Quality Framework

Table of Contents:
Introduction
Section One: Standard Quality Processes
Section Two: Response to Concerns
Appendices (Terms of Reference, Quality Matrices and Template Report)

Introduction

Purpose

The purpose of Health Education England (HEE) working across the South West, Quality Management is to gather, analyse and actively use information to ensure that the environment, governance, support and curricula of doctors in training is being delivered to the standards set out by the regulator, the General Medical Council (GMC) and Health Education England. The Quality team, at both the Severn and Peninsula sites, act on behalf of the Postgraduate Dean as the link to the GMC, which quality assures all medical education and training activities.

A robust quality management system aims to support the training of highly competent doctors in order to benefit patients both now and in the future. Patient safety has the highest priority when considering all aspects of education and training.

HEE is formally reviewed and quality assured by the GMC, which conducts scheduled visits and scrutinises quality management data.

The Quality function also reports to HEE regionally and nationally and to the Performance Directorate and is multi-professional in focus.

Please note that as nomenclature has changed to reflect the HEE framework, sometimes both old and new terminology has been reflected in this document for clarity to stakeholders.

Scope

The HEE geographical scope is across Cornwall, Devon, Somerset, Wiltshire, Bristol and Gloucestershire and includes all GMC approved training posts whether they are in Foundation, Core, Specialty or General Practice.

HEE responsibilities are articulated in The Trainee Doctor GMC publication.

There are a total of 21 Local Education Providers (LEPs) across the acute and mental health areas and 110 programmes. HEE is required to quality manage all LEPs and programmes that are hosted within this area.

Stakeholders

The success of the Quality function is dependent upon excellent working relationships with stakeholders, including medical Royal Colleges, Schools and the LEPs across the South West. Education and Training is delivered by LEPs who are responsible for quality control.

HEE has a responsibility and requirement to utilise expert (Royal College or Faculty) and lay externality when appropriate to support its processes. This also forms part of its governance mechanisms. It provides public input to the process and ensured consistency of approach across the UK.

The Framework

This framework provides the process and structure of quality activities for primarily PGME across HEE but is evolving to reflect the multiprofessional learner remit. It replaces the previous frameworks used by Severn and South West Peninsula.

All medical training and education providers within the South West are signatories of the HEE Learning and Development Agreement (LDA); this legally binding contract sets out the expectations for all education and training providers, and the minimum requirements that must be delivered to trainees. There is overlap between the Quality Framework and the LDA, but both processes complement one another to ensure that all LEPs continue to provide high quality education and training to all doctors in training within HEE.

Where overlap and joint working opportunities exist to the benefit of HEE the Quality Team aims to link with non-medical colleagues and workstreams.

Activities

The HEE Quality team utilise a number of mechanisms to ensure the highest quality of education and training is delivered.

There is a scheduled cyclical review of all activity (Standard Processes) supported by a proactive structure for risk (Response to Concerns). Numerous sources of information are triangulated to drive these processes including the GMC National Training Survey (NTS), Visit reports, Programme Review/Specialty review (Quality Panel) reports, end of placement (EoP) surveys, Annual Review of Competence Progression (ARCP) outcomes and feedback from other organisations and individuals.

HEE working across the South West will also identify examples of good practice and disseminate these locally and nationally, as appropriate.

Staff

Staff members include:

  • Associate Dean for Quality (Peninsula)
  • Associate Dean for Quality (Severn)
  • Quality Manager (Peninsula)
  • Quality Manager (Severn)
  • IT Information Analyst (Peninsula)
  • Quality Data Specialist (Severn)
  • Practice Placement Quality Lead
  • Quality and Information Co-ordinator (Peninsula)
  • Quality Support Manager (Severn)

Principles

Overriding principles include:

  • To promote excellence.
  • To support individuals and organisations to promote the best possible educational standards.
  • To have systems and processes that are cost-effective, fair and transparent.
  • To work in partnership with others, to ensure that best practice is implemented.
  • To continually assess the effectiveness of activities.
  • To ensure patient safety is paramount.

Back to: Top


Section one: Standard Quality Processes

Standard Process: Timeline (diagram 1) / Reports Required (table 1)
Quality Advisory Board
Quality Surveillance Groups
Annual Senior Leader Visit/Multi-Professional Review  (Contract Meetings)
Interim Senior Leader Visit/Multi-Professional Review (Contract Meetings)
Reporting from the Annual and Interim Senior Leader Visit/Multi-Professional Review (Contract Meetings)
GMC National Training Survey
Quality Register
Programme/Specialty Reviews (Quality Panels)
End of Post Surveys
Good Practice
Educational and Clinical Supervisor Accreditation
Equality and Diversity
Trainee Support
Externality/Lay Representation

 

 

Standard Process Timeline

Diagram 1

PGME Quality Timeline - Standard Processes

QF Diagram 1 7.4.16

 

The Quality function runs standard monitoring processes throughout the year which are illustrated in Diagram 1 above.

Back to: Section One / Top 

Not all standard processes are mandatory and further clarity is therefore provided below in Table 1:

Table 1: Standard Quality Processes

  Report required:
Quality Surveillance Group (QSG) Mandatory
Reporting to Governing Body Mandatory
Reporting on ARCP results Mandatory
End of Post (EoP) surveys Optional
Senior Leader Visit/Multi-Professional Review (Contract Meetings) Mandatory
Programme/Specialty Reviews (Quality Panels) Mandatory
GMC National Training Survey (NTS) Mandatory
Good Practice Reports Mandatory
School Visits Optional

  Back to: Section One / Top

Quality Advisory Board

Purpose

The purpose of the Quality Advisory Board (QAB) is to provide advice, feedback and comment to the multi-professional Quality Team on quality management processes and decision making within the Severn and Peninsula footprints of HEE.

Core functions are to:

  • review the quality team’s actions against the GMC’s requirement as regulator.
  • review quality issues arising within education, with a focus on issues of contention or significant risk.
  • comment and advise on response to concerns and risks on the Quality Register and to review the effectiveness of the interventions.
  • provide externality, achieved by including representatives at the Board who are either outside the quality team or HEE.

