Foundation Programme (Surgery) - Level 2 visit report

 

Local office name: Health Education England, working across the South West

Organisation under review: Royal Cornwall Hospitals NHS Trust

Placements reviewed: Foundation Programme (Surgeru)

Date of Review: Thursday 16th November 2017

 

BACKGROUND

Reason for Review

2017 GMC National Training Survey and the HEE Quality Panels process indicated some concerns for foundation trainees working in surgical posts at the Royal Cornwall Hospital

No. of Learners met

6

No. of Supervisors/Mentors met                        

7

Other Staff members met

3

Duration of review

4 hours

Intelligence sources seen prior to review

GMC NTS results 2017, Quality Panel results 2015-16 and Rota's

 

PANEL MEMBERS

Name Job Title
Dr Martin Davis Head of Quality, HEE
Dr Hiu Lam Interim Head of Foundation School and Associate Dean, HEE
Dr Steve Boumphrey Foundation Programme Director, Derriford Hospital (Plymouth)
Mr Bill Wylie Lay Representative
Ms Jane Bunce Quality Manager

 

EXECUTIVE SUMMARY

A review of the Foundation surgical programme at Royal Cornwall Hospitals NHS Trust was instigated in response to concerns raised by trainees through the GMC National Training Survey (NTS) and Quality Panels process.

Supportive environment, overall satisfaction and induction were flagged through the 2017 GMC NTS and the posts were graded as Requires Improvement or Inadequate through the 2016 Quality Panel process.

A number of requirements are suggested within the report to:

  1. Clarify how trainees should access senior support
  2. Improve communication of rotas
  3. Allow trainees more flexibility around annual leave
  4. Improve consistency in how The Lounge is managed
  5. Embed a culture of learning within the department
  6. Raise the issue of unacceptable behaviour, by a minority of senior staff, within a senior staff departmental forum

The posts are acknowledged by trainees as having great potential for providing an excellent learning environment but this will require the issues highlighted in this report to be addressed.

REPORT SIGN OFF

Outcome report completed by (name) Dr Martin Davis / Ms Jane Bunce
Chair's signature Dr Martin Davis
Date signed 17th January 2018
 
HEE authorised signature Dr Martin Davis 
Date signed 17th January 2018
Date submitted to organisation 17th January 2018

 

 ORGANISATION STAFF TO WHOM REPORT IS TO BE SENT

Job title Name
Director of Medical Education  Dr Chris Williams
Directorate Manager Mrs Lisa Duckham
College Tutor Mr Mike Clarke

 

RISK SCORES (1-25)

Score prior to review Likelihood 4 - Impact 3 = 12 AMBER 
Proposed scores following review  Likelihood 4 - Impact 3 = 12 AMBER

 

PATIENT/LEARNER SAFETY CONCERNS

Any concerns listed will be monitored by the organisation. It is the organisation's responsibility to investigate/resolve.

Were any patient/learner safety concerns raised at this review?  NO 

 

EDUCATIONAL REQUIREMENTS

Recommendations are a proposal as to the best course of action.

Please note that the Department provided an action plan in advance of the Triggered Visit and this is included at Appendix 1.

Were any requirements to improve education identified? YES

 

Related Domain(s) and Standard(s) 

Learning Environment and Culture, supporting learners

Summary of findings
  1. Supervisors were confident of their availability to offer necessary support to their trainees however the panel found that trainees were less confident in this respect.
Required action
  1. Department to issue more explicit guidance on how trainees should access senior support both in context of elective ward work and acute work on The Lounge.

 

Related Domain(s) and Standard(s)

Learning Environment and Culture, supporting learners

Summary of findings
  1. The panel were told that change to the rota's is not communicated well and there is very little flexibility around allocated leave.
Required action
  1. Department to improve communication around rota management and to devise a mechanism to allow more flexibility around annual leave.

