Foundation School - Emergency Medicine F2 Level 2 visit report
|Chair||Miss Georgia Jones (Head of Peninsula Foundation Programme)|
|Level 2 Visit Date||Tuesday 24th January 2017|
|Trust under review||Royal Cornwall Hospitals NHS Trust|
|Foundation (Emergency Medicine)|
|Grade of trainees under review||F2|
|Reason(s) for review||
The GMC National Training Survey reported five years of consistent red outliers for workload for Emergency Medicine F2 posts.
The Foundation School also took the opportunity to review other domains which have the potential to cause concern.
Dr Anne Hicks (Head of Peninsula School of Emergency Medicine)
Dr Katharine Robinson (Emergency Medicine Consultant)
Dr Jeremy Langton (Deputy Postgraduate Dean)
Mrs Sophie Rose (Quality and Information Coordinator - note taker)
Mr Karl Westgarth (Rota Manager)
Dr Toby Slade (Clinical Director)
Dr Jenny Ferrant (Emergency Medicine Consultant)
Dr Anna Shekhdar (Emergency Medicine Consultant)
Dr Jonathan Wyatt (Emergency Medicine Consultant)
|Quality Register Item no. (s)|
1. Executive Summary
This was a Level 2 urgent concern review.
The Emergency Medicine Foundation Year 2 posts have been identified as negative outliers for workload in the GMC trainee survey for the last 5 years and for Handover in the last year. The posts have otherwise performed relatively well: they were positive outliers for Adequate Experience in the 2016 GMC survey. The department has a good record of supporting trainees who need additional help and the Fl posts were positive outliers in the 2016 GMC survey for Overall Satisfaction, Adequate Experience, Supportive Environment and Workload.
The high level of service pressure on ED departments nationally is widely acknowledged and, while our main focus was the F2s, the employer needs to consider the impact of working patterns on all staff groups in the department.
While the panel did not see any evidence that the rota fails to comply with contract or Working Time
Regulations, compared with other local F2 rotas the Truro F2s typically work longer hours with fewer days off. There is less bunching of similar rota shifts and a lack of a graduated movement into night shifts, both of which are recognised as being useful aids in helping individuals adapt to changing and anti-social work patterns.
The main outcome of the review visit was a commitment from the department to consider the rota afresh, giving due consideration to the pattern of different types of shift duties. The department had already ensured that trainees don't come back to a weekend working after a week's annual leave. In line with other trusts, it will consider lengthening shifts in order to enable more days off. The department also plans to reduce the number of staggered shift starts and consider the safety of staff finishing shifts in the early hours of the morning. The new rota will also prioritise attendance at teaching, with "overstaffing" on teaching days and regular teaching commitments being written into the rota so that they are visible to all. The 13.45 start time would be brought back to 1 pm so that F2s could attend the generic teaching programme.
Other areas identified for change were enhancing induction to confirm expectations about roles and responsibilities, consenting practice and handover protocol. The department will consider including the senior nurse in the medical handover, introducing an MDT safety briefing and standardising the weekend handover at 6pm. Recognising the challenges that the shift pattern presents to attendance at face-to-face teaching and training, the department would also like to enhance its provision of learning resources by developing an online component. Consideration would also be given to allowing F2s the time to make up teaching sessions that they were not rostered to attend.
The department responded positively to the issues raised by the review team and there is a considerable will to effect change. Given the nature of the changes required and for them to be sustainable, it will need support from the wider organisation (not only the education team) to provide an environment which is reliably consistent with the standards required for training.
It was recognised that, given the scale of the changes required, the rota manager would make some changes to the rota for April 2017 and plan for the full new rota for the August 2017 changeover. A follow up meeting was agreed to take place in May.
Required Action - Adaptations to existing rota for April 2017 and new rota in place for August 2017 addressing "step-wise" progression of duties into nights; increasing days off and ensuring that trainees can meet the requirement to attend teaching.