The Board will review a variety of sources of data and information including:

  • Significant outcomes of LEP Senior Leader Visit/Multi-professional Review (Contract meetings)
  • GMC National Training Survey results
  • Status of supervisor training and accreditation
  • Results from the GMC ARCP reports
  • The annual GMC Dean’s Report
  • Programme/Specialty Review (Quality Panel) outcomes
  • Urgent concern review (Level 3 and 4)
  • Red* and Red risks on the Quality Register

Organisation

Board decisions will be minuted and the minutes circulated to stakeholders. They will be publically available on the PGME website.

The QAB will be convened every six months and will function according to the agreed Terms of Reference, included within this document as Appendix 1.

Members

Members of the QAB include:

  • Associate Deans for Quality in Severn and Peninsula (alternating Chair)
  • The Director of Education and Quality, South
  • Postgraduate Dean, HEE working across the South West
  • A Director of Medical Education from Severn and Peninsula
  • An Associate Postgraduate Dean representing Primary Care from Severn and Peninsula
  • A Head of School from Severn and Peninsula
  • A Foundation Programme Director from Severn and Peninsula
  • Quality Managers at Severn and Peninsula
  • Quality Data Specialist, Severn
  • Quality and Information Co-ordinator, Peninsula
  • A Lay advisor
  • A Trainee Representative from Severn and Peninsula
  • Healthcare Dean, SW LETB
  • Undergraduate representatives from Bristol, Exeter and Plymouth Universities
  • Medical Education Manager from Severn and Peninsula

To attend as needed:

  • Deputy Postgraduate Dean from Severn and Peninsula

Minute taking will be alternated between the Quality Support Manager (Severn) and Quality and Information Co-ordinator (Peninsula).

Back to: Section One / Top

Quality Surveillance Groups

Quality Surveillance Group (QSG) meetings bring together regional intelligence to safeguard the quality of care for patients. There are two QSGs in the Severn area, 1 QSG in Peninsula. This may be subject to change and HEE will respond accordingly to ensure information sharing.

Significant concerns are raised and discussed in this forum.

The reporting format for the QSGs is determined by the QSG groups and the Quality Management function is responsive to their requirements.

Information which is sent to QSGs by Severn and Peninsula is communicated to the respective Quality Manager counterpart for information.

Information obtained by the HEE attendee is shared with the Quality Team within five working days.

Updates are to be provided at the Quality Board.

Back to: Section One / Top

Annual Senior Leader Visit/Multi-Professional Review (Contract Meetings)

HEE must provide reassurances to the regulator of medical education and training, the GMC, that postgraduate medical education and training across the South West is being provided in accordance with the standards published within ‘The Trainee Doctor’ (GMC, 2011).

To ensure that the GMC’s standards and requirements are being met and to promote quality improvement within the LEPs and training programmes, HEE undertakes Annual Senior Leader Visit/Multi-Professional Review (Contract Meetings) with each LEP. This assures HEE that education and training is on the LEP Board Agenda.

Annual Senior Leader Visit/Multi-Professional Review (Contract Meetings) are a mandatory requirement. Interim Senior Leader Visit/Multi-Professional Review (Contract Meetings) are encouraged but not compulsory.

In order to facilitate discussion, HEE will utilise the relevant Quality Register which contains areas of good practice and areas of development. The results of the GMC NTS will form a significant part of the Quality Register and each meeting agenda. Other items included in the Quality Register and meeting agenda will be identified from sources such as:

  • ARCP data
  • End of Post surveys
  • LEP Quality Management visits
  • Triggered School Visits
  • Information from Programme/Specialty Review (Quality Panel) reports
  • Good Practice items from Dean’s Report
  • Any other evidence that is brought to the attention of HEE.

Information and actions culminating from the Annual Senior Leader Visit/Multi-Professional Review (Contract Meetings) will update the LEP action plan and HEE Quality Register.

Information held on HEE systems and discussed at Senior Leader Visit/Multi-Professional Review (Contract Meetings) might be disclosed to the regional QSG and/or discussed at bi-annual QAB meetings if it is appropriate to do so.

The Annual Senior Leader Visit/Multi-Professional Review (Contract Meetings) dates will be agreed six months in advance where possible.

Annual Senior Leader Visit/Multi-Professional Review (Contract Meetings) will take place from November to March each year.

The purpose of this meeting is to engage directly with the Board of the LEP to discuss specific areas of concern and good practice.

The Quality Team will provide an agenda for the meeting to the LEP no less than ten working days prior to the meeting taking place, thus ensuring the meeting focuses on key areas of concern / development and key areas of good practice.

Attendees at the Annual Senior Leader Visit/Multi-Professional Review (Contract Meeting) representing the LEP should include:

  • Medical Director
  • Director of Medical Education
  • Medical Education Manager (optional)
  • Chief Executive

It is essential that at least one Trust Board executive member is present.

The following HEE personnel should attend the Annual Senior Leader Visit/Multi-Professional Review (Contract Meetings):

  • Associate Dean for Quality
  • At least one other Executive Member of Postgraduate Medical Education
  • Quality Manager
  • Quality & Information Co-ordinator/Quality Data Specialist

Back to: Section One / Top

Interim Senior Leader Visit/Multi-Professional Review (Contract Meetings)

Interim Meeting dates will be agreed six months in advance where possible.

Interim Meetings can be face to face or via telephone. Meetings will normally occur in the 2 months after the release of the GMC NTS results.

The purpose of the meeting is to discuss the current LEP Quality Register, ensuring that the required progress is being made and to identify issues that are delaying progress.

At this meeting additional items that are considered to be of significant concern but were not previously known to either party, can be added to the Quality Register.

The primary evidence for this meeting will be the LEPs Quality Register and the results of the GMC NTS.

The Quality Team will provide an updated Quality Register to the LEP no less than ten working days prior to the Interim Meeting being undertaken. In addition an agenda for the meeting will be sent to the LEP no less than five working days prior to the meeting taking place, thus ensuring focus on key areas of concern / development and key areas of good practice.

