A Framework of Quality Assurance (FQA) for Responsible Officers and Revalidation Ahead of the Curve RO conference 4 June 2014

FQA - Introduction Objective Key principles Background How the FQA will support Responsible Officers, Designated Bodies (DBs) and Higher Level ROs FQA - Core Standards FQA - Core Standards Categories FQA – Origins and Development FQA - Process FQA - Work stream Summary NHS England | Revalidation | FQA2

FQA - Objective The implementation of a framework of quality assurance (FQA): Encompassing all mechanisms by which ROs and DBs demonstrate to patients, the public, doctors and organisations that robust, consistent processes to monitor the performance of doctors are in place and are functioning effectively. Evidence based on the Medical Profession Regulations (2010, amended 2013) and in associated guidance. Designed to help ROs give confidence to their board (or an equivalent governance or executive group), patients, their own ROs, that the necessary functioning systems are in place and that appropriate action is being taken on the basis of the information they generate. NHS England | Revalidation | FQA3

FQA - key principles: FQA must support all ROs in fulfilling their statutory duties The model is of a single process of monitoring, culminating in the generation of an Annual Organisational Audit (AOA), which will feed a report from RO to their board (or an equivalent governance or executive group) and also the RO’s appraisal The reporting process for ROs must be: Streamlined Coherent Integrated – with other systems of quality assurance And minimise disruption and duplication of effort NHS England | Revalidation | FQA4

FQA - Background The FQA is about implementation of the RO Regulations (including Revalidation) and comprises: A set of ‘core standards’ derived from the regulations and associated mandatory guidance; Quarterly progress reports (appraisal rate) An Annual Organisational Audit (AOA); An Annual Report Template to help ROs in their reporting of progress to their DB; A statement of compliance (signed by DB board or equivalent governance or executive group member); and It also states that there must be mechanisms in place to help ROs achieve and demonstrate calibration and consistency of their decision-making (eg RO and appraiser networks). NHS England | Revalidation | FQA5

FQA – the elements: ‘Core Standards’ The FQA team has identified every item in the RO Regulations and all the associated mandatory guidance which must be in place (and which ROs will be expected to demonstrate) These have been compiled into a single list Each item has been referenced to the specific point or section of the regulations or guidance Each point of evidence or question of the reporting system for ROs is derived from the core standards Currently shows mandatory and good practice - excellent practice standards will be gathered and shared over time NHS England | Revalidation | FQA6

The designated body and responsible officer Appraisal policy, leadership and governance capacity and capability Monitoring performance and responding to concerns policy, leadership and governance capacity and capability Recruitment and engagement NHS England | Revalidation | FQA7 FQA – core standards categories

FQA – the elements: AOA ROs are familiar with RST’s ORSA exercise which assessed ‘readiness’ for implementing revalidation The AOA, based on the core standards, is similar, but assesses DB progress in implementing revalidation For ROs, the AOA provides a means of demonstrable assurance that systems and processes in their DB meet nationally agreed standards AOA data feeds into RO’s annual report to their board (or an equivalent governance or executive group) and submitted to higher-level RO along with a statement of compliance. These will be collated into a national annual report. It also feeds into the RO’s portfolio of supporting information for their appraisal. A process of independent verification will be introduced to support ROs in demonstrating performance NHS England | Revalidation | FQA8

FQA Process RO Report to DB Board* RO Monitors DB Progress ERIB RPB QCRC HR Governance Recommendations Quarterly Report Regional RO Higher Level RO 4 Reports 1 Report Compliance Statement AOA exercise DB Board* Approval NHSE Board Minister Annual Quarterly Monthly 700 Reports Independent Verification Governance Boards GMC Data Appraisals * Or Director or Executive Team as applicable NHS England | Revalidation | FQA9

Outcomes/benefits NHS | Presentation to [XXXX Company] | [Type Date]10 NHS England Provides; Designated bodies need to; Outcomes/ benefits Quarterly report Submit data to Regional Teams Helps ROs maintain systems to support measurement of appraisal rates Annual Organisational Audit (AOA) Submit via upload portal provided with AOA electronic return Provides a means of demonstrable assurance that systems and processes in the DB meet nationally agreed standards Board ReportTable at the relevant governance committee Support RO in ensuring sufficient resources and support are provided. Ensures the organisation is reminded of the requirements of the RO Regulations Independent Verification Review another DB’s systems & processes Receive feedback on your revalidation systems & processes Helps provide assurance that DBs are meeting the requirements of the RO Regulations. Develops understanding of best practice and provides mechanism for ensuring consistency

Making the most of the FQA Establish & maintain systems and processes for revalidation to meet requirements for FQA e.g. appraisal rate reporting Tailor to the needs of the organisation e.g. Board report Ensure the organisation understands the requirements of the RO Regulations Arrange an external quality assurance review, by peer review or through an independent organisation and submit report to support independent verification NHS | Presentation to [XXXX Company] | [Type Date]11

Suggestions for challenge by Boards (1) Non-executives of designated bodies may wish to constructively challenge their boards by asking: What integrated systems are in place for monitoring doctors’ performance? How does the organisation support staff-grade doctors and associate specialists, recognising good practice, encouraging and supporting development and learning? What are the annual percentages for completed appraisals for each grade of doctor? NHS | Presentation to [XXXX Company] | [Type Date]12

Suggestions for challenge by Boards (2) What systems are in place for monitoring the impact of the organisation’s implementation of the regulations on equality and diversity issues? How is the quality of medical appraisals assured? How is the quality of medical recruitment checks assured? How many doctors have required remediation in year? How is this remediation supported and funded? NHS | Presentation to [XXXX Company] | [Type Date]13

Suggestions for challenge by Boards (3) How is patient input to feedback on doctors obtained? How are current systems for patient feedback used for input into appraisals? How are quality improvement activities required for appraisal used to support the organisation’s priorities? What percentage of revalidation recommendations have had to be deferred and why? How is the organisation meeting its statutory duty to support the RO in implementation of the regulations? NHS | Presentation to Ahead of the curve. National ROs conference | [4 June 2014]14

Independent verification to provide assurance that there are robust systems in place to underpin the statutory responsibilities of the responsible officer minimum of once per revalidation cycle for each designated body. undertaken by the higher level responsible officer’s team desk top review of evidence and a visit to the responsible officer at the designated body if required to identify and disseminate good practice ROs may provide evidence to support independent verification through a report from an external QA review NHS | Presentation to [XXXX Company] | [Type Date]15

External quality assurance review Guidance and sample specification available Ensure it is carried out by independent personnel Based on core standards Submit full report to higher level RO’s team Share examples of good practice through RO networks Develop an action plan to meet standards where necessary Want to know more? Attend the workshop this afternoon NHS | Presentation to [XXXX Company] | [Type Date]16

Discussion points Does your designated body’s systems and processes align with the FQA? If not what changes are required? How will you make these changes? Can you make the reporting process as slick as possible? (quarterly reports and AOA) Does your Board (or equivalent) understand the requirements of the RO Regulations? If not what can you do? What mechanisms do you have for learning from other similar designated bodies? NHS | Presentation to [XXXX Company] | [Type Date]17

Discussion points Do you have identified people with responsibility for specific core standards? What examples of good practice / innovations can you share with others? NHS | Presentation to [XXXX Company] | [Type Date]18