been any other concerns?

Yes No

If yes, what were they and what was the outcome, current status?

Print Name

Position

Organisation

Signature

Date completed


Appendix D – Supporting Information submission timeline


Appendix E – Application form for deferment of appraisal This application is for doctors who wish to postpone their appraisal in such a way that they will not have an appraisal during one appraisal year April to March.

Surname:

Forename:

Division:

Specialty:

GMC No:

Email:

Work: Contact numbers: Mobile: Home:

Please indicate the dates of your last 4 appraisals (month and year) and names of your appraisers:

Name of appraiser

Date of appraisal (month and year)

Please answer the questions below:

Please indicate why you wish to request a deferment of your appraisal and when you would next like to be appraised.


Do you anticipate having any breaks in practice in the next 2 years?

If you have missed any appraisals in the last 4 years please indicate the reason why.

Are you currently under investigation by the Trust, or GMC for any issue regarding your clinical performance?

Any further comments.

Please submit copies for the Output form for the last 4 appraisals carried out. Name: Date: Signature: Divisional Director’s Name: Date: Signature: By signing this form the Head of Service or Clinical Lead is supporting this application. Please return this form to: Workforce Systems Technical Facilitator


Appendix F – Appraiser annual reflection (To be completed by the appraiser and submitted to the local QA lead prior to the QA review meeting) Appraiser name…………………………………………Date..……………………………

Questions Response

How many appraisals have you done in this appraisal year?

How many could you do in the next year?

How long do you spend on appraisals?

Preparation: Interview: Writing up: Follow up:

What do you enjoy about the appraiser role? What has gone well? What are your strengths?

What improvements have you made over the last year?

What actions have you taken to address any difficulties identified before?

How many appraisal support group or skills update meetings have you attended? Please outline your main learning points and how and whether they have influenced your work as appraiser.

What areas have you found difficult in your work this year?


Have you appraised any Drs about whom you had performance concerns? How did you handle this?

Do you feel you would like to continue in your role as an appraiser next year?

If you intend to continue as an appraiser, do you feel you have any specific training needs?

Have you had difficulties with the administration of the appraisal system?

What additional support could the Trust offer you in your role as an appraiser?

Do you have any other comments or feedback?


Appendix G – Rating tool Appraiser name:_____________ Date:_____________ Reviewer:____________

Performance: 4 = Good 3 = Fair 2 = Needs improvement 1 = Raises concern

1. The form has factual statements with no subjective comment.

2. Statements are appropriate to the section of the Good Medical Practice Guidelines, summary of discussions.

3. There is a detailed description of what supporting information has been seen.

4. There is a description of what the supporting information actually shows.

5). Where supporting information is missing or poor, there are action points addressing this.

6. Progress is charted in relation to last year’s actions and PDP.

7. Actions are SMART.

Overall assessment of the Output form, summary of discussions (please select one)

Good Fair Needs improvement Raises concern


How to use the rating tool

The MAG form, summary of discussions should contain factual statements. There should be no subjective comments, which are difficult to corroborate. Sections must not be left blank, but it is acceptable to say “not applicable” for areas where there is no activity (e.g. management, research or teaching).

Statements should be appropriate to the section of the MAG form. Examples: Education described in GCC, PDP progress described mainly in MGMP, not GCC.

Supporting information: There needs to be a description of what supporting information has been seen. This can be done either by listing supporting information outside a commentary section or by denoting which documents have been seen within the section.

There needs to be a description of what the supporting information shows. For example, the statement: “Has achieved high CPD points in…” is ambivalent by itself, unless written as “CPD report submitted shows achievement of high CPD points”. Alternatively, the above statement may be complemented by a subsection, e.g. “Supporting information submitted in folder”.

Where supporting information is missing or poor, there should be action points addressing the correction of this. If supporting information quality is a concern, the appropriate actions listed should include the production of relevant supporting information for the next appraisal year. This applies only to sections where there is activity, i.e. where the commentary does not say “not applicable”.

Progress in relation to last year’s actions and PDP should be charted. Statements need to refer to last year’s actions and state to what extent they were achieved. If aims were not achieved, the reasons should be explored and it should be made clear if the item is being carried forward. The key is ensuring that the appraiser notices last year’s actions and whether they have been followed through. However, the Form 4 should not be marked down because of last year’s actions being unclear, absent or not carried through.