The following persons should attend the Interim Meeting and represent the LEP:

  • Director of Medical Education
  • Medical Education Manager (optional)

The following HEE persons should attend the Interim Meeting:

  • Associate Dean for Quality

Optional attendees from HEE include:

  • Quality Manager
  • Quality & Information Co-ordinator/Quality Data Specialist

Back to: Section One / Top

Reporting from the Annual and Interim Senior Leader Visit/Multi-Professional Review (Contract Meetings)

HEE will take notes at each Annual Meeting and circulate to the LEP within ten working days of the meeting taking place. Notes of Interim Meetings may be taken for HEE internal purposes only.

The respective Quality Team will aim to provide a revised Quality Register within twenty working days of the meetings taking place, taking into account any additional evidence and outcomes from the meetings.

The LEP has ten working days from receipt of the Quality Register to respond to any of the revised areas.

The information contained within the Quality Register will form part of HEE working across the South West's Dean’s Report to the GMC.

Back to: Section One / Top

GMC National Training Survey

The GMC runs annual, mandatory training surveys known as the GMC National Training Survey (NTS) which is normally open for completion between March and May.

HEE aims to maximise trainee response rates through sharing best practice activities, using motivational methods and reinforcing strong engagement with Trusts and Schools. Completion of the NTS is not linked to ARCP outcomes.

Whilst the survey is open and following the closing date, patient safety and undermining concerns are managed locally by the relevant quality function. Progress towards resolution is monitored through the Quality Register.

Following the survey closure date the Quality Team completes analysis of data and produces:

  • a joint Executive Summary (Severn and Peninsula) and
  • a standard Excel report for each Trust and Programme.

The above reports are made available via the HEE website as well as being circulated by email to key stakeholders.

It is the responsibility of the Quality Team to update the local Quality Register with the relevant NTS results in line with the agreed thresholds for reporting. Please also see above section on ‘Quality Register’

Relevant outcomes of the NTS are shared and discussed as necessary at the Quality Advisory Board.

Back to: Section One / Top

Quality Register

The Quality Register is the central database used by the Quality Team for recording quality management issues in HEE, both risks and good practice.

The Quality Register is used as the repository for all information for reporting to the GMC in the Dean’s Report. It is a live database that is continually updated by the Quality Team.

The Quality Team shares appropriate sections of the Quality Register with HoS/DMEs (and TPDs as required) for action/comment at least twice a year.

Good practice information can be added to the Quality Register at any time but is submitted to the GMC upon their request. LEPs, Schools and trainees are encouraged to submit Good Practice examples via the Quality Team at any time. In addition the Quality Team will prompt submission of Good Practice items normally around the time of the annual Dean’s Report submission (also see Good Practice section below).

As stated above, the Quality Register is a live document and is continually kept up-to-date with input from Programme/Specialty reviews (Quality Panels), Quality Management LEP Senior Leader Visit/Multi-Professional Review (Contract Meetings), GMC NTS results, ARCP results, Response to concerns and any other triangulated information. All action planning is noted and monitored on the Quality Register.

Issues from the Quality Register are discussed at the Quality Advisory Board as appropriate.

Back to: Section One / Top

Progamme/Specialty Reviews (Quality Panels)

Background

The Quality Assurance of Postgraduate Medical training requires the review of multiple sources of information in order to establish that training sites and programmes meet the standards set out by the GMC in Good Medical Practice (2013) and the Trainee Doctor (2011):

Quality Panel assessments of training programmes are one such source of evidence which can be used to review an educational programme in its entirety, thus allowing generic programme wide issues and challenges to be reviewed and addressed.

Process

The Quality Team supports a mandatory annual School assessment of all training programmes.

Programme/Specialty Reviews (Quality Panels) should be run by all schools with oversight by the HoS with a standardised report being provided to the Quality Team.

The reviews will run from July to December so that the current years GMC NTS results can be used to inform the process.

A Programme/Specialty Review (Quality Panel) has the remit to evaluate all the composite posts within the programme. The mandate is to produce an outcome for each post. Comments must be restricted to posts and not post holders.

There is acknowledgement that the programmes for which Programme/Specialty Review (Quality Panel) should run vary in their post composition, locality over which they run and specialty requirements that they should consider. The composition of the panel and its discussions should reflect this. The data considered and outcome of reviews must have consistency across HEE working across the South West for our quality processes to be robust and credible.

 

Programme/Specialty Review (Quality Panel) formation

The review will be chaired by the Training Programme Director (TPD) or equivalent e.g. specialty tutor. There will be Lay Representation on most reviews; this will depend upon availability and resource and Lay Representation will be audited by the Quality Team. Also see TPD Information Sheet (Severn / Peninsula) and Lay Representation Information Sheet (Severn / Peninsula)

The specialty will decide the number and roles of other review members. There must be a trainee representation and the number of trainees on the review must exceed the number of other review members including the Chair. Exceptions to this may occur in small specialities where this composition is impossible.

The trainee representatives should be allocated specific posts within the programme for them to report upon using the Quality Matrix (Appendix 2). This must be clear to the trainee at the time they are recruited to the review. Please also see Trainee Information Sheet

It is anticipated that the other non-trainee representatives will be a selection of accredited Educational Supervisors from the programme being evaluated.

External representation will occur at either the request of the review Chair or the Quality Team. A Head of School, Associate Dean or Quality Team member may attend the review at the request of the review members or in a quality assurance capacity.

 

Evidence to be reviewed by Programme/Specialty Review (Quality Panel)

The Review Chair and members can consider any information that they deem pertinent to inform their discussion. They must as a minimum consider the following information.

  • That calendar year’s GMC National Training Survey data
  • Reports from previous year’s review(s) and/or LEP school visit(s)
  • Reports from Response to Concern (Triggered) visit(s) if applicable
  • Summary ARCP data for previous 12 months
  • Supervisor (Trainer) accreditation data
  • Quality Data Grade, attributed by Quality Team and SWE and EEE Scores, attributed by trainees (see above information sheets)
  • Recruitment figures for Programme

The review must not discuss the individual performance of named trainees.

Reporting

Each Programme/Specialty Review (Quality Panel) will produce a report in a structured format (Appendix 4). There is no requirement to document the detailed discussion that has led to the review’s decision on each post.