2. Educational Requirements
GMC Domain 1 Learning Environment and Culture
R1.12 Organisations must design rotas to:
a) make sure doctors in training have appropriate clinical supervision
b) support doctors in training to develop the professional values, knowledge, skills and behaviours required of all doctors working in the UK
c) provide learning opportunities that allow doctors in training to meet the requirements of their curriculum and training programme
d) give doctors in training access to educational supervisors
e) minimise the adverse effects of fatigue and workload.
3. Educational Recommendations
GMC Domain 1 Learning Environment and Culture R1.12
1. In relation to the requirement above, consider reducing staggered starts and changing the 13.45 start time to 13.00, lengthening shift to allow more days off, making training commitments visible on the rota and providing additional staffing to cover teaching attendance.
2. Consider building in study time for teaching sessions that trainees are not rostered to attend.
3. Liaise with rota manager at Plymouth Hospitals NHS Trust to discuss their approach to solving similar issues.
4. Enhance induction as suggested in the document.
5. Introduce safeguarding protocol for finishing late shifts.
6. Include senior nurse in medical handover.
7. Introduce MDT safety briefing.
8. Introduce educational faculty.
9. Follow up meeting in May with review team to assess progress.
4. Summary of discussions with groups
There are three Fls and seven F2s in post within the Emergency Department at Royal Cornwall Hospitals NHS Trust.
No trainees were present for the discussion however their views had been sought through the Quality Panel in November and the end of placement survey that fed into that panel. A copy of the rota had been provided prior to the visit and compared with F2 ED rotas from other trusts.
1. GMC trainee survey Spring 2016:
We considered the domains that flagged for F2 EM posts and all EM posts. There is no narrative in the GMC trainee survey but there was a nearly 100% response rate.
For F2s, the issues were high intensity of workload day and night; most reported working beyond rostered hours on a daily basis and feeling short of sleep on a daily basis because of the work pattern. While the quality of clinical supervision was rated as good or excellent by 6/7, all at some point said they were forced to cope with problems beyond competence or experience; 2/7 report some expectation to obtain consent for procedures where they feel they do not understand the proposed interventions and its risks.
For all posts, there is a range of opinion as to whether handover arrangements between shifts and departments ensures continuity of care but the item getting the strongest negative response is "appropriate members of the multidisciplinary team are included in handover". For induction 2/20 said they didn't get all the info they needed at the start of post, 3/20 said no one explained their role and responsibilities. There is also a range of opinion about the quality of induction but the item is a bit ambiguous (referring to induction to post and induction to organisation) so we have gone back to the GMC about that item. Local teaching was rated as less than good by just under half of all trainees and half said their work wasn't covered while they attended. Not all trainees described this as protected time. For regional teaching, 5/7 could get to it some of the time, 2/7 most of the time.
2. RCHT F2 ED November 2016 feedback
There were 3/7 responses to the F2 post survey in November 2016. They highlighted many good aspects of the posts including supervision, feedback, ability to get assessments done and clinical skills mix. 3/3 recommend the post. The main areas flagged were rota issues, balance of service and training, problems getting to teaching and difficulties taking study leave.
Free text comments included:
"If there was anything important it would be impossible to attend due to rota commitments. I was allocated to ALS midway through my annual leave which with current rota was unacceptable and I had to switch the dates."; "Fixed pattern of rota makes it impossible to take study leave. There is only a few weeks you're on a day shift and only then you could be excused from duties. Majority SHO shifts are either late shifts or nights and there is very little option to swap with anyone because other trainees are most likely working."
"Departmental teaching was on the same day as FY2 teaching which made it difficult to attend both."
"If the department was busy it was difficult for nearly all the juniors to leave. I rarely made teaching as often my rare off days were the only days I could go. Also often on late shifts or nights and coming in would make me too tired for work."
"I managed to attend mandatory teaching once in this post. On other occasions there were only F2s on duty and we couldn't be all released to teaching. The rota is structured in this way that Wednesday is often a one and only day off in the week and usually after a late shift so it is difficult to come to work in your already limited spare time."
"There is inadequate time off after night shifts - one day is not enough to recover and comeback for a day shift. There is too much variety in the pattern of the shifts - eg nights followed by days, and lates followed by days. Weekends and night shifts are the most stressful and they are often combined in a one long stretch of unbearable shifts.