Actions must be SMART, with clear reasoning. Not all sections will need to have actions, so the entry “none” is acceptable. Where no activity has been undertaken, it is appropriate not to have any actions identified. Full marks should be awarded for all of these. “Continue” is not to be considered a SMART action.


Appendix H: Job Description for a Medical Appraiser Job Purpose The medical appraiser will carry out appraisals in line with the Revalidation and Senior Medical Staff appraisal policy (PP33). Accountability For appraisal purposes, the medical appraiser will be accountable to the Trust’s Responsible Officer. Key Areas of Responsibility The following core elements in relation to the medical appraiser role include:

1 Following attendance at the appropriate initial training, the medical appraiser will be reviewed following a probationary period on completion of their first three appraisals.

2 In normal circumstances, the medical appraiser will undertake a minimum of four and a maximum of 12 appraisals per year.

3 Undertake pre appraisal preparation in line with the appraiser training and current guidance.

4 Conduct the appraisal interview in line with core principles from the appraiser training and Gateshead Senior Medical Staff Appraisal Policy (PP33) This will include:

o agreeing an agenda with the doctor which should include an appropriate; balance of personal, professional and local objectives;

o building a positive working relationship with the doctor; o supporting the doctor in considering practice over the last year and agreeing

objectives and personal development plan with the doctor; o agreeing a summary of the appraisal meeting.

5 Complete post appraisal documentation in line with PP33 Policy.

6 Requirement to participate in on-going support and development to address development needs in the role of appraiser including any items identified in his/her own PDP.

7 Requirement to participate in performance review in the role of appraiser.

8 Requirement to participate in the management and administration of the appraisal system (including reporting the progress and completion of allocated appraisals).

9 Requirement to participate in arrangements for quality assurance of the appraisal system.

10 Requirement to participate in formal training and appraiser support groups.

11 Must comply with all aspects of the PP33 Policy and in particular the confidential nature of the appraisal process must be adhered to. Breaches of confidentiality will be dealt which under appropriate trust policies.

12 Comply with indemnity arrangements for appraisers as detailed in PP33 Policy.

13 Comply with other trust policies as outlined in PP33 Policy.


Communications and Working Relationships

1 Medical Director/Responsible Officer Deputy Medical Director Workforce Systems Technical Facilitator Divisional Directors Divisional Managers Heads of Service Postgraduate tutors Royal College advisers Other medical appraisers

Job Description Agreement Job Holder’s Signature Date RO/Deputy RO Signature Date


Person Specification

ESSENTIAL DESIRABLE

Qualifications Medical degree (plus any postgraduate qualification required). GMC License to Practise. Where appropriate, entry on GMC specialist register.

Completion of initial medical appraiser training prior to undertaking appraisals.

Experience Experience of managing time to ensure deadlines are met.

Involvement in medical education or training.

Experience of applying principles of adult education or quality improvement.

Knowledge The role of medical appraiser. The purpose and process of medical appraisal. The principles of revalidation/relicensing. The educational principles and techniques which are relevant to medical appraisal.

Responsibilities of doctors as set out in Good Medical Practice.

Principles of clinical governance, evidence based medicine and clinical effectiveness.

Knowledge of the health sector in which appraisal duties are to be performed. Knowledge of relevant local and national healthcare context. Knowledge of local professional development and education structures.

Understanding of principles of equality and diversity.

Understanding of principles of information governance. Understanding of legislation and guidance relating to data protection and confidentiality.

Knowledge of relevant Royal College speciality standards and CPD guidance.


ESSENTIAL DESIRABLE

Skills Objective evaluation skills.

Good oral communication skills - including active listening skills, the ability to understand and summarise a discussion, ask appropriate questions, provide constructive challenge and give effective feedback.

Knowledge of local professional development and educational structures.

Motivating, influencing and negotiating skills.

Understanding learning needs assessment.

Good written communication skills - including the ability to summarise clearly and accurately.

Adequate IT skills for the role - this will include familiarity with web-based appraisal support systems.

Attributes Excellent personal integrity, personal effectiveness and self-awareness. Ability to adapt behaviour to meet the needs of a doctor.

Commitment to ongoing personal education and development.

Good working relationships with professional colleagues and relevant stakeholders. Ability to work effectively in a team.

Personal Qualities

Motivated, enthusiastic, conscientious and a positive role model.

Enjoying respect of colleagues.

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