 

Related Domain(s) and Standard(s) 

Learning Environment and Culture, supporting learners

Summary of findings
  1. The panel heard that The Lounge can work well and be beneficial for patient flow, however it also heard that there are days when it could work a lot better.
Required action
  1. Department to improve consistency of how The Lounge is managed, ensuring trainees receive the necessary senior support to enable them to discharge patients in a timely manner. 

 

Related Domain(s) and Standard(s)                      

Learning Environment and Culture, supporting learners

Summary of findings
  1. Trainees told us that consultants are very willing to answer questions but it was felt that educational and learning opportunities could be improved by explaining the reason for a decision rather than the decision itself when time allows this to happen.
Required action
  1. Department to work towards embedding a culture of learning to support on the job teaching and learning.

 

Related Domain(s) and Standard(s)   

Learning Environment and Culture

Summary of findings
  1. Instances of unacceptable behaviour by seniors to trainees were reported to the panel. This was restricted to a minority of seniors (unnamed) but confirmed by the cohort of trainees seen.
Required action
  1. Raise this at a departmental meeting of seniors emphasising zero tolerance of this. It is not expected that an investigation is to be carried out.

EDUCATIONAL RECOMMENDATIONS

Related Domain(s) and Standard(s)                                               

Learning Environment and Culture; supporting learners; developing a sustainable workforce

Summary of findings

 

It was acknowledged that the reduction in Foundation trainees working in Surgery had impacted on workload.  Encourage momentum of appointment of non-medical learners to cover surgical activity with forward planning over a longer cycle than 12 months at a time. Specialist nurse input was valued by the learners interviewed.

The department and Trust should be more pro-active about thinking how wider workforce roles can support patient care. They may wish to utilise HEE workforce and transformation team in these discussions.

GOOD PRACTICE

Good practice is used as a phrase to incorporate educational or patient care initiatives that are worthy of wider dissemination, deliver the very highest standards of education and training or are innovative solutions to previously identified issues worthy of wider consideration.

Learning environment/Prof.group

/Dept/Team  

Good Practice

Related Domain(s) &

Standard(s)

  The posts were acknowledged by trainees to have great potential for learning if the issues addressed in this report can be addressed.

 

 

SUMMARY OF DISCUSSIONS WITH GROUPS

 

LEARNERS

The panel met with Foundation trainees based in Colorectal, Vascular, Urology, Upper GI and Breast Surgery.

 

Senior support

The panel heard that when consultants and registrars are in theatre, it can be daunting accessing senior support.

In some departments there can at times only be an F1 on the ward although it was acknowledged that trainees would feel comfortable accessing help from each other on different wards.  When on-call trainees described being able to access help.

Trainees described The Lounge, which is a triage area for surgical patients who could be potentially managed without an admission, was described as not as effective as it could be; although when it works, it works very well.  Its efficiency can be dependent upon the senior cover for that day. Trainees felt exposed in this area and on occasion may admit a patient to a ward to ensure patient safety, which if unnecessary needlessly impacts on available beds in the hospital.  Patients can come in to The Lounge at 9am and potentially wait until 7pm for senior decision making.

The intention is for a consultant or registrar to visit The Lounge at points throughout the day to make decisions. This is inconsistent in its application.  If they are held up in theatre, this can result in a sudden rush to complete discharge arrangements as The Lounge is about to shut.  Furthermore, from 7pm trainees have to hold the bleep which can result in an unmanageable workload.  (Post meeting note: this was 5pm previously but department has made changes to the rota such that an F1 undertakes ward jobs 5pm-7pm and handover at 7pm those outstanding to enable F1s to leave on time and reduce workload for on call F1).  Trainees were concerned that very sick patients can inadvertently be admitted to The Lounge.

 

Workload

The need for more registrars was highlighted by the trainees, describing the current cohort as ‘pulled everywhere’.

The Trust has been looking at how the wider workforce can support rotas.  Upper GI has a specialist nurse and whilst they can’t do everything, when available this really helps.

A lack of consistency in senior cover was described; with some days have 4 registrars and others, none.  Some weeks, staffing numbers seemed OK and sometimes not.

Trainees said that no Physician Associates had been employed in surgery.  The specialist nurses are valued and provide a really good link for the trainees and go ‘above and beyond’ to be helpful.

