Postgraduate School of Paediatrics Quality Management Visit to Plymouth Hospitals NHS Trust, Royal Devon and Exeter Hospital and Royal Cornwall Hospital

8th September 2015

 

Primary author of report (name and job title): Dr Tom Sulkin, Head of School

Provider visited: South Devon Healthcare NHS Trust

Date(s) of visit: 15th May 2015

Visit team (names and educational job titles):

Chair

Dr Giles Richardson

Panel member

Dr Yadlapalli Kumar

Panel member

Dr Dermot Dalton

Panel member

Dr Jonny Graham

Panel member

Associate Dean

Dr David Bartle

Dr Jeremy Langton (PM only)

Programme

No. of trainees seen

No. of trainers seen

Paediatrics

14

12

Evidence considered prior to review taking place: Feedback questionnaires from some of the trainees and trainers

2015 GMC National Training Survey

Date visit report ratified by HESW – Peninsula

17th November 2015

Date visit report made available to provider

18th November 2015

Date provider ratifies visit report

23rd October 2015

Circulation of this report: Peninsula Postgraduate Medical Education Quality Team

Director of Medical Education

 

 

 

 

Executive Summary

 

Key Recommendations

1. Medical teams should display professionalism in all areas of work. Prompt timekeeping, quality of teaching programmes and job planned consultant attendance to help facilitate teaching sessions will improve the quality of teaching. Action: To be monitored through Quality panel reviews, GMC survey on local teaching and College Tutor and Trainee rep feedback at School Board meetings.
2. Trust staff must feedback regularly to trainees ongoing attempts to recruit to vacancies at all levels within department through rota coordinators.  Action: Immediate. 
3. Regional training dates for the academic year to be released at the earliest opportunity by the School of Paediatrics for study leave purposes, and a proportion of sessions should be facilitated by videoconferencing facilities over the next 12 months.
4. Handover should be timely, include a unit safety briefing, contain relevant clinical information, and be multi-disciplinary in nature.  To be implemented by August 2015.
5. All trainees should be allocated an educational supervisor (ES) at the start of a hospital training post.  A trainee should be allocated an additional clinical supervisor (CS) if the ES is not in the same area of work as the trainee.  Supervisors should designate a monthly departmental meeting to address training and supervision issues.  Output from this meeting should be fed back to trainees at the least on a quarterly basis.
6. Junior doctor induction must include information about who and from whom they can get support out of hours and at weekends by December 2015.

 

The School of Paediatrics within the South West Peninsula actioned a stage 2 quality visit to the Local Education Providers (LEP)  of Paediatric Services in three hospitals in July 2015.  The three services reviewed were Royal Cornwall Hospital NHS Trust - Paediatrics, Plymouth Hospitals NHS Trust -General Paediatrics and Royal Devon & Exeter NHS Trust - Neonatal Paediatrics. 

 

The three services were chosen for review following publication of the GMC National Trainee Survey for 2015 which showed potential concern in the quality of the services provided over several GMC indicators.  In some instances there had been an anticipation of trainee dis-satisfaction as a result of shared information through the Annual Review of Competency Progression (ARCP) process, but in other areas the results were not anticipated.  In view of the downward trends to negative outliers, a stage 2 review of LEPs was deemed the best way of understanding issues from the current cohort of trainees and trainers and to allow opportunity to rectify problems identified.

 

The day was coordinated from the Neonatal Intensive Care Unit at Derriford Hospital in Plymouth. Video-conference links were established with the hospitals in Exeter and Truro.  Derriford Hospital staff attended in person. Trainees and trainers were spoken to separately.  Overall there was good engagement from both trainees and trainers from all three LEPs.  The focus of questioning revolved around those areas within the GMC survey where performance had been deemed poor and solutions were sought to those problem areas. Common themes emerging included senior and trainee staffing, clinical and administrative workload, balance between service provision and training, educational supervision, efficient and timely handover. 

 

 

Paediatric Triggered Visit of PHNT, RD&E and RCH – 9 July 2015

 

Royal Cornwall Hospital

The visit was conducted via videoconference from PHNT with RCH trainees and trainers at separate meetings with the following being a record of those interviews.

