Foundation School Quality Management Visit to the ROYAL DEVON AND EXETER NHS FOUNDATION TRUST

 

28th May 2014

 

 

PostgraduateSchool undertaking visit: Foundation

Primary author of report (name and job title): Georgia Jones, Head of Peninsula Foundation School

Local Education Provider visited: Royal Devon and Exeter NHS Foundation Trust (RDE)

Visit team (names and educational job titles)

Chair

Ms Georgia Jones, Head of Peninsula Foundation School

Panel member 1

Prof Hisham Khalil, Director of Clinical Studies and Inter-Professional Learning, Plymouth College of Medicine and Dentistry

Panel member 2

Dr Cate Powell, Director of Medical Education, Royal Cornwall Hospitals NHS Trust

Panel member 3

Mr Matthew Bowles, Director of Medical Education, Plymouth Hospitals NHS Trust (previously Foundation Programme Director)

Panel member 4

Ms Caroline Rawlings, Medical Education Manager, Northern Devon Healthcare NHS Trust

Panel member 5

Ms Jane Bunce, Peninsula Foundation School Manager

Medical externality

Prof. John Saetta, Foundation Programme Director, East of England FoundationSchool

Lay representative

Mr John Moran, Lay Representative

Programme / Specialty

No. of trainees seen

No. of trainers seen

Foundation Year 1

32

14

Foundation Year 2

20

Evidence considered prior to review taking place: GMC trainee survey (2013); Trust’s current action plan based on GMC survey and other visits; Summary of trainee experience of educational supervision (2011-13)

Date visit report ratified by SWPPME

8th August 2014

Date visit report made available to provider

8th August 2014

Date provider ratifies visit report

1st September 2014

Circulation of this report:  PPME Quality Team, RDE Director of Medical Education, RDE Foundation Programme Directors, RDE Medical Education Manager

 

Executive Summary

The foundation programme at the RD&E currently hosts 42 full-time F1s, 37 full-time F2s and two less than full-time trainees. It includes 3 academic programmes.

The trust scores above the national mean for the overall satisfaction of foundation trainees with their training (GMC trainee survey 2013).The overall impression given by the trainees was that they valued the training and working experience they were getting at the RD&E. Many had discussed it with their peers in other parts of the Peninsula and outside the region and seemed very confident that their experience compared extremely well. 

Departmental induction is generally well provided with a few exceptions. The development of the Trainee Toolbox on-line resource should supplement the process well.

The trust has made significant progress with ensuring appropriate consenting practice; comments from the trainees indicated that some T&O registrars’ expectations of F2s’ consenting needs some further attention.

Significant recent developments in the extent of consultant-led patient reviews and improved staffing in medicine at weekends seem to have made a positive impact on the trainees’ working experience. We understood that the trust is moving to 7 day consultant review with Gastro and Cardiology not yet included due to other service demands.

The formal teaching programme would benefit from review and trainee involvement in its development. Excellent examples of departmental teaching were reported, such as in Plastics and Geriatrics and in Gastro where there was weekly teaching and a journal club but in some departments, trainees felt that formal and informal teaching was lacking.

The trust has had plans to implement a Hospital at Night model for a few years but these have not yet been realised which seems to have held back associated developments such as the implementation of an electronic handover system and the development of clinical support roles. Weekend handover of patients from MAU to the wards was flagged as a patient safety concern to which the trust is responding.

There are some pockets of activity where workload appears to be particularly high: the Neonates rota is built on too few people and there are reported staffing gaps in T&O and Gastro. The trust is shortly to implement a Surgical Admissions Unit which it is hoped will address the surgical out-of-hours high workload.

The newly introduced simulation programme for foundation trainees is not yet fully embedded. The education team has had difficulties securing faculty and technical support to deliver simulation and the trainees were unclear as to whether the sessions were mandatory.

There is a monthly education team meeting and an education committee that includes the heads of School and Specialty Tutors. Board level representation of education matters is through the Medical Director via the Director of Medical Education. The education team is to be congratulated for its role in the development of the Quality Improvement Academy which supports trainees to develop and deliver quality improvement projects, helping the trainees to achieve the curriculum outcome and benefit the service delivered by the trust.

The visiting team was delighted to have such good representation from trainees and supervisors and appreciated the effort made by all to secure this attendance.

Georgia Jones

Head of Peninsula Foundation School

  

Key recommendations

 

Ref

Department / Programme / Specialty

Key recommendation(s)

 

Date for review

1

Medicine

There needs to be a robust mechanism for handover of patients from MAU to the wards out-of-hours.