 

Rotas

The rota coordinator was described as not always being receptive to junior doctor needs.  There is an elective rota and an on-call rota.  The on-call rota can get changed and not communicated to the elective rota, which has caused confusion regarding trainees’ responsibilities.

The rota doesn’t acknowledge potential inexperience when placing trainees in clinical areas for example as an F1, you can be on the ward on your own on your first day which can be difficult.

The F1 weekend cover rota was described as ‘chaotic’ and the outliers are reportedly unmanageable.  Trainees said they fail to leave on time as it difficult to handover jobs. Finish times particularly on a Sunday are not realistic of the work that needs to be done before the trainee is able to leave. (Post meeting note: There are not enough staff and department has had to reduce the number of F1s in the afternoon on Sunday to create hours to provide the additional F1 5-7pm during the weekdays outlined above). 

 

Annual leave

Trainees described being given fixed options of annual leave.  It was not possible to get time off for a family event even if sufficient notice is given. Swapping leave with other trainees was not encouraged as it can lead to breaches of contractual hours.

 

Supportive environment

The panel was informed that when certain combinations of medics and nurses are working together the environment can be very unpleasant and hostile.

When asked about unacceptable behaviour the trainee group agreed that this has occurred on more than one occasion. It is restricted to a small minority of senior staff. The panel did not feel it was an appropriate environment to explore this further by naming individuals.  One senior was described as having made a fair point but it was done in an undermining bullying fashion, rather than in a constructive manner.

It was acknowledged that when busy, people do get stressed.

One trainee described asking ‘silly’ questions when first in post but the consultant did not mind and said they would prefer to be asked.

Trainees described the jobs as daunting at first.  If your first job as an F1, the induction needs to be clearer about who to contact in an emergency.

 

Teaching

Trainees described formal teaching difficult to attend when working on St Mawes or in The Lounge.  Limited opportunistic teaching takes place on the ward.  Trainees said that if one asks a question, one will receive an answer but no explanation as to why this is the case.

Trainees saw their role as dealing with triage, admin or managing simple medical jobs.  It was difficult to get WBAs completed when working in surgery.

The trainees view The Lounge as an ideal opportunity to receive teaching.

The formal teaching offered on a Friday was well received but only 3 trainees can go due to the rota.

 

Trainee priorities

The trainees were asked to name 3 things they would prioritise:

 

  1. More registrars to help with discharge and decision making
  2. Senior presence on The Lounge and the ward to allow for timely discharge
  3. An F2 on St Mawes all the time – currently the F1 can be on their own

 

SUPERVISORS

Senior support

The trainers said they would be surprised if trainees did not know who to contact for clinical support as this is included within the induction.

Consultants all carry mobile phones and they encourage trainees to contact them.

The consultants said they have an active presence within the department and have the opportunity to see trainees each day.  They are present over the weekend.  They acknowledged that visible support is not always as obvious as other specialties, due to their need to be in theatre.

The Tower surgical wards are roughly ½ mile from other surgical environments. This exacerbates the perception that consultants are not visible and makes working together as a team more difficult. 

The consultants felt that The Lounge works well as a triage space and for patient flow.  They acknowledged that a lot of cases could be triaged earlier in the day. Their workload pulls them in different directions and hence the triage system becomes less efficient.  The day before the visit had been particularly chaotic resulting in patients still in The Lounge at 8.30pm.

The consultants acknowledged that acutely unwell and therefore inappropriate patients could end up in The Lounge; however, a new standard operating policy had been put in place to address this.  

 

Workload

The drop in F1 numbers (17 to 15) has negatively impacted on the department as has the need for locum registrars who were in short supply and therefore producing unreliability in staffing levels. 

The department has been investigating other roles to help manage the rota. A programme to train nurse specialists has been instigated.  They have been bringing in 3 a year but the programme has around a 25% attrition rate.  Furthermore, as the department has to re-apply for funding each year the proposed solution has inherent instability built into it. They find this frustrating and feel that decisions are reactionary rather than proactive.