"A lot of OOH work which was extremely tiring at times."
"There are Registrar vacancies that are not filled and when working while these rota gaps persist, it makes it difficult to gain feedback from your senior who is already significantly overstretched. When mandatory teaching takes place there should be a mix of F2 and core trainees so F2s could be relieved for the training."
"None of the days in ED is ever the same and you learn something every day. Seniors are readily accessible and it's easy to get feedback. Great opportunity to learn to perform procedures. And beyond all a brilliant team that is always willing to help and works effectively together."
"Despite being very busy you are exposed to a lot of situations that you can learn from. Also there is a very supportive team."
3. Rota issues
The F2 ED rotas from Exeter, Plymouth North Devon and Torbay were compared with the Truro rota. Truro F2s typically worked more nights, had fewer normal working days off and worked more hours on average per week. The frequency of working weekends and lates was about the same. One of the Truro week's leave ends with a weekend working. Truro F2s were rostered to be working on an F2 teaching day 5/15 weeks which was
comparable with Plymouth..
In the Quality Panel for Truro, the trainees appreciated the fact that weekend frequency had been reduced for the August 2016 start. The main point presented was the pattern of different working shifts which did not help the trainee to adapt to night shift by leading in to increasingly later starts and they thought contributed significantly to the extreme fatigue they described.
Three trainers attended the meeting along with the clinical director and rota manager. The clinical director described the current working environment for all staff in the ED, with the department working at over 100% capacity and the experience of "crowding". Standard Operating Procedures for managing patients in the corridor had been in place since the summer.
The trainers advised that the typical four month rotation for an F2 in Emergency Medicines consists of the following:
- An induction which includes IT training, an introduction to the department and their first simulation on sepsis. In the afternoon the leavers and starters have a social gathering.
- In-house training from 8.30am-11 am on Wednesdays (Paediatrics, trauma and medical sim).
- F2 Trust training 1 pm-2pm on Wednesdays
- Additional ad hoc training
- Assigned Clinical Supervisor
At the end of the placement, trainees provide feedback on their post and their clinical supervisor which is then fed back to the clinical supervisors. There is a consultant meeting once a week and all trainees are discussed at this meeting on a monthly basis.
There was an extensive discussion about the rota pattern which was acknowledged as being somewhat chaotic. It was recognised that changes had been made to the rota over a number of years in response to different issues and the time had come to go back to the drawing board and start afresh. Shift types needed to be grouped together so that trainees could go "step-wise" into nights to help with body-clock adjustments. An offer was made for contact with the Plymouth rota manager who had experience of dealing with this issue.
The trainers acknowledged that their trainees did have fewer normal working days off but that they run shorter shifts (in particular 10 hrs vs 12 hours elsewhere). On balance, the review team thought trainees preferred to have longer shifts with more days off.
The department had already ensured that trainees don't come back to a weekend working after a week's annual leave.
The department would consider reducing the number of staggered shift starts so that more people started work at the same time. This would simplify the work pattern and help with a more "collegiate" team feeling.
There was an agreement to "overstaff' teaching days so that attendance at teaching did not compromise cover.
The review team considered that the new rota should clearly show that it was giving weight to trainees' teaching requirements.
The rota manager advised that typically three juniors and one registrar working 1Opm-8am and one registrar will work 6pm-2am.The team discussed the arrangements for trainees finishing shifts at 2am and advised that appropriate safety measures should be put in place e.g. options for on-site accommodation or taxi home.
The department currently puts effort into making sure that all staff take their breaks. The department is redesigning the staff room which they hope will also encourage the trainees to take regular breaks.
It was recognised that, given the scale of the changes required, the rota manager would make some changes to the rota for April 2017 and plan for the full new rota for the August 2017 changeover.
The panel were informed that local teaching is not currently timetabled formally on trainee's rotas. This could impact on their ability to attend as sufficient numbers may not be rostered to cover and the message isn't being reinforced for trainees and others in the department that that's where the trainees are expected to be. The trainers agreed to consider moving departmental teaching to the afternoon and to change the 1.45pm shift start time to 1pm so that F2s working that afternoon can attend. As F2s cannot be rostered to attend every teaching session, the department will also consider rostering F2s the time to make up those teaching sessions so that they are not required to do this in their own time in an already busy placement.