 

Trainees

There were 5 trainees present and the areas that were discussed were the red outliers from the 2015 GMC NTS as follows:

  1. Handover
  2. Feedback,
  3. Regional and local teaching,
  4. Study leave,
  5. Supportive environment,
  6. Overall satisfaction.

 

Local Teaching

The trainees informed the panel that there are 5 hours per week of teaching usually in the mornings.  This is not consultant or senior trainee led and is therefore muddled in its content  It is over simplified to meet the needs of the more junior trainees and non-paediatric trainees such as F2 and GP trainees.  It is therefore of little value to the trainees enrolled in Paediatric specialty training.

 

There is a consultant led session held on a Friday and this is well received.  There are additional teaching sessions in radiology and a paediatric journal club,  however these are held in the afternoon and are not protected teaching sessions. Trainees are often bleeped during the sessions and this detracts from attendance at these sessions.

 

The trainees were asked if they would prefer to have fewer teaching sessions per week, but led by consultants/senior trainees, and of better quality with more relevant curriculum based subjects.

 

The trainees were unanimous that they would prefer fewer sessions overall but a focus on quality.

 

In relation to the issue of unprotected teaching the trainees were asked if they had any solutions to this problem.

 

The trainees suggested that the ANNP’s on the neonatal unit could help by taking the bleep to allow the trainees to attend their training without being interrupted by the bleep for routine matters. 

 

The trainee working day starts at 0830, teaching also starts at 0830 with handover taking place at 0910, which makes handover tight for end of shift time constraints.

 

The trainees also informed the panel that on Tuesdays, there are parallel sessions running  with seniors teaching seniors and juniors teaching juniors. Simulation sessions run on alternate Wednesdays.

Recommendation - Reduce the amount of sessions being provided and improve the quality of local teaching with senior support present.

 

Regional Teaching

The main issue in relation to regional teaching is geography, with the training at ST4 – ST5 level taking place 8 times a year in Bristol and 4 times a year in Exeter. RCH trainees have considerably further to travel to either of these locations than their counterparts around the region, and generally at their own expense.  There is no additional funding for travel to attend these courses, which means they would exhaust their study leave budget through this and other leave requests. Accommodation has to be considered if they are to attend early starts in Bristol and late finishes – neither of which fit well with their already tight rota situation.

 

Despite this the trainees informed the panel that the quality of the teaching was good.

Recommendation:- Conduct some regional teaching sessions via videoconferencing in the 2015-16 training year.

 

The trainees were asked by the panel if they would be prepared to travel to Plymouth and Exeter for videoconferencing if it could not be arranged on a multi – centre conference.  They stated they would as a trial and this would likely be a better alternative to travelling to Bristol.

 

The trainees informed the panel that ST1 – ST3 teaching within Peninsula is generally fine.

 

The trainees asked if there was anyway of the dates for teaching being made available sooner to allow them to plan into their rota’s through their new rota coordinator the days the need to be out of the trust for teaching.

Recommendation – Regional training dates for ST1-3, ST4-5 and ST6-8 to be released by Peninsula and Severn. Dates being implemented and the dates now on website for the majority of the sessions for the next year.

 

Rota Gaps

The trainees informed the panel there are numerous gaps in the SHO and registrar rota.  The trainees are aware that the Trust had made lots of attempts to obtain locum cover to fill those gaps but to no avail.  There have been occasions where consultants have acted down.  The issue this creates is that there is a pull from the general paediatrics department to cover the neonatal department and training is sacrificed in favour of service delivery.

 

There was agreement that the majority of issues raised are caused by the rota gaps, although the trainees believe even with a fully staffed rota hours and work would still be tight.

 

When asked how staffing issues could be improved the trainees suggested advertising for long-term locum cover. The Trust routinely advertises for short-term out of hours cover, and given the geography of RCH this is not working. They also pointed out there is a lot of pressure by the trust to get the trainees to cover rotas and there is a feeling of guilt by the trainees if they refuse.

Recommendation – Trust staff to feedback regularly to trainees ongoing attempts to recruit to vacancies within department.