The consultants voiced an interest in learning what other Trusts do in terms of utilising other staff to fulfil roles traditionally undertaken by trainee doctors. They were keen to explore different workforce models.

 

Rotas & Educational Roles

The consultants confirmed that there is time in their job plans for educational supervision.  Clinical Supervision has become more time consuming, this is not recognised in current job plans.

The department tries to ensure that a trainee’s Clinical Supervisor is from within the elective block in which the trainee is working and therefore has working time with them during their surgical placement.

Any sickness exposes the rota and they would be keen to explore a flexible workforce model to help address problems caused by rota gaps.

 

Teaching

The trainers said that teaching in the workplace is challenging due to pressure of time but they acknowledged this was something to which to aspire.

They were aware they should be supporting trainees to complete WBAs. It was recognised that locums and registrars are unable to do these.

 

 

MANAGEMENT TEAM

The management team were aware of the trainee staffing shortages.

They confirmed that an SHO is now embedded within the rota on St Mawes.

The team reinforced the consultants’ frustration regarding the inability to obtain rolling finance to train nurse specialists.  There were currently 6 in post and the department would like to recruit more. Re-applying for funding was described as time consuming and therefore frustrating.

The team recognised the rota issues described by the trainees. They are proactively performance managing this and would like to be made aware of problems so that they can deal with the issue.  They were trying to have a greater presence in the clinical environment. The panel heard that trainees have approached the management staff for support when issues have arisen.

They confirmed that rotas are all compliant with the new junior doctor contract.  Where trainees require flexibility within the rota, the management staff advised trainees to go to them directly.

The team agreed that they would look at the induction process to improve communication about clinical supervision and senior support and ensure requirements for weekend cover are clear.

The team felt that the majority of the consultant surgeons were approachable.   When asked if they would be surprised to hear that unacceptable behaviour of a minority had been witnesses, they said that they would not be surprised.

 

 

Appendix 1

 

RESPONSE TO GMC & QUALITY PANEL FEEDBACK

Foundation Programme, Royal Cornwall Hospital

Trigger Visit by HESW 16th November 2017

 

Background

In response to results from the national GMC trainees’ survey 2017 as well as the quality panel 2016, concerns were raised regarding provision of training at Foundation level in surgery, which has prompted a ‘trigger visit’ by HESW.

It is notable that surgery has dropped from 16 F1s to 14 F1s over the last 18 months resulting in major challenges in covering the rota requirements that are essential to provide safe patient care.

 

Concerns raised

Surgery FY1

GMC Survey

a)     Supportive environment

b)     Overall satisfaction

c)      Induction

 

Quality panel

a)     Effective educational environment – Requires improvement

b)     Safe supportive working environment – Requires improvement

c)      Quality data – requires improvement

d)     Overall grading – Requires improvement

 

Comments:

Negative - Shambolic rota, little feedback, hard to complete SLEs, not supported, no time for clinic & theatre, no formal teaching, poor middle grade cover.

Positive – Supportive in urology & vascular

 

Surgery FY2

GMC Survey

a)     Reporting systems

b)     Teamwork

 

Quality Panel

Similar concerns as above

 

Comments:

Negative - Poor induction, difficult to do SLEs, stay late

Positive – Good fun and great surgical exposure and good learning experience

 

Actions taken

Supportive Environment

  1. Change to Consultant job plans September 2016

Additional Consultant time was added to the acute service to cover the emergency CEPOD theatre operating from 08:00 – 12:00 with a nurse assistant. This meant that the on call Consultant, registrar and SHO were free to complete the post-take surgical ward round and support the F1 in completing tasks generated from the ward round, including completion of discharge summaries.

 

  1. All registrar off-site outpatient clinics removed

Middle grades were scheduled to attend commitments on the main RCHT site only providing support to the F1s / F2s each day.

