Version: / 1.0
Policy Lead: / Dr Michael Holland
Policy Category: / Clinical/Human Resources
Date issued:
Review date:
Ratified by: / Governance Executive
Date ratified:
Name of responsible committee:
Target audience: / Senior Doctors
Approved by ………………………………..Committee. / Date:
Ratified by the Governance Executive. / Date:
Equalities Impact Assessment / Assessor: Dr Michael Holland / Date:
Child Safeguarding Assessment / Assessor: / Date:
HRA Impact Assessment / Assessor: / Date:
Contents
Section / Page /1 / Introduction / 3
2 / Purpose of Policy / 3
3 / The Aims of Appraisal / 3
4 / Summary of the Development of the Policy including Consultation and Communication with Stakeholders / 4
5 / Roles and Responsibilities / 4
6 / Timing of Appraisals / 5
7 / Exceptions / 5
8 / Training Grade Doctors / 6
9 / Locums / 6
10 / When Must An Appraisal Meeting be Adjourned? / 6
11 / What is an unsatisfactory Appraisal? / 6
12 / Confidentiality / 6
13 / Complaints / 7
14 / Appraisal – The Link with Job Planning / 7
15 / Appraisal – The Link with Clinical Excellence Award Applications / 7
16 / Doctors in Difficulties / 7
17 / Doctors Involved in Disciplinary Procedures / 7
18 / The Future / 8
19 / The Appraiser Team / 8
20 / Revalidation: A 5-yearly Exercise / 9
21 / Quality Assurance for Appraisals and Revalidation / 9
22 / Procedure to be followed for Doctors who have not completed an annual Appraisal / 10
Policy Standards / 11
Implementation and monitoring compliance
Associated Documentation / 12
References / 33
Appendices
Appendix A / Equality Impact Assessment
Appendix B / Version Control Sheet
Appendix C / Plan for Dissemination of Procedural Documents Policy
1 Introduction
All doctors must undertake an annual appraisal in order to demonstrate and record that they comply with good medical practice as recommended by the General Medical Council. The process and content of this appraisal is being strengthened in order to meet the higher quality that will be required for revalidation. This policy focuses principally on Consultant and non-Consultant grade doctors’ appraisal. Medical Appraisal and Revalidation are Contractual requirements for medical staff.
2 Purpose of Policy
The Appraisal and revalidation systems are supportive mechanisms focused on enhancing local systems of quality improvement, they are also designed to assist in the identification of performance issues so they can be dealt with at an early stage. The Appraiser will review various sources of information with the doctor to gain a rounded impression of that doctor’s practice and inform a mutually agreed professional development plan. Appraisal will identify doctors who are struggling to provide the supporting information that is needed to demonstrate achievement of generic and specialist standards. It will assist those doctors in identifying support and developmental needs at an early stage, before there is any question of concerns about patient safety. The Medical Director, as Responsible Officer, is personally accountable to the Trust Board for ensuring that all Senior Medical staff are appraised and any follow up action taken.
3 The Aims of Appraisal
· Set out personal and professional development needs and agree plans for these to be met
· Regularly review a doctor's work and performance, utilising relevant and appropriate comparative operational data from local, regional and national sources
· Consider the doctor’s contribution to the quality and improvement of services and priorities delivered locally
· Optimise the use of skills and resources in seeking to achieve the delivery of general and personal medical services
· Identify the need for adequate resources to enable any service objectives in the agreed job plan review to be met
· Provide an opportunity for doctors to discuss and seek support for their participation in activities for the wider NHS
· Utilise the annual appraisal process and associated documentation to meet the requirements for GMC revalidation against the nine headings of ‘Good Medical Practice’.
4 Summary of the Development of the Policy including Consultation and Communication with Stakeholders
The policy was developed by the Trust Clinical Directors’ meeting through which it was consulted and communicated to all senior doctors across the organisation.