Each post (or grouping where appropriate) will be considered from the perspective of providing a ‘Safe Working Environment (SWE)’ and ‘Effective Educational Environment’(EEE). In each of these two domains the posts will be graded by trainee representatives as Excellent, Good, Requires Improvement or Inadequate. The Quality Matrix template for this, to ensure consistency across programmes and specialties is in Appendix 2.

A third score will be available to the Programme/Specialty Review (Quality Panel) that represents data that the quality team (Quality Data Grade) has received from other sources such as the GMC NTS, intelligence from other reviews, etc. This will be in the same format of Excellent, Good, Requires Improvement, Inadequate.

In order to generate an outcome for the post the Programme/Specialty Review (Quality Panel) should note all three scores and generate an overall score for the post.

The report must state clearly the action that is required for the post graded to move to the next level i.e. Inadequate to Requires Improvement, Requires Improvement to Good and Good to Excellent. This should raise the quality of training and ensures we are aspiring to excellence.

When considering all three contributing grades from ‘Safe Working Environment’, ‘Effective Educational Environment’ and additional quality data, there are 3 possible combinations:

  • All three are the same grade in which case this becomes the overall grade
  • There are two of one grade and one of another, the majority grade becomes the overall score
  • Each of the three grades are different in which case the middle grade become the overall rating

On rare occasions one issue may stand out as a problem in a post with otherwise good scores. It is important to capture the problem in the report and so it is proposed to include an Anomaly Score on the report, e.g. a post may generate a ‘Good’ but trainees have no dedicated teaching in which case the report would record the score overall as ‘Good’ but ‘Requires Improvement’ for teaching.

The scores should be completed before and the given score discussed at the review. It is not intended that each post is meticulously scored at the review itself.

The report, when agreed by the review, will be sent to the Education Leads of the posts cited in the report for comment and response. The Chair of the review will respond to any feedback and decide whether this alters the outcome the review made, before forwarding a final Programme/Specialty Review (Quality Panel) Report to the Head of School and Quality Team.

The Quality Team will keep a register of the grading of each of the posts and determine how those posts rated as Requiring Improvement or Inadequate are dealt with in the context of the Quality Register and Dean’s Report to the GMC.

Outcome of Programme/Specialty Review (Quality Panel) Report

The report will be submitted to the Head of School and Quality Team for approval and clarification (if required).

Once the report is approved it will inform the Quality Register. Those items which meet the thresholds contained within the Quality Framework will be submitted to the GMC via the annual Dean’s Report.

The report will also be distributed to the Education Providers hosting the posts via the relevant Director of Medical Education (DME). It is expected that the DME will distribute the information to the departments that host the posts.

Posts that are graded as Inadequate may be subject to enhanced management. Those posts graded as Outstanding may be included in the HEE postgraduate medicine good practice report.

The reports will be published on the relevant HEE working across the South West's website in the Quality Management section.

Back to: Section One / Top

End of Post Surveys

As part of the continual performance monitoring of training posts learners may be required to complete a questionnaire towards the end of each post providing detailed feedback on the training received. Surveys may be run at School level or by the Quality Team.

End of Post Surveys are an optional rather than mandatory quality process. Schools may use surveys if they feel it will enhance local quality management of programmes.

The Quality Team can advise on questionnaire format as necessary and can provide access to an appropriate online survey system.

Results of any surveys conducted should be shared with the relevant TPD, Head of School, School Manager and Quality Team.

Results where fewer than 3 responses are received will not be made available, except in circumstances where patient care or patient, trainee or trainer safety is potentially or actually being compromised.

Where a trainee indicates concerns with patient care / safety within a specific provider or placement, the results may require further investigation and the anonymity of the trainee may be disclosed to facilitate this. This will only be done with the trainee's knowledge.

In the event of a serious patient safety or bullying concern being raised, the relevant HoS and DME should be contacted by the Quality Manager and asked to take appropriate action. Such issues will be added to the Quality Register, as appropriate.

Back to: Section One / Top

Good Practice

The Quality team emphasises the importance of Good Practice examples and uses all triple green flags on the GMC NTS for this purpose as well as encouraging all programmes, Schools and Trusts to report excellence to the Quality function for inclusion on the GMC Dean’s Report and HEE working across the South West's website.

Good Practice case studies are available on the Quality Team website along with the GMC template for Good Practice examples.

Also see the Quality Register section above.

Back to: Section One / Top

Educational and Clinical Supervisor Accreditation

Ensuring our trainers (Faculty) are trained and able to undertake their role is of high priority to us as an organisation and for the GMC as the regulator.

We aim to ensure our policies relating to educational and clinical supervisor accreditation are consistent with the GMC document ‘Recognition and Approval of Trainers 2012’.

Definitions

An educational supervisor is a trainer who is selected and appropriately trained to be responsible for the overall supervision and management of a specified trainee’s educational progress during a training placement or series of placements.

A clinical supervisor is 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 (The Trainee Doctor GMC Feb 2011). * HEE adds to this that a trainee can only have one Clinical Supervisor at one point in time; this is the individual responsible for writing a formal report of the trainees progress. Many other clinicians will supervise clinical work.

Approval

A supervisor must engage in and complete training defined in the Faculty section of the PGME website. Their position as supervisor must be accepted by the local education provider (LEP) and the school of the trainee they are supervising is enrolled with. The Director of Medical Education (DME) will agree on behalf of the LEP. The Training Programme Director (TPD) will agree on behalf of the school.

The supervisor must be a Consultant or SAS doctor with a permanent contract with an LEP within the geographical footprint of HEE.

Training

All supervisors must be trained. The training requirements will be explicit within the Faculty section of the PGME website. The training will be linked to the Academy of Medical Educators Framework and be consistent with the standards contained with the GMC document ‘The Trainee Doctor’.

The content of training will change in response to feedback from supervisors, new developments in the provision of training and guidance issued from the regulator, the GMC.

Selection

A supervisor will be selected by the LEP and TPD. They must agree to undertake the conditions of approval of supervisors.