End September 2014

2

T&O

Review the care of patients: trainees reported that due to gaps, there are not enough doctors to see patients on exceptional days

Ensure that there is a planned induction in place and monitor its delivery.

End September 2014

4

Induction

Some departments are still reported as having inadequate inductions. Recommendation to implement the Deanery’s minimum standards for induction which include departmental teaching for new doctors about commonly presenting problems.

End November 2014

5

Patient care

The role of foundation doctors in completing Treatment Escalation Plan (TEP) forms needs to be clarified and understood by the trainees and those supervising them.

End September 2014

6

Handover

The Trust has an IT Project Broad and recognises the need for IT support for handover, however progress is slow. Recommendation that this issue is given new impetus to enable robust patient handover.

 

7

Colorectal Surgery

Review the hours worked by colorectal trainees as these are reported as excessive.

End November 2014

8

Consent

Significant progress has been made in this area. Some pressure points remain: we recommend that the T&O registrars are reminded of consenting policy and their role in ensuring appropriate practice.

End September 2014

9

Medicine working pattern

Review the appropriateness of the 12 day working pattern which trainees described as exhausting and taking leave just to break it up.

End November 2014

10

Physician assistant roles

Review the Trust’s infrastructure of workforce support for tasks such as phlebotomy and cannulation. As well as a lack of provision, trainees reported underuse of staff who had been trained in these skills.

End November 2014

11

Teaching programme

F1s reported that the rotating day is too difficult for them and the departments to manage and F2s would prefer whole day teaching rather the 2 hours per fortnight. F1s were encouraged to propose a teaching programme and order to the education team. Recommendation to engage with trainees to consider alternatives to the current arrangements.

End November 2014

12

Simulation training

Confirmation that this is a mandatory part of the training programme. The trust needs to identify the technical support to deliver the programme.

End November 2014

 

Areas of good practice

Department / Programme / Specialty

Area(s) of good practice

Programme

The trainees reported feeling very supported and described approachable consultant colleagues and other senior colleagues who were easy to access directly for support.

Trainees reported enjoying the experience of training in the RD&E and were generally of the opinion that training here was better than anywhere else.

Programme

Development of a “Trainee Toolbox”: a trainee quality improvement project to extend a national initiative to the RD&E: process by which up-to-date information about particular posts that supports induction is uploaded and available on-line to the next foundation trainee rotating.

ED, Psychiatry, Rheumatology, Geriatrics, Neonates, Cardiology

Examples of good departmental induction practice were provided.

Education team

General high level of support provided to trainees and trainers.

Programme

Trainees reported a level of experience that was within their competencies and did not feel out of their depth.

Education team

Development of the QualityImprovementAcademy – an educational infrastructure to support trainees in quality improvement projects.

Surgery

Positive attitude of nurses to teaching practical procedures

 

 

Summary of the visit

Patient safety inc. handover and induction

Some departments are delivering a very good and comprehensive induction for trainees e.g. ED, Psychiatry, Neonates, Cardiology (3 hours with a consultant reported) and Geriatrics. Others still need development e.g. trainees reported they are given a handbook for vascular but not much else and that they needed someone to talk them through the information; the colorectal induction was described as a 10 minute chat; it was reported that there was no induction in T&O; a trainee in O&G was given the bleep in the morning and a walk around the department in the afternoon. The trust has an existing action to instigate an induction handbook and register in all departments. The “trainee toolbox” is being developed as an on-line resource for new doctors rotating into departments. Trainees said that the handover from the outgoing trainee was the most important aspect and the trust is encouraged to consider how this process might be formalised.

An issue was raised that there was no induction for trainees in AMU if they were not there for the first post induction.

Trainees reported that while there were handover arrangements in place, an IT system to support this process was needed to prevent patients being overlooked. Trainees identified handover of patients from AMU to the wards at the weekend as an area of weakness and that patients could get missed despite ward rounds happening.

Trainees were unclear whether they should be completing Treatment Escalation Plan (TEP) forms. There is a variation in practice across departments with consultants only completing in some cases and foundation trainees completing them in others.

Department / Programme / Specialty

Area(s) of development

Medicine

There needs to be a robust mechanism for handover of patients from MAU to the wards out-of-hours.

Induction

The trust is encouraged to implement the Deanery’s minimum standards for induction which include departmental teaching for new doctors about commonly presenting problems.

AMU

Ensure that an induction is planned for every trainee working in AMU whatever time of year they are working