Continuing Medical Education and Clinical Governance: Experience in UK Dr Danielle B Freedman Associate Medical Director Luton and Dunstable Hospital NHS Trust Luton, Bedfordshire UK

Introduction to Clinical Governance in UK Setting Standards Monitoring Standards Continual Medical Education (CME) versus Continual Professional Development (CPD) CPD Schemes to underpin Clinical Governance Revalidation “Outcomes” – case studies

Introduction health organisations will have a statutory duty to report on quality issues quality of health care services and the clinical performance of individuals and teams will be accountable by statute ‘The New NHS Modern - Dependable’ states: 1997

Setting, delivering, monitoring standards National Institute for Clinical Excellence (NICE) National Service Frameworks (NSF) Professional self-regulation Clinical governance Commission for Health Improvement National Performance Framework National Patient and User Survey National Clinical Indicators Patient & public involvement Clear standards of service Dependable local delivery Monitored standards Lifelong learning

Clinical Governance is central to strategy “A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish” 1998 A First Class Service Dept of Health, UK

“Clinical Governance is about doing the right things, to the right patient at the right time in the right place, and getting it right first time”

Clinical Governance involves guaranteeing quality: Clinical effectiveness and practice of evidence based medicine Optimisation of clinical care Risk management Learning from adverse events/incidents and complaints Continuous professional development Good quality clinical data systems Involvement of patient and carers

Setting Quality Standards Strategy of NHS: set clear, national quality standards and ensure optimisation of clinical care through: National Service Frameworks (NSF) National Institute for Clinical Excellence (NICE)

1. National Service Frameworks (NSF) a)Optimised procedures lead to quality and consistency of product b)In clinical care in UK there is variation and lack of optimisation c)In UK 101 ways of looking after patients with same condition - NOT unusual d)NSF will set National Standards and define service models for Specific Diseases and Services Reduce undesirable variations in practice

e)Evidence based f)Attempt to lead to continual improvement in care, reduce variation in practice, improve patient access and improve clinical outcome ExamplesNSF Coronary Heart Disease, Care of Older People, Diabetes Mellitus 2004 Renal Disease clinical effectiveness cost effectiveness

National Institute for Clinical Excellence (NICE) Clinical and Cost Effectiveness “The National Institute for Clinical Excellence will act as a nationwide appraisal body for new and existing treatments, and disseminating consistent advice on what works and what doesn’t” First Class Service – Dept of Health 1998 Function 2.

What does NICE do? Health Technology Appraisals (HTAs) Clinical Guidelines (18) Interventional Procedures (since July 2003) (109) Confidential Enquiries-research reports looking at ways patients are treated eg Maternal deaths Independent organisation for England and Wales - established in 1999 (Special Health Authority) Produces guidance in 4 ways:

Health Technology Appraisals Recommendations based on a review of clinical and economic evidence involves patient organisations, professional bodies, manufacturers Completed within 62 weeks Continuous process of appraisal of evidence and consultation As of January 2005 – 87 published HTAs eg HTA 69 – Liquid based cytology NICE is asked to look at particular drugs/devices and diagnostic tests where availability varies or where there is uncertainty over its value

Duties of a doctor “make the care of your patient your first concern respect the rights of patients to be fully involved in decisions about their care keep your professional knowledge and skills up to date act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practice” The duties of a doctor as set out by the GMC in the latest version of its guidance Good Medical Practice (2003) include responsibilities to: 3.Setting Quality Standards

Monitoring Standards CHI  Healthcare Commission (April 2004) Clinical Audit Consultant appraisal and revalidation [General Medical Council] National Patient Safety Agency [NPSA] “Benchmarking” – Clinical Indicators

Healthcare Commissions (HcC) 2004 Responsibilities Inspecting all NHS Trusts Licensing private health-care provision Concluding VFM audits Validating published performance statistics Publish star ratings Surveys of patients and staff Focus on positive outcomes for patients, users of services and public

Continuous Medical Education [CME] – the move to Continuous Professional Development [CPD] Before 1995:No formal obligation for doctors to record participation in CME 1995 – 2000:Royal Colleges develop and monitor structured system of CME Since 2000:Recognition that CME is only a component of CPD