Registration

An approved supervisor will be registered with HEE. The supervisor will be registered on the approved database, currently Intrepid. The LEP will be responsible for ensuring that the approved supervisor is registered against the appropriate trainee. HEE working across the South West will record the evidence for training undertaken and notify the supervisor, LEP and TPD if it is deficient.

Time

The LEP must ensure that the supervisor has the role recognised within their job plan. The Educational Supervisor should have identified SPA time for the role.

HEE will monitor and audit this via the annual Senior Leader Visit/Multi-Professional Review (contract visit) process identified within the quality framework.

Feedback

All supervisors will receive feedback on their role. Each school will be responsible for ensuring this.

The feedback will be provided in confidence to the supervisor. It should be used for their own reflection and within the appraisal process

Appraisal

The role of supervisor should be identified within the individual’s job plan. Appraisal of the role should be contained with the appraisal process the individual undertakes to provide evidence for revalidation and registration.

Back to: Section One / Top

Equality and Diversity

All training programmes within HEE are based on principles of fairness and equity.

The quality function supports all leaner activities which promote positive steps towards equality across all activities and to eliminate discrimination and harassment.

Data is obtained at the point of recruitment for all trainee doctors commencing work in the South West and recorded on the Intrepid Database. The strands of data typically collected are:

  • Age
  • Race
  • Sex
  • Gender reassignment
  • Sexual orientation
  • Religious belief
  • Disability
  • Location of obtained primary medical qualification

All data collated is governed by the HEE data and information policies and the Data Protection Act (2010).

On an annual basis HEE analyses the equality and diversity data that has been obtained and the outcomes are made available on its website and also included in its Annual Report.

Any person employed by HEE to undertake recruitment, selection and/or ARCP activities will be required to have up to date equality and diversity training (renewable every 3 years). All HEE staff are required to complete mandatory equality and diversity training on a 3-yearly basis.

The Quality function will support its recruitment colleagues with providing an analysis of equality and diversity reports concerning trainees annually and will publish these on the HEE website as required.

Back to: Section One / Top

Trainee Support

Trainees are both part of training programmes under the auspices of the Postgraduate Dean and are employees of healthcare organisations. In fulfilling both of these roles they incur certain rights and responsibilities.

While the Postgraduate Dean is responsible for managing delivery of training to learners this is always within the context of employing bodies. Therefore trainees clearly have an employment relationship with their individual employer and are subject to individual employers policies and procedures.

It is important that employers are fully aware of the performance and progress of all doctors, including trainees in their employ. In addition there must be a systematic approach to dealing with poorly performing trainees.

The Postgraduate Dean should be involved from the outset where performance issues relating to trainees arise.

Trainee support policies and processes are available on the SPME and PPME websites:

Peninsula / Severn

Back to: Section One / Top

Externality/Lay Representation

Lay Representatives are an integral part of HEE working across the South West's processes including:

  • All recruitment of postgraduate doctors
  • Curriculum and assessment systems, including ARCP
  • HEE quality management processes such as Level 2 and 3 Urgent Concern Review
  • Programme/Specialty Reviews (Quality Panels)
  • Board Meetings
  • Appeals review hearings

As part of their role Lay Representatives are encouraged to offer non-clinical judgements for areas important to the public and trainees and to voice any concerns.

Lay Representatives are encouraged to be proactive and to provide feedback (both positive and negative). This may take the form of verbal feedback on the day of the event through the relevant panel/meeting Chair.

In addition representatives are expected to complete a report to HEE following attendance at each event.

Back to: Section One / Top


Section Two: Response to Concerns - Urgent Concern Reviews

Response to Concerns Processes (diagram 2)
Level 1 Paper Based Review
Level 2 Urgent Concern Review - School
Level 3 Urgent Concern Review - Quality
Level 4 Urgent Concern Review - GMC Enhanced Monitoring

Diagram 2

PGME - Response to Concerns Processes

QF Diagram 2 7.4.16 

Response to Concerns (as illustrated in Diagram 2 above) are reactive and undertaken according to need, with the intention to gather further information around a perceived issue, address the issue and/or escalate.

These reviews will arise from the on-going scrutiny of available information presented to the HEE Quality team which includes, but is not limited to:

  • GMC National Trainee Survey results
  • Complaints, whistle blowing, or other issues of concern / dissatisfaction raised
  • Critical or untoward incidents (that compromise learning and/or patient or trainee safety)
  • Continued non-compliance to quality standards

Response to Concerns are split into four levels. In all situations, as with any performance management framework, attempts should be made to address an issue at the lowest possible level.

Concerns regarding the provision of education and training may be raised via a number of routes. The identified standard mechanisms for managing them across HEE are included in the following sections.

Progress will be monitored by the relevant PGME function via the Quality Register.

Back to: Section One / Section Two / Top

Level 1: Paper-Based Review

The first level of the Response to Concerns comprises a Paper-Based review.

The Paper-Based Review is an efficient way to ensure that low risk issues are addressed and dealt with appropriately whilst minimising delays and uncertainty.

Examples of low risk issues where a Paper-Based review is considered appropriate include:

  • any issue not impacting on patient safety that can potentially be resolved quickly
  • ongoing concerns that have not been resolved by the Trust in the way anticipated
  • whistle blowing/concern raised that is perceived to be low risk by the Head of School

The issue is recorded on the Quality Register and details sent to the Head of School (HoS) and/or the relevant Director of Medical Education (DME).

The School or LEP will address the issue and respond back to the relevant quality function within one month of receipt of the issue being placed on the Quality Register.

The issue will be monitored through the Quality Register by the relevant quality function, in collaboration with other stakeholders, until it has been satisfactorily resolved.

If the Quality function decides that the issue has not or cannot be resolved through level 1 of the framework, it will be escalated to the next level.

Back to: Section One / Section Two / Top

Level 2: Urgent Concern Review - School

The second level of the Response to Concerns comprises a visit to a LEP by the relevant school.

This level of review will be invoked if the Quality Team and school deem that a paper review hasn’t resolved, or is not sufficient to deal with, the issue.

The DME of the relevant LEP must be made aware of the intention to visit and be invited to attend a feedback session at the end.

