“…I’ve spoken to the department, and we feel we’ve had the NSF, and we’ve had the HCC, and we really are not interested in participating in any kind of review process.”

APA Peer Review of the SW A Mug’s Tale Dr Simon P Courtman Plymouth

Draft Proposal for Revised APA Inter-Departmental Peer Review Scheme  “….. a voluntary process with the aim of raising standards of paediatric anaesthetic practice within an anaesthetic department. The process should allow for experiences to be shared, with the dissemination of good or innovative practice”.

Pilot Project in the South West  Amiable  Dedicated  Dynamic  Functional – strong existing regional network - SWACA

Barnstaple Truro 170 miles

General Considerations

Politics  National  Healthcare Commission  20 cases  Separate environment  PLS and Child protection  Local politics  Love thy neighbour?  Bigger brother

Peer Review Scheme I. Basic Peer Review Departments will self check against criteria in a freely available template, collecting evidence of sound departmental structure, organisation and management which allows for the provision of high standards of patient care. II. Peer Review Visit  send the self assessment report with summary of evidence to the peer review group.  A team of 4 will visit the hospital for 1 day, see the clinical and administrative areas, interview staff, observe clinical practice and go into issues in more depth.  Following this a full report of the findings of the Peer Review Group will be sent.

Basic Peer Review  Department’s perceived strengths and weaknesses compiled by the paediatric anaesthetists  Check-list of criteria for good practice  RCA, AA, NSF, HCC  360° appraisal of the department by colleagues and patients/families – revised June 08  Case studies Critical incidents

South West Wave 1

South West Wave 2

Self Assessment – Strengths and Weaknesses  The paediatric anaesthetists make a list of those aspects of their work which they perceive as good and those they think need improving.  The aspects which need improving are considered, any which can be fixed from within the department are addressed.  The process is repeated until eventually the list consists only of strengths, and of weaknesses over which the group has no control.

Strengths 1.Small team who all get on well despite having strong individual views but will play the consensus game 2.Trust wide view developing of the paeds management and a familiarity amongst staff of who the paeds team are. 3.Flexibility amongst the team regarding on call swaps and list re- arrangements. 4.Plym Unit. A small compact efficient well equipped and staffed unit for doing paeds 5.“Having me!”

Weaknesses  Lack of a dedicated out of hours paeds unit with dilution of paeds experienced theatre staff (e.g out of hours ODP’s)  Low throughput of small paeds cases leading to limited exposure for team  Lack of paeds surgery cover  No PICU  Difficult paeds airways cases limited to small number of consultants  Limited paeds related meetings in dept ( e.g. journal club)

360° appraisal of the department by colleagues  People to contact  Head of Department of Anaesthesia  Surgeons with paediatric practice  Consultant paediatricians  Chief Executive  Medical Director  Theatre Manager  Directorate Business Manager  Anaesthetic Secretary Senior ODP / anaesthetic nurse Recovery staff Senior paediatric ward nurses, Play specialist Trainees PICU Consultant Local transfer team Pain team ED Consultant

360° appraisal of the department by colleagues  How is the paediatric anaesthetic department perceived? Strengths and weaknesses  Is the clinical anaesthetic service high quality? Have you any major concerns with the management of the department, the delivery of the anaesthetic service or with individual anaesthetists?  Do the anaesthetists work as a team with each other and with colleagues?  Formal working relationships with colleagues: multidisciplinary committees and clinical teams – do they exist and do they work?  Informal working relationships with colleagues: collaboration on management of theatre lists, care for individual patients – does it work?

360° appraisal of the department by colleagues  Colleagues are invited to help in the department’s self-review by offering 360° appraisal.  This is a voluntary process being undertaken by the paediatric anaesthetists to consider and improve their service.

Timeline

The Peer Review Visit  Source of Anxiety  Realistic expectations  Confidentiality  Difficult to Organise

Picking the Team I. Peer review organiser identifies Visiting Peer Review Team a) two doctors ideally from the local paediatric anaesthetic network and a lay visitor from the APA list. II. Selection of peer review teams a) The APA peer review committee have a list of anaesthetists and lay people who can make up a visiting team b) Where the local paediatric anaesthetic network is established, the two doctors in the team might be drawn from it; otherwise from APA members in the same region. It is hoped that establishing peer review through local networks would also encourage their development c) Safeguards are necessary to ensure that peer review could not be misused for local political or rival institutional purposes. d) The lead reviewer will collate and write the report and should have peer review experience e) The peer review team could include, in addition as an observer, an APA member interested in taking part in peer review

Picking the Team  Balance and kudos  Which clinicians?  Lay persons experience  Adolescents

The Peer Review Visit Association of Paediatric Anaesthetists Interdepartmental Peer Review - Derriford Hospital Visiting team 5 th September 2008 Dr Peter Stoddart – Consultant Anaesthetist, Bristol – Lead Dr Rebecca Mawer – Consultant Anaesthetist, Truro Dr Kate Thornton – Consultant Anaesthetist, Frenchay Mrs Anna Mumford- Local Lay Member Mrs Madeleine Wang – Lay member and APA Peer Review Committee Observer Dr Trottie Kirwan – Consultant Anaesthetist, Chelsea – APA Peer Review Committee Observer

Review Visit Schedule 09:00 review team meets and discusses aims of day 09:30 tour of areas accessed by children, meet children, parents and staff 12:30 lunch, meet other anaesthetists, surgeons etc 14:00review team discusses observations 14:30review team and local anaesthetists discuss aspects of portfolio to establish areas of good practice and areas to improve 16:00end (ish)

APA Peer Review Report  Review team lead collects feedback from all team members and from visited centre  Collates report within realistic timeframe (???)  Draft sent to reviewed centre for comments  Final version published Final version published  PRIVATE – for your eyes only

Feedback  “It has been an invaluable experience”  “FYI - that's a glowing endorsement in Andrea speak”  “We are happy with this report and believe it is well judged and gives a good summary of where we are and where we need to be.”

Regional Co-ordinator

Lessons Learned  It takes time

Timeline – even longer

Lessons Learned  Roll with it Ali vs. Foreman, Kinshasa 1974

Lessons Learned  Engage “no” =“call me back” “I said no” =“time to reflect” “The dept said no”=“Would you be a reviewer?” “Yes” “We’ll do it next”

Lessons Learned  Review Teams and Visits Assign team to centre and arrange time Rescheduled every review so far Lay person expectations unachievable  Short supply  No review experience  No experience with children  Try primary school teachers?

Lessons Learned  Reassure Anonymity of provided information Confidentiality of portfolio Privacy of final report

Was it worth it?  Portfolio is a satisfying definition of what you are and what you do  Peer review visit is an unexpected chance to share  Peer review visit is a chance to get support  Learn a lot about each other

Animal Love