CPD “systematic maintenance, improvement and broadening of knowledge and skill and development of personal qualities necessary enabling the clinician to perform professional and technical duties throughout their working life” No evidence that CME alone improves clinician’s performance: only increases their knowledge. [Matos-Ferreira 2001]

Faculties of the Academic Medical Royal Colleges developed CPD schemes for their members 2000 – 2002: 2002:CPD: The Ten Principles

CPD Schemes in UK Improve the safety and quality of Medical Practice Encourage the principles of life long learning Make transparent the outcomes processes and systems required for successful implementation Audit progress [comply with Union Européene des Médicins Spécialistes [UEMS]

 College / Faculty CPD scheme available to all members and at reasonable cost to non- members who practise in a relevant specialty  Units or Credits for CPD based on activities eg delivering a new lecture 5 credits  250 credits to be collected in 5 years  Clinician submits ‘returns’ annually to College or Faculty  College audits proportion of ‘returns’ on annual basis  Standards for review of returns

 If ‘unsatisfactory’ outcome clinician is referred to Royal College Regional CPD adviser for advice (see example) Then referred to Royal College “Quality Assurance Framework for CPD”

1999[Bristol Inquiry, Kent and Canterbury] GMC “All doctors must be able to demonstrate that they can continue to be fit to practise in their chosen field” Evidence required:Formal review of practice and clinical performance ie Clinical Audit 1999CMO “Supporting doctors, protecting patients” requirements of governance and methods that would address poorly performing doctors

2000GMC“Revalidating doctors; ensuring standards, securing the future” Major emphasis of revalidation will be based on annual appraisal process [encompassing Clinical Audit and CPD] 2001 GMC [General Medical Council] “Good Medical Practice” Information for revalidation 2002 Royal Collegeseg RCPath “Guidance for pathologists on successful annual appraisal and revalidation” 2005 GMC Revalidation 5 yearly basis Annual Consultant appraisal HcC (2004) responsible for inspecting Consultant appraisal systems within hospitals

Several linked to CPD in health care eg Recommendation 82, it should be mandatory for all health-care professionals to participate Bristol Royal Infirmary Inquiry “Kennedy report 2001” made 198 recommendations

“Outcomes” 1 Assess development of clinical governance Recommendations for Education, training and development [CPD], and appraisal Study in West Midlands, England (Grainer et al 2002) Part of the model for successful implementation of Clinical Governance

There is an education, training and development strategy at organisational level There is a committee to draw together education, training and development issues There is a process for identifying education, training and development needs and outcomes linked to an appraisal process All staff are aware of their responsibilities to patients and colleagues, eg reporting poor clinical practice There is a Director with responsibility for co-ordinating Education and Training across the organisation

Clinical staff have individual performance review or appraisal, and this is appropriately recorded Clinical staff have personal development plans Training and development needs are linked to the business plan The culture is blame-free, supportive, educational, proactive, open and listening Life long learning education and training are tailored to both the individual’s and the organisation’s needs There is development of Clinical Teams working towards a genuine multi-professional agenda Access to comprehensive library and information facilities and support is readily available

“Outcomes” 2 Achieving progress through Clinical Governance [ Freeman and Walshe, 2004] Improving quality [includes CPD] Managing risk Improving performance [includes CPD] Corporate accountability Leadership and collaboration National Study in England Number of trusts = 100

Results Score Most Important Corporate accountability Managing risk Performance improvement Leadership and collaboration Improvement quality * * Most Achievement Corporate accountability Risk Management Improving performance Leadership and collaboration Quality improvement * * * includes CPD

Conclusion Since 1998 Continuous Quality Improvement [CQI] is mandatory in delivery of healthcare in NHS Clinical Governance underpins CQI CPD and CME underpin Clinical Governance and CQI Key goal is to improve patient outcome Government in UK (DOH 1998, 2002, Royal College of Nursing 1998, Royal College of General Practitioners 1999, Audit Commission 2001) “recognise clear link between education training and development in meeting patient needs and delivering high-quality care”.