Examples of when a Level 2 review is required include:

  • Any issue directly impacting on patient safety and where an appropriate action plan from the Trust is not forthcoming/has not sufficiently addressed issues
  • Significant areas of concern raised through an End of Post Survey
  • Triple red outliers raised through the GMC NTS where an appropriate action plan from the Trust is not forthcoming/has not sufficiently addressed issues
  • LEP self-referral
  • Where a Level 1 issue has not been resolved within reasonable timescales

Suggested attendees:

The visiting panel is likely to include:

  • HoS and/or Training Programme Director (as Chair)
  • Administration (if required)
  • Member of Quality Team (optional)
  • Associate Dean (optional)

The HoS will request relevant LEP staff to attend who are best placed to address the issue of concern but these are likely to include:

  • Director of Medical Education
  • Medical Education Manager
  • Education Lead – FPD, clinical tutor and/or service lead
  • Trainees

The Head of School (HoS) will advise further on attendance as necessary.

Process:

The School will contact the relevant PGME quality function and discuss the proposed visit with them and remain in communication throughout the process. A Quality Team representative should be invited to attend the visit if available.

The HoS will decide who is best within their school to address the concern.

Where the identified area of concern over arches more than one School, a letter should be sent to the relevant HoSs to make them aware of the concern.

The School will arrange a meeting date and agenda with the LEP. The DME (or equivalent) must be included in visit arrangements.

At least 6 weeks’ notice will be given to the LEP. However in certain situations HEE reserves the right to visit with less notice - if the concerns are serious - for example with issues of patient or trainee safety.

Appropriate pre-visit background data will be collected and distributed prior to the visit to all stakeholders and visiting team.

The visit team will convene to discuss the background evidence and confirm issues for review (good practice and cause for concern).

The panel will meet trainees either together or in appropriate groups followed by a separate meeting with supervisors.

Following the day’s review, the panel will convene to review findings and share views. The panel will agree final conclusions and summarise areas of good practice, areas of improvement or enhancement, and general outcomes for feedback.

At the end of the visit the review panel will provide verbal feedback to the LEP. The DME (or equivalent) must be invited to attend this session along with any LEP representatives deemed appropriate. This session provides an opportunity to provide instant feedback on the key findings of the visit and briefly discuss some suggested ways of addressing areas of concern that have been identified.

After the visit, the panel will produce a report summarising the visit using the information obtained, including actions where appropriate, and will circulate the report amongst the panel for comments and agreement. The aim is to complete this within one month of the visit. Please see Appendix 4 for a copy of the report template.

Once agreed by the panel a copy of the report should be sent to the Quality Team for comments following which the Quality Team will circulate it to the relevant DME. The LEP will then have ten working days to respond and agree its contents, including any proposed actions and recommendations.

Action plans will be recorded on the HEE working across the South West's Quality Register by the relevant quality function and monitored appropriately. 

Satisfactory outcome – if the issue is resolved:

Following the above process, if the HoS is satisfied that the triggered review actions and recommendations have been implemented and the initial area(s) of concern have been addressed, they will write to the relevant Quality function recommending the triggered review status be closed.

When writing to the relevant Quality function, the HoS should ensure that the outcomes relating to each specific action and recommendation on the triggered visit report are available (including any evidence) and summarise the current situation relating specifically to the areas of concern that were initially identified.

The relevant Quality function will review and verify the evidence provided by the HoS and liaise with relevant stakeholders prior to making a recommendation to the Postgraduate Dean.

The Postgraduate Dean will consider the evidence and:

if the Postgraduate Dean agrees that the triggered review status should be closed, they will formally write to the DME (or equivalent) and Medical Education Manager (or equivalent) and Medical Director informing them that the triggered review status has been closed.

if the Postgraduate Dean does not agree with the recommendation that the triggered visit process is closed, they will write directly to the HoS informing them as such and request they work closely with the relevant Associate Dean for Quality to ensure the matter progresses further; this may involve escalating the triggered visit level.

Unsatisfactory outcome – if the issue is not resolved:

If the HoS is not satisfied that the triggered visit actions and recommendations have been implemented or the initial area(s) of concern addressed, they will write to the relevant Quality function recommending that the triggered visit process not be closed.

When writing, the HoS should ensure that the outcomes relating to each specific action and recommendation on the triggered visit report are available (including any evidence) and summarise the current situation(s) relating specifically to the areas of concern that were initially identified and explain as to why they feel it has not been successful.

The relevant Quality function will review and verify the evidence provided by the HoS and liaise with the relevant stakeholders prior to making a recommendation to the Postgraduate Dean.

The Postgraduate Dean will consider the evidence and:

If the Postgraduate Dean agrees that the triggered review status should remain open they will meet with the Quality Team to decide if the triggered review level should be increased to a Level 3 or if a revision of the actions and recommendations with continual monitoring should be undertaken.

The Postgraduate Dean will write to the HoS informing them of the decision and requesting they work closely with the Associate Dean for Quality to ensure the matter progresses as necessary.

Following the meeting with the Postgraduate Dean, the Quality Team will liaise directly with the HoS concerning the status of the triggered review process and write to inform the appropriate LEP DME (or equivalent), Medical Education Manager (or equivalent) and Medical Director concerning next steps.

If the Postgraduate Dean disagrees that the triggered review process should remain open they will write formally to the HoS explaining the decision and offer the opportunity to meet with the Associate Dean for Quality.

In the event of closure, the Postgraduate Dean will formally write to the DME (or equivalent), Medical Education Manager (or equivalent) and Medical Director of the respective LEP informing them that the triggered review process has been closed. 

Back to: Section One / Section Two / Top

Level 3: Urgent Concern Review - Quality

This level of the framework should be utilised when there are significant issues identified within a LEP and is led by the relevant Quality Team although may be conducted as a joint Quality/School visit.

Examples of when a Level 3 response is appropriate include:

  • Issues that present a high risk to patient safety
  • High risk issues to trainee safety and the delivery of education
  • Any whistle blowing or concern raised that is perceived to be high risk
  • GMC NTS red outliers indicating significant patient safety issues
  • LEP self-referral
  • Where issues identified in Level 2 have not been resolved in reasonable timescales

HEE will utilise a level of clinical externality / lay membership. The visit may apply to a single specialty, several specialties, or the whole educational activity of a LEP.