5 Roles and responsibilities
5.1 Chief Executive - is accountable to the Board of South London and Maudsley NHS Foundation Trust for ensuring the resources and systems are in place for robust medical appraisal for employed / contracted doctors. S/he is accountable for ensuring that appraisal and clinical governance systems are integrated and co-ordinated at both strategic and operational level. The Chief Executive will ensure that indemnity is provided for appraisers in South London and Maudsley NHS Foundation Trust.
5.2 Medical Director/Responsible Officer - is accountable to the Chief Executive and the Board of South London and Maudsley NHS Foundation Trust for implementing and managing the appraisal process including appraisal outcomes. The Medical Director (or his nominee) will receive, review, act upon appropriately and securely store all form 4s and PDPs. S/he will also be responsible for preparing an annual report on appraisal for the Quality / Risk Management / Clinical Governance Committee and the Board of Directors and for any actions arising from this. S/he will ensure that appraisers are properly recruited, trained and regularly assessed to carry out their role. S/he will ensure that all necessary administrative and managerial systems are in place to manage the appraisal system effectively.
5.3 Clinical Director - is responsible for carrying out appraisals or identifying appraisers in their service area and ensuring that appraisals are carried out in line with South London and Maudsley NHS Foundation Trust policy. S/he will have overall responsibility for appointing appraisers (see Appendix 1 for job description and application forms). In conjunction with the general managers / service managers s/he will support the provision of data collection, complaints, SUIs and other essential organisational information to the doctor to enable the doctor to provide appropriate evidence for their appraisal and will contribute to the job-planning meeting. S/he will also be responsible for making decisions on appraiser allocation if there is any perceived or actual conflict of interest between an appraisee and an appraiser. S/he will also be responsible with the academic department for arranging joint appraisals where this is appropriate e.g. doctors with mixed academic / service roles.
S/he will also notify the Medical Director of any doctors who have not completed the appraisal process in line with South London and Maudsley NHS Foundation Trust policy.
5.4 Appraiser - is responsible to the clinical director for carrying out appraisals to the standards laid out in this policy.
Appraisers will receive formal training, have a job description and fulfil the criteria set out in the person specification (Appendix 1). The Clinical Directors will confirm the support for doctors who apply to be appraisers within their area. All appraisers are required to have formal training in Equality and Diversity issues as specified in South London and Maudsley NHS Foundation Trust’s Equality and Diversity Policy.
Appraisers will assess the portfolio of supporting information provided by the appraisee against the attributes in Good Medical Practice and the current speciality standards set by the Royal College of Psychiatry, with a view to identifying weaknesses and gaps so that these can be addressed in the appraisee’s PDP. A review of the previous year’s PDP will also take place and where this has not been completed satisfactorily the reasons for this are understood.
Appraisers will receive annual feedback and review of their performance using appraisee survey forms (Appendix 2) and a review of a sample of form 4 / PDPs that they have signed off. They will require ongoing training and their development needs will be identified in their own PDPs.
The appraiser is responsible for ensuring that a signed off electronic version of form 4 and the personal development plan is received by the Medical Director’s Office.
5.5 Appraisee – is responsible for collating and preparing supporting information for the appraisal meeting. The portfolio must show evidence of appropriate personal reflection by the doctor. The GMC has consulted recently on the proposed new framework for revalidation which contains details of a revised set of attributes and domains based on ‘Good Medical Practice’ with accompanying college specific requirements for supporting information (see ‘Good Psychiatric Practice’, Royal College of Psychiatrists). Consultants are encouraged to familiarise themselves with the content and nature of the proposed specialist standards (see Appendix 6 for College Framework for Revalidation) in collating their appraisal portfolio prior to revalidation being introduced (Appendix 7 Appraisal Checklist).
The portfolio of supporting information provided by a doctor should reflect the breadth of all of the doctor’s professional practice – including indirect patient care activities such as clinical audit, management and advisory roles across all healthcare organisations (including private practice). The appraisee is responsible for submitting their portfolio/electronic access to their appraiser two weeks prior to the appraisal.