 

Feedback/Supervision

The trainees informed the panel that if they start their rotation in neonates, they have an educational supervisor who could be in either neonates or general paediatrics. They do not necessarily have a sub-specialty specific clinical supervisor.

Recommendation - RCPCH recommends that if the educational supervisor is not in the same area of work as the trainee, the trainee should have a designated clinical supervisor in that area of work.  RCH should endorse this.

 

Trainees indicated that they may be left unsupervised at times on general paediatric wards when the wards are busy (there is always a consultant on call) .The Consultant working pattern has been changed from September 2015 with a second consultant only for the evenings covering the Paediatric Observation unit from 5 pm till 9.30 pm and a second consultant from 9am to 12 noon on the weekends.. In neonates senior supervision is much more prevalent.

 

The trainees did however stress that RCH is a great place to work, and wanted to re-iterate that this was not a negative moaning session, but an attempt to improve their experience and environment in RCH, both for themselves and future trainees.

 

Handover

The neonatal unit handover takes place in an office before medical rounds. It is doctor to doctor handover, with no safety briefing given.  There is no formal handover for the neonatal clinic.

 

The general paediatric handover is again doctor to doctor and ad-hoc, but does include a safety briefing.

Recommendation – Handover should be timely, contain relevant clinical information, include a safety briefing and be multi-disciplinary in nature.

 

The final comment by the trainees was that due to the limited numbers they are all feeling stressed out and clinical service is taking priority over training.

 

Trainers

Drs  (MT) and  (CW)

The chair of the panel, Dr Giles Richardson, informed both trainers of the trainees concerns in relation to rotas, quantity and quality of training, and a lack of bleep free teaching.

The panel were informed that the 0830 – 0915 morning teaching should not be junior to junior teaching and in fact this was audited by CW, and only happened 4 times in the last 6 months.

There is only teaching with consultants present on Thursday’s and 2 Wednesday’s a month opposite the simulator training.

The panel were informed that the morning teaching is usually bleep free, however consultant attendance at this teaching was sporadic and very much dependant on individual consultants.

Recommendation - the number of departmental teaching sessions be reduced, with a focus on consultant presence and improved quality of teaching.

 

CW, informed the panel that they can get consultants to attend all teaching sessions under the current regime.

Recommendation – Service Line Director adjusts consultant job plans to ensure a start time for teaching of 0830, to help with attendance issues.

 

The panel pointed out that the issue around non-protected teaching was mainly an issue with the lunchtime sessions and asked if the ANNP’s could help with cover during this time, to reduce the amount of bleeps the trainees receive.

CW, informed the panel that this will require discussion with the nurses.

The panel asked if the consultants could also help with holding the pager. 

CW, informed the panel that would be more difficult and would very much be dependent on individual consultants.

There was further general discussion and  CW provided one specific example of a teaching session - at a recent journal club session he was leading, 10 minutes had elapsed after the programmed start time and he still had very few trainees present. He went looking for them, only to find some sitting in the doctor’s mess. In summary, there is joint responsibility by both trainers and trainees to ensure they are on time for their teaching sessions.

CW, went on to say that at a recent staff meeting there was a much more collegiate approach by all those present and it is hoped this togetherness could be maintained with input and enthusiasm from both trainers and trainees.

There was recognition by the trainers that they feel they have let the end go, and  are working hard to rectify this, but they do feel it will require an attitudinal shift by both trainers and trainees.

Recommendation – Trainers and trainees work together to ensure RCH becomes an ‘on-time’ paediatric department.

 

Rota Issues

MT, gave a description of the rota issues and the factors behind the current situation, and the steps being taken to rectify this.

Recommendation – Trust staff to feedback regularly to trainees ongoing attempts to recruit to vacancies within department.

 

Supervision

The chair of the panel briefed the trainers on supervision issues as perceived by the trainee. The panel recommendation was also shared with the trainers. The trainers agreed to take action to resolve this situation.

Recommendation -  a monthly trainee meeting as part of another meeting to resolve any supervision issues.  He also informed the panel that the consultants do discuss trainees at their regular meetings.