They also discussed making all teaching papers/resources available online to those who are unable to attend a local teaching session. This is in line with what is offered at Plymouth. The department said that they needed some technical assistance to make this happen - a suggestion was that one of the trainees may like to take this on as a project
The rota manager confirmed that he has been working closely with the postgraduate managers since August 2016 to ensure that all requests for study leave have been approved. He had not turned down any requests for study leave and that he has worked with the post grad team to switch training days when needed e.g. for ALS. He sent a message to trainees about 2-3 months before start date about any requests for leave. The rota manager already gets notice of ST training days and writes them into the rota — a request was made for trainees not to be rostered on immediately before or after the training day. He also needs the ACCS training days which are on the Deanery website.
Trainers were advised that overall feedback for induction was positive however they feel that more emphasis could be made on the specific role and responsibilities of trainees at different grades. The department had not yet been asked to complete work schedules for their trainees and it was likely that this exercise would make the roles and responsibilities more apparent.
The panel suggested that the following points be added to the departmental induction:
1. Handover protocol - reemphasise escalation of referral if no response after 1 hour
- Clearly confirm that F2s are not expected to consent for procedures they are not doing themselves
- Study leave protocol: encouraging study leave applications — telling trainees that study leave had not been declined by the department since August 2016
- Emphasis on appropriate behaviour to interrupt a senior at night time to request advice/guidance
Departmental handovers had been changed since August 2016 with the introduction of a checklist, reiteration of the safety message of the week, note of patient deaths, review of staffing situation, output from the patient data system and going through the white board. Handover takes place at Sam, 1pm, 5pm and 10pm, with the big handovers at Barn and 5pm. From the discussion, it was agreed that it would be beneficial to formalise a 6pm handover at weekends.
Handovers are not currently multi-disciplinary and the relevance of this was discussed. The trainers decided that they will look to invite a senior nurse to handovers and consider a separate MDT safety briefing. They felt that there was more scope for MDT handover on the Clinical Decisions Unit. Trainers advised that they are looking to formalise the handover timings at weekends to accommodate those on the twilight shifts.
The department use a yellow sticker system to highlight low MEWS score patients who require two hourly observations. For handover to medical teams — patients are always referred to consultants and there is a "visible" handover. Surgical referrals are made by telephone to the SRU. Handover protocol is covered in induction — team will reemphasise escalation of referral if no response after 1 hour
The trainers were surprised that 2 trainees were reporting some expectation to obtain consent for procedures where they feel they do not understand the proposed interventions and its risks. They said that there was a clear message in the department not to undertake consenting for others and wondered if this expectation was coming from other departments. This issue had not flagged in the Quality Panel so we agreed to look at the next GMC trainee report and follow up if raised again.
The department needs to identify its educational faculty delivering EM training, in line with College requirements. It currently has 9 consultants providing 6 w.t.e. The team discussed focussing the training resource in fewer consultants, who should meet regularly and record educational meetings — the suggestion was ACCs lead, College Tutor and one other.
It was agreed that there would be a review meeting in May 2017.
The review team reported the findings of the review on the day to Mrs Johanna Gilbert, Senior Manager, Medical Education
4. Quality Process
Once the panel Chair has shared and agreed this report with all attendees for factual accuracy, it should be sent to the relevant Quality Manager (see below).
The final report will be issued to the DME by the Quality Team, as appropriate.
Peninsula: Jane Bunce (firstname.lastname@example.org)
The Quality Team will review and update the quality register and report to the General Medical Council (GMC), as appropriate.
5. DECLARATION BY CHAIR
I confirm this completed report is a true and accurate account of the level 2 visit. The key recommendations have been identified within this report in good faith.
I confirm that any significant areas of concern e.g. trainee safety or patient safety concerns have been brought to the attention of the relevant Director of Medical Education (or equivalent) and Medical Director for immediate attention.
Name: Dr Martin Davis (Associate Dean for Quality) Date: 27th February 2017