 

  1. Employed F2 doctor as F1

Due to the further drop in F1s a previous F2 doctor was employed as a Trust grade F1 to support the rota April – July 2017

 

  1. Employed locums to fill middle grade rota gaps

Directorate engagement enabled us to employ locum doctors to fill many of the rota gaps reducing the requirement for internal locum shifts

 

  1. Rota change

Pulled back working hours from Sunday with additional 2hr work on an F1 each day (1700 – 1900) to complete unfinished ward jobs on outlying wards.

 

  1. Addition of F2 or CT to surgical assessment unit (St Mawes Ward)

An additional F2 or CT is now rostered to St Mawes ward 08:00 – 17:00 on a 1 in 10 basis to support the solitary F1 covering the St Mawes ward during the day, in addition to their normal on call and elective commitments.

 

  1. Training and introduction of Gastrointestinal Nurses (GINs)

Training of experienced GI nurses (GINs) to support Foundation doctors in the elective and emergency setting. Further GINs currently being trained.

 

  1. Weekly diary meeting

Review cover at all levels to ensure safe provision of patient care in surgery and adequate supervision of F1s / F2s. Rota reviewed including annual and study leave applications.

 

Overall Satisfaction

  1. Introduction of local departmental teaching programme for F1 / F2s

Combination of case presentations (enabling completion of SLEs for CBDs and observation of teaching), bedside teaching (enabling completion of CEXs) and invited speakers. 12:30-1:30pm on Friday.

 

  1. Combined ward rounds within most surgical specialties

Facilitates teaching ward round opportunities, improves exposure to a broader range of cases thus increasing experience and creates a sense of ‘being part of a team’, with improved social interaction between members of the team.

 

  1. F2s attend CEPOD emergency operating

This has enabled protected time in theatre with further learning opportunities (e.g. DOPS)

 

  1. Presentation at monthly governance meeting of relevant departmental Trust target performance measures

A move away from ‘ranting’ group emails regarding VTE prophylaxis, antibiotic course prescription, discharge summary completion rates, to enable open discussion, address issues that may have contributed to underperformance, praise good performance and support junior doctors in achieving targets

 

Induction

  1. Structured local departmental induction programme

Checklist used to ensure all crucial aspects covered (derived from ‘initial clinical supervisor’ checklist on Horus portfolio). Focus on managing expectations of F1s / F2s within surgery and structures of support / escalation as well as incident reporting.

 

  1. Allocation of educational and clinical supervisors

Provided at commencement of the post at induction to prevent delays in arranging initial meetings

 

  1. Surgical ‘handbook’

Written by previous F1s / F2s outlining top tips for those doctors working within surgery

 

Reporting Systems

  1. Outline of reporting systems used in the Trust at induction

F1s / F2s encouraged to openly report concerns and a support structure for doing this is outlined at induction (incl. Datix reporting)

 

  1. Feedback of outcomes from ‘Datix’ events at monthly governancemeeting

Plans to introduce “Top 5 learning events” in monthly audit meeting

 

Teamwork

  1. Combined ward rounds

Most surgical specialties have now developed combined ‘grand ward rounds’, as outlined above. This demonstrates to trainees effective working between members of the multidisciplinary team and harbors a sense of being a ‘team member’.

 

Summary

In response to the results from both the GMC survey and Quality Panel feedback, we have made a number of significant changes which we hope will improve the training environment and thus future feedback results. This information has been presented at the surgical directorate meeting and in my role as College Tutor I have distributed these results to all  surgical specialties involved to ensure that changes can be made accordingly.

 

The ongoing reduction in F1 doctors within surgery, with increasing numbers being allocated to specialties where they are ‘supernumerary’ is undoubtedly impacting on the entire surgical service, resulting in reductions in our elective capacity as well as additional knock-on effects on training at both CT and ST doctor level. We are keen to work closely with HESW in the future to improve our training provision further.

 

Michael G. Clarke MD FRCS(Gen)

Consultant Upper GI & Bariatric Surgeon

College Tutor for Surgery

3rd November 2017

 

 

Date of report: 20th November 2017

Author: Dr Martin Davis / Ms Jane Bunce

Job Title: Head of Quality / Quality Manager