 

Handover

The trainers were informed of the panel recommendations in relation to improving their handover.

CW, informed the panel that the recommendations already happen in general paediatrics and the issue is being rectified in neonates.

CW, also informed the panel that the nursing staff on the general side are invited to the handover, but do not routinely attend.

Recommendation – Handover should be timely, contain relevant clinical information, include a safety briefing and be multi-disciplinary in nature.

 

Regional Teaching

The panel informed the trainers that the rota coordinator needs to be informed of the dates of regional teaching to ensure the trainees can attend. 

CW, will make sure the trainees are not on the service rota for those dates.

Recommendation – Regional training dates for ST1-3, ST4-5 and ST6-8 to be released by Peninsula and Severn. Dates being implemented and the dates now on website for the majority of the sessions for the next year.

 

Royal Devon & Exeter

The visit was conducted via videoconference from PHNT with RD&E trainees and trainers at separate meetings with the following being a record of those interviews.

 

Trainees

There were 6 trainees present and the areas that were discussed were the red outliers for neonates from the 2015 GMC NTS as follows:

  1. Overall satisfaction
  2. Workload.

The trainees present informed the panel they were generally happy and a little surprised at the results of the GMC survey, however they did go on to inform the panel of issues as follows:

 

Workload

This can be high in neonates due to staffing levels. Raised level of concern around supervision levels outside of normal working hours.  A consultant covering neonates is on call from home and available from 1700 daily.

Trainees believe that one way to reduce their workload would be for nurses to take on certain tasks such as heel prick samples.  They are trained to do this and it would go some way to reducing their workload during busy periods.

The junior trainees did not feel there were any patient safety issues, and feel they get reasonable support from the general paediatric registrar should they need it.

The handover in neonates is generally Reg to SHO, and not consultant led.  The morning handover however is consultant led and is a ward round, however timings can be variable especially on a Monday and Friday leading to shifts over-running.  The trainees are rota’d for half days to try and compensate for the long night shifts they do, however the trainees generally never finish these shifts or leave on time.

The trainees reported that clinical supervision during the day is very good, and that there are a number of consultants now available to sign off WPBA’s  - which was a weak area in a previous LEP visit.  They also feel they get good feedback.

The trainees unanimously agree that most of the problems stem from the rota issues.

The panel asked if the rota could be improved and were informed by the trainees that it is a six person rota and after several periods of monitoring, it is compliant, however the only way they could see for it to be improved, would be to increase the numbers on the rota. 

Recommendation – Handover must be more structured and multidisciplinary ensuring night SHO leaves shift at correct time. This should be regardless of whether the handover is complete or not – any other consultant level handover issues should be addressed outside of these times.

There was some general discussion around teaching with no complaints or issues reported by the trainees.

 

Trainers

There were 3 trainers in attendance and they informed the panel that the current rota on neonates had been designed by the SHO’s and approved by the trust as EWTD compliant, however they informed the panel that the majority of the poor feedback regarding this had in fact come from F2’s all of whom only have 4 months in the department as part of their rotation.

In relation to the issues about getting trainees away post nights and after the handover on time, the consultants informed the panel the reason they have a consultant to consultant handover before the formal handover from the night shift trainee is due to errors by trainees in the past. 

Recommendation - – Handover must be more structured and multidisciplinary ensuring night SHO leaves shift at correct time. This should be regardless of whether the handover is complete or not – any other consultant level handover issues should be addressed outside of these times

 

The trainers did also go on to say that whilst trainees may leave late on occasion this is compensated by them leaving earlier at other times.

There was discussion about getting trainees time allocated to outpatient clinics, and the panel were informed that the current system is that there is a general paediatric clinic on Tuesday and a neonatal clinic on a Wednesday, but that trainees are not always released to attend these.

Recommendation  - consultants act down to ensure trainees get to attend outpatient clinics once a week.

 

The question of support for the night shift in neonates was addressed. The trainers informed the panel that there is a consultant presence between 1700 and 2200 in general paediatrics - this is to help free up the middle grade doctor who can then support the neonatal unit. This is in addition to the on call consultant covering neonates. The situation will be further enhanced by the introduction of an ANNP from September 2016.

