Case study: South Tees Hospitals NHS Foundation Trust
ORSA (Organisational Readiness Self-Assessment) is a self-assessment tool designed by the NHS Revalidation Support Team to help designated bodies in England determine whether they are ready for revalidation.
The objectives of the ORSA exercise are to:
- ensure designated bodies understand what will be needed when revalidation starts
- identify and prioritise areas for development at a local, regional and national level
- contribute towards the Secretary of State’s assessment of readiness for revalidation in 2012.
The exercise was a two-stage process. The first stage or base-line assessment was completed by designated bodies in April/May 2011, based on the picture at the end of March 2011. A further full assessment of organisational readiness will take place in April/May 2012 to highlight progress made during 2011/12 and to inform the Secretary of State's overall assessment of readiness.
South Tees Hospitals NHS Foundation Trust, runs both acute and community services, with specialist services covering a population of 1.5 million in Tees Valley, parts of Durham, North Yorkshire and Cumbria. It has a workforce of 9,000 employees, including over 500 consultants, SAS doctors and non-training grade doctors.
Appraisal and revalidation has been a priority for the Trust for a number of years. They had been training appraisers and appraisees and monitoring appraisal data for consultants and SAS doctors since 2007. A Revalidation Steering Group was set up in May 2009, including senior clinicians, HR and clinical effectiveness representation, and continues to meet regularly.
South Tees submitted its ORSA return by 31 May 2011 for the appraisal year April 2010 to March 2011. The self-assessment revealed that, although the Trust was making good progress in its preparations for revalidation, there were a few areas it needed to focus on over the coming months. These included:
- ensuring they allocated sufficient resources to enable the RO to undertake his responsibilities
- updating their medical appraisal policy to meet the new requirements of the Responsible Officer Regulations
- ensuring they had a sufficient number of trained medical appraisers
- putting in place a system for performance managing appraisers
- putting in place a system for to obtained information from a new doctor’s previous RO
“Most of the issues we’d picked up previously,” explains Professor Robert Wilson, Responsible Officer and Medical Director for South Tees NHS Foundation Trust, “but the discipline of having to work through it step-by-step and knowing there was going to be external scrutiny was really useful.”
Following this analysis, the Trust developed an action plan, which included:
- developing a business case to address outstanding resources in order to fulfil revalidation statutory requirements, to be presented to the board
- completing and approving the new appraisal policy by December 2011
- providing further training and workshops for appraisers to be ‘revalidation ready’
- ensuring appraisers receive feedback from those on whom they undertake appraisals
- ensuring pre-employment and RO information is received from other organisations for newly appointed doctors.
One of the main challenges has been the process of ensuring all the doctors they are responsible for receive an annual appraisal. The Trust aims to achieve 100% of doctors receiving annual appraisals by the end of 2012-13.
Sue Wooding, Revalidation Manager, explains that sometimes doctors might not complete their appraisal within a 12-month period due to clinical commitments leading to the appraisal meeting being cancelled or the paperwork not being finished in time.
“We’re trying to get organised and get ahead of the game,” explains Professor Wilson. “We have 525 doctors who need to be revalidated so we need to think ahead. We aim to get 25% through an appraisal in each quarter.”
“We’ve been chasing doctors who haven’t had an annual appraisal,” adds Sue. “We need to get to 100%.”
Finally, although most of their doctors recognised the reasons for appraisal and revalidation, Sue explains that “there were a few that felt ‘we’ve heard it all before’. The message we’ve put out is ‘It’s here now. This is definitely happening.’ "
Responsible officer training
Responsible Officer, Professor Wilson and Jim Hall, Deputy Responsible Officer completed modules 1 and 2 of the responsible officer training in June 2011. They will complete the third and final module in November 2011. Professor Wilson has found the training particularly useful:
“There were a lot of senior people in the room so we had a well-informed discussion about what the challenges were and how we can help each other,” he explains. “I found it reassuring that others were facing the same challenges.”
The regional responsible officer network, which meets every month, was also a useful forum:
“We identified areas where we can help and learn from each other, says Professor Wilson. “It’s been a forum for sharing best practice.”
The Trust has identified that resources will be required to enable substantial appraiser training, staffing and support for the revalidation manager to ensure compliance and ongoing development of data systems and data collection. A business case will be prepared to address outstanding resource issues.
Training and development of appraisers
Consultant appraisers had been attending in-house appraisal training workshops since 2007. At the time of writing, 93 consultants had undertaken formal appraisal training.
The Trust expects to offer ‘revalidation ready’ training for new appraisers and ‘top up’ training for current appraisers from 2012/13. It is also implementing the Client Focussed Evaluations Programme (CFEP), a patient and colleague feedback tool, which will help appraisers understand the findings and outcomes in order to give feedback to their appraisees.
SAS doctors had not previously received appraisal training, but three appraiser training sessions have now been organised by the Postgraduate Manager and will take place between September and November 2011. This will help raise their awareness of what’s required and what revalidation will mean for them.
Quality assurance of appraisers
The Trust is also focusing on quality assurance of appraisers. All appraisers can now expect to receive feedback from those doctors on whom they perform appraisals. The outcomes of completed appraisals will be reviewed and all medical appraisers will undergo an assessment after their initial training or probationary period.
Clinical governance data systems
The Trust will proactively remind individuals when their appraisal is due and direct them to an individual report based centrally on their clinical governance system. Currently, doctors have to contact the relevant manager to access information about any complaints, claims and incidents relating to their practice, in preparation for their appraisal meeting. The Trust plans to provide this information together with the clinical information mentioned above.
Involving the board
Professor Wilson has been responsible for engaging the board, taking information from the ORSA exercise and other learning from the local responsible officer network.
“We used the ORSA exercise as a gap analysis to help us identify where more work was needed and what resources we needed to do this properly. I was able to then discuss this with the board,” he says.
“The board were surprised at how detailed the work has been and the volume of the work. They now know how much there is to do.”
Benefits and next steps
Overall, the Trust has found the ORSA exercise invaluable:
“It’s assured us that we’re in a good position for revalidation,” says Professor Wilson, “but it’s highlighted a small number of areas where we’re not in an ideal position and it’s allowed us to focus on those. It’s been a useful benchmark to help us both learn from and help others.”
“It’s given us a structure, so instead of having bits of information in different places, it’s all in one document,” reflects Sue.
“We’ve come a long way in the last six months. We know where we’re heading, we’re putting things in place and we’ve briefed the Trust board so they’re aware of what they have to do.”