The appraisee is responsible for raising any concerns about the appraisal process in accordance with this policy. S/he is also responsible for completing the appraisee survey form (Appendix 2) as feedback at the end of the appraisal process.
The appraisee is also responsible for agreeing a date for the appraisal meeting with the appraiser. If an appraiser wishes to use an appraiser that is external to the Trust then this must be agreed in advance with the relevant clinical director. In addition in this circumstance it is the appraisee’s responsibility to inform the appraiser that by undertaking the appraisal the appraiser is agreeing to comply with this policy and to work within the standards set for appraisers including participation in the quality assurance programme.
6 Timing of Appraisals
All Consultants and non-Consultant grade doctors employed by the hospital are expected to undertake their annual appraisal in the 1st quarter each year. See Appendix 3 and 4 for details of Appraisal process.
7 Exceptions
These are only acceptable for Consultants and non-Consultant grades new to the Trust and have only been employed by SLaM for less than 9 months or for those on long-term leave or sabbatical for over 3 months of the appraisal year. For these groups, appraisal may be deferred to the following year at the latest in agreement with their Clinical Director.
8 Locums
Locums who work at the Trust for more than six months should have a formal appraisal before they leave. Locums who work at the Trust for shorter periods should have a brief exit appraisal (see Appendix 8 for exit form). This should facilitate such doctors to maintain high standards of medical care and to prepare for revalidation.
9 Training grade doctors,
The annual review of training constitutes their appraisal and the timing of this varies by specialty and grade.
10 When Must an Appraisal Meeting be adjourned?
Where it becomes apparent during the appraisal process that there is a potentially serious performance, health or conduct issue (not previously identified) that requires further discussion or investigation, the appraisal meeting must be stopped. The matter must be referred by the appraiser immediately to the Medical Director to take appropriate action. Maintaining High Professional Standards in the Modern NHS policy may need to be followed.
11 What is an unsatisfactory appraisal?
Guidance is given in the above policy on what is considered to be essential and optional documentation that should be detailed in the portfolio (see Appendices 5, 6 and 7).
If any part of the essential documentation is not identified in a portfolio (unless a satisfactory explanation can be offered by the appraisee) then this must be brought to the attention of the appraisee prior to the appraisal meeting as indicated in Appendix 4 (the Appraisal Process). This should provide an opportunity for the appraisee to produce the relevant piece of information. If the information is not forthcoming and there is no satisfactory explanation offered then the appraisal meeting should not go ahead and the Medical Director should be informed.
An unsatisfactory outcome of appraisal may also arise from:
· failure to address issues that have been previously raised about clinical performance or personal behaviour
· the appraiser’s judgement that there is inadequate evidence in any section of the appraisal documentation.
· failure to complete the previous years PDP without adequate explanation.
Part of the developmental approach to appraisal should be in supporting the appraisee in improving the quality of evidence year on year in the appraisal portfolio. It is only when there has been a clear failure to respond to actions outlined in previous Form 4s that the appraisal could be considered as being unsatisfactory. If the issues cannot be resolved with the appraisee then the matter should be referred to the Medical Director.
12 Confidentiality
· The detailed discussions that take place during an appraisal are confidential to the appraiser and appraisee. However, if something emerges during this discussion that has a significant potential effect on patients’ safety (for an example, an appraisee reveals that they are dependent on recreational drugs), then the appraiser is obliged to share this information with the Medical Director under the principles of Maintaining Medical Excellence.
· Prior to an electronic appraisal system being put in place Form 4 should be copied to the Medical Director. The contents of Form 4 may be shared with the Chief Executive and the relevant Clinical Director.
· The consultant appraisee is responsible for keeping their original appraisal documentation for five years (until used for revalidation). Any information shared with the Medical Director or other trust managers must be kept securely in line with the trust’s policy on data protection.
· In the future, in terms of preparing for revalidation and for purposes of assurance, appraisees may be required to show the Medical Director/Responsible Officer the contents of Form 3, including supporting documentation to enable the responsible officer to make an evidence-based decision regarding the recommendation for revalidation.