Recommendation – Induction focus to improve emphasis to junior doctors on how and from whom they can get support out of hours and at weekends.

  

 

Plymouth Hospitals NHS Trust

The visit was conducted with PHNT trainees and trainers at separate meetings with the following being a record of those interviews.

 

Trainees

There were 3 trainees present and the areas that were discussed were the red outliers from the 2015 GMC NTS as follows: 

  1. Overall satisfaction
  2. Local teaching
  3. Regional teaching
  4. Feedback
  5. Supervision. 

The trainees started by informing the panel that there are current paediatric vacancies in the Trust at both consultant and middle grade.  This has led to a very tough service rota with a shortage of registrars in particular.  The rota has been changed to meet service requirements, and currently there is no consultant teaching, although there is a new plan in place to rectify this.

 

Teaching

There is currently only one teaching session planned per week which takes place at 0830 – 0900 for SHO/REG’s and the consultant attendance at this is variable with little or no buy in by the consultants.  This has been going on for about 2 years.

There is currently no trainee lead for teaching but there is now a consultant lead for teaching who is putting in place a plan to improve quantity and quality of teaching in the Trust. 

Recommendation (made subsequent to the visit): To have a trainee lead for teaching at each Trust.

 

Handover

This always overruns and is not an efficient use of time.  Delays are caused by detailed discussions relating to specific cases, a general lacklustre approach to handover and poor attendance through staffing issues.

Recommendation: SBAR format recommended and School understands this is being implemented across the units.

 

Regional Teaching/Study Leave

The trainees reported that access to study leave works well and the quality of regional teaching has improved.

Recommendation -  study days are to be built into the rotas by the central rota coordinator, although trainees do still need to apply for study leave.

 

Supportive Environment

Trainees informed the panel that supervision levels for SHO’s at night and in CAU are generally fine.  Trainees do receive feedback from the monthly consultant meeting, however other personal feedback is difficult due to clinical workload and staffing issues. Trainees have to book appointments to see their supervisors via their secretaries and meetings do not always happen.

The chair of the panel asked the trainees if there were any patient safety issues -  there was no comment by those trainees present.  The trainee representative on the panel stated there are issues due to staffing levels.

The chair of the panel asked the trainees how the rota could be improved, and the only answer given was to increase staff numbers, because at the moment the trainees are picking up additional shifts.

The chair of the panel asked if trainees got access to clinics, to which they replied yes and that previous issues have now been resolved.

There was agreement by the trainees that the majority of the issues can be resolved with a full rota design.

 

Trainers

There were 7 trainers present and issues put to them by the panel focussed on the recent GMC survey.  A report was read out to the meeting by one of the trainers, CD.  Please refer to the information supplied on pages 15 – 17 in answer to the issues raised (if you require a copy of this report please contact the Quality Team at jane.bunce@southwest.hee.nhs.uk). 

 

Visit Panel Chair Declaration

This completed report is a true and accurate account of the discussion that I participated in or that were reported to me from this visit.

The key recommendations identified within this report have been identified with good faith.

I can confirm that any areas of significant concern that have a direct impact upon patient safety have been brought to the attention of the relevant Director of Medical Education (or equivalent), responsible Medical Director and Executive Lead for Quality at Health Education South West Peninsula Postgraduate Medical Education.

Chair name:

Dr Giles Richardson

Chair educational role:

 Training Programme Director ST4 – ST8, SW Peninsula Post-Graduate School of Paediatrics

Date of signature:

15/09/2015

 

 

 Health Education South West Peninsula Postgraduate Medical Education Declaration

I as signatory on behalf of Health Education South West, Peninsula Postgraduate Medical Education can confirm that the information and associated recommendations provided via this report have been reviewed and deemed appropriate for the purpose as stated.

The recommendations contained within this report have been documented as part of the quality management processes of Health Education South West, Peninsula Postgraduate Medical Education and where appropriate, will be reported to the General Medical Council (GMC) as required.

Name:

 Dr Martin Davis

PPME educational role:

 

 Associate Dean for Quality

Date of signature:

 

 17/11/2015