Suggested attendees:

The visiting panel is likely to include:

  • Postgraduate Dean or Deputy Postgraduate Dean
  • Associate Dean for Quality
  • School representative(s) – HoS, Training Programme Director, STC Chair (without a conflict of interest)
  • Clinical externality, from outside the Severn or Peninsula e.g. College/Faculty representative
  • Member(s) of Quality Team
  • Lay membership
  • Administration/scribe

The Associate Dean for Quality will request relevant LEP staff to attend who are best placed to address the issue of concern but these are likely to include:

  • Director of Medical Education
  • Chief Executive Officer
  • Medical Education Manager
  • Education Lead – FPD, clinical tutor and/or service lead
  • Trainees
  • Relevant LEP representatives – e.g. Educational and Clinical Supervisors

The Associate Dean for Quality will advise on attendance as necessary.

Process:

When an issue has been identified within a School or LEP, the HoS or appropriate person will raise it with the Associate Dean for Quality and Quality Manager. The Associate Dean for Quality and Quality Manager will decide if the identified issue should be resolved by the formal Level 3 process.

Where the identified area of concern over arches more than one School, a letter should be sent to the relevant HoSs to make them aware of the concern.

The Associate Dean for Quality and Quality Manager will formally write to the appropriate DME (or equivalent) describing the area of concern and informing the LEP that HEE will be undertaking a visit to investigate the highlighted area of concern.

The relevant quality function will make appropriate arrangements for the visit, liaising with the relevant DME (or equivalent) and Medical Education Manager (or equivalent), drawing together a timetable and agreeing appropriate panel members and relevant trainees and trainers.

At least 6 weeks’ notice will be given to the LEP. However in certain situations HEE reserves the right to visit with less notice - if the concerns are serious - for example with issues of patient or trainee safety.

Appropriate pre-visit background data will be collected and distributed by the Quality Function to all stakeholders and visiting team.

The visit team will convene to discuss the background evidence and confirm issues for review (good practice and cause for concern).

The panel will meet trainees either together or in appropriate groups followed by a separate meeting with supervisors.

Following the day’s review, the panel will convene to review findings and share views. The panel will agree final conclusions and summarise areas of good practice, areas of improvement or enhancement, and general outcomes for feedback.

At the end of the visit the review panel will provide verbal feedback to the LEP. The DME (or equivalent) must be invited to attend this session along with any LEP representatives deemed appropriate. This session provides an opportunity to provide instant feedback on the key findings of the visit and briefly discuss some suggested ways of addressing areas of concern that have been identified.

Following the day’s review the Chair of the visit panel will write a report summarising the visit using the information obtained, including actions where appropriate, and will circulate the report amongst the visit panel for comments and agreement. The aim is to complete this within 1 month of the visit.

Once agreed by the panel a copy of the report should be sent to the Quality Team for comments following which the Quality Team will circulate it to the relevant DME. The LEP will then have ten working days to respond and agree its contents, including any proposed actions and recommendations.

Upon agreeing the triggered visit report and proposed actions, the LEP will enter a period of monitoring and review.

The LEP will be provided with a follow up date, where the agreed actions and recommendations will be reviewed to ascertain that satisfactory progress has been made.

The identified concern and any agreed or completed actions will be included on the Quality Register and within the Dean’s Report submitted to the GMC.

Triggered Visit Action Plans will be discussed at the Quality Advisory Board as deemed appropriate by the relevant Quality function.

Satisfactory outcome - if the issue is resolved:

Quality will review and verify the evidence provided during the visit and, after liaising with the relevant stakeholders, make a recommendation to the Postgraduate Dean that sufficient evidence has been received enabling the triggered review status to be closed.

The Postgraduate Dean will consider the evidence and:

If the Postgraduate Dean agrees that the triggered review status should be closed, they will formally write to the DME (or equivalent) and Medical Education Manager (or equivalent) and Medical Director informing them that the triggered review status has been closed.

If the Postgraduate Dean does not agree with the recommendation that the triggered visit process is closed, they will meet with the Quality Team to decide if the triggered review level should be increased to a Level 4 or if a revision of the actions and recommendations with continual monitoring should be undertaken.

The Postgraduate Dean, the Quality Team will liaise directly with the LEP DME (or equivalent), Medical Education Manager (or equivalent) and Medical Director concerning next steps.

The relevant Quality function is responsible for communicating the decision/details of the next steps to the relevant HoS.

If it is agreed with the Postgraduate Dean that the triggered review status can be closed a period of monitoring through the standard quality management process will be instigated.

Unsatisfactory outcome - if the issue is not resolved:

Quality will review and verify the evidence provided during the visit and, after liaising with the relevant stakeholders, make a recommendation to the Postgraduate Dean that insufficient evidence has been received and the triggered review status cannot be closed.

The Postgraduate Dean will consider the evidence and:

If the Postgraduate Dean agrees that the triggered review status should remain open they will meet with the Quality Team to decide if the triggered review level should be increased to a Level 4 or if a revision of the actions and recommendations with continual monitoring should be undertaken.

Following the meeting with the Postgraduate Dean, the Quality Team will liaise directly with the LEP DME (or equivalent), Medical Education Manager (or equivalent) and Medical Director concerning next steps.

If the Postgraduate Dean disagrees that the triggered review process should remain open they will write formally to the DME (or equivalent) and Medical Education Manager (or equivalent) explaining the decision and informing them that the triggered review process has been closed.

The relevant Quality function is responsible for communicating the decision/details of the next steps to the relevant HoS.

In the event of closure a period of monitoring through the standard quality management process will be instigated.

Back to: Section One / Section Two / Top

Level 4: Urgent Concern Review - GMC Enhanced Monitoring

This process follows Level 3 in all respects except that the GMC also actively participates in this visit due to the severity of the issues which have been identified.

Examples of when a Level 4 response is appropriate include:

  • When it is deemed necessary by the Postgraduate Dean, the QAB or the Executive Team that all other efforts to resolve an issue or issues within a training programme or LEP have failed.
  • When issues of extreme concern have been identified within a training programme or LEP.

Enhanced monitoring: In situations where HEE and Trusts have failed to make necessary improvements to training the GMCs enhanced monitoring process will be implemented. Issues that require enhanced monitoring are those that could adversely affect patient safety, doctors’ progress in training, or the quality of the training environment. The database of issues requiring enhanced monitoring as well as further information on this process is available on the GMC website.

The Postgraduate Dean will make the ultimate decision to action level 4 of this framework.

The Postgraduate Dean will formally write to the appropriate regulator, e.g. the GMC, advising them of the identified areas of concern and requesting a formal review.

The Postgraduate Dean will formally write to the Chief Executive, Medical Director, Director of Medical Education (or equivalent) and Medical Education Manager (or equivalent) of any Local Education Provider involved with the identified areas of concern.

The Postgraduate Dean will formally write to the Heads of School involved with the identified areas of concern.

The Quality Team will act as a point of contact for the appropriate regulator.

The Quality Team will ensure compliance with the relevant regulatory framework for the specified visits and work with the regulator to ensure that any actions or recommendations are appropriate and feasible.

Suggested attendees:

The visiting panel is likely to include:

  • Postgraduate Dean or Deputy Postgraduate Dean
  • Associate Dean for Quality
  • GMC representative
  • School representative(s) – HoS, Training Programme Director, STC Chair (without a conflict of interest)
  • Clinical externality, from outside the Severn or Peninsula e.g. College/Faculty representative
  • Member(s) of Quality Team
  • Lay membership
  • Administration/scribe

The Postgraduate Dean/Associate Dean for Quality will request relevant LEP staff to attend who are best placed to address the issue of concern but these are likely to include:

  • Director of Medical Education
  • Chief Executive Officer
  • Medical Education Manager
  • Education Lead – FPD, clinical tutor and/or service lead
  • Trainees
  • Relevant LEP representatives – e.g. Educational and Clinical Supervisors

The Postgraduate Dean/Associate Dean for Quality will advise on attendance as necessary.

Following the day’s review the Chair of the visit panel will write a report summarising the visit using the information obtained, including actions where appropriate, and will circulate the report amongst the visit panel for comments and agreement. The aim is to complete this within ten working days of the visit.

The agreed report should be submitted to the Postgraduate Dean, Quality Team and other relevant PGME stakeholders, who will review it and as necessary seek any further clarification or amendments.

The agreed report will be distributed to the relevant DME (or equivalent). The LEP will have ten working days to respond and agree its contents, including any proposed actions and recommendations.

Upon agreeing the triggered visit report and proposed actions, the LEP will enter a period of monitoring and review.

The LEP will be provided with a follow up date, where the agreed actions and recommendations will be reviewed to ascertain that satisfactory progress has been made.

The identified concern and any agreed or completed actions will be included on the Quality Register and within the Dean’s Report submitted to the GMC.

Back to: Section One / Section Two / Top


 

Appendices

Appendix 1

Quality Advisory Board Terms of Reference

 

Purpose

  • To provide advice, feedback and comment to the education Quality Management function on quality management processes, programmes and decision making.
  • To review the Severn and Peninsula actions relating to quality management against the GMC’s requirement as regulator.
  • To review new and long-standing high risk quality issues arising within education, with a focus on significant issues.
  • To comment and advise on Response to Concerns and Risks on the Risk Register, and to review the effectiveness of the interventions.
  • To provide externality in terms of input, by including representatives at the Board who are both outside the quality function and HEE.
  • To review policies and processes created by the Quality function to support education across HEE.

To review sources of data and information including:

  • Significant outcomes of LEP Senior Leader Visit/Multi-Professional Review (Contract meetings)
  • GMC National Training Survey results
  • Status of Supervisor Training
  • Results from the GMC ARCP reports
  • The GMC Dean’s Report
  • Programme/Specialty Review (Quality Panel) outcomes
  • Level 3 and 4 urgent concern review
  • Red* and Red risks on the Quality Register

Organisation

  • Board decisions will be minuted and the minutes circulated to all stakeholders e.g. relevant leads in the Trusts and Programmes and the Executive team.
  • Meetings will be convened every six months from September 2014
  • Meetings will normally run from 10am – 1pm.Board members will be emailed information a fortnight before the date of the meeting

Roles and Responsibilities

Chair

  • Associate Deans for Quality in Severn and Peninsula (alternating)

Attendees:

  • Associate Deans for Quality in Severn and Peninsula (alternating Chair)
  • The Director of Education and Quality, South
  • Postgraduate Dean, HEE
  • A Director of Medical Education from Severn and Peninsula
  • An Associate Postgraduate Dean representing Primary Care from Severn and Peninsula
  • A Head of School from Severn and Peninsula
  • A Foundation Programme Director from Severn and Peninsula
  • Quality Managers at Severn and Peninsula
  • Quality Data Specialist, Severn
  • Quality and Information Co-ordinator, Peninsula
  • A Lay advisor
  • A learner representative from Severn and Peninsula
  • Healthcare Dean, SW LETB

To attend as needed:

  • Deputy Postgraduate Dean from Severn and Peninsula

Minute taking will be alternated between the Quality Support Manager (Severn) and Quality and Information Co-ordinator (Peninsula).

Where clear conflicts of interest arise, individual board members will not partake in the decisions made.

Please note that information shared at this meeting may be confidential and sensitive. All attendees should use professional integrity with information of this nature

These Terms of Reference will be reviewed at regular intervals.

Appendix 2

Effective Educational Environment and Safe Working Environment (E-Form / For Print)

Appendix 3

Quality Data Matrix which is provided by the quality team for the review team use to grade individual posts at the Programme/Specialty Review (Quality Panel) (E-Form / For Print)

Appendix 4

Programme/Specialty Review (Quality Panel) Outcome Report (Excel Document)

Appendix 4

 Quality Intervention Agenda

 

We are in the process of updating our Quality Framework to bring it in line with the requirements of the new HEE national multi-disciplinary Quality Framework.  In the meantime, please find below the following documents for use with any Triggered Visits which take place.

Quality Review Outcome Report 2017

Quality Intervention Agenda

Back to: Section One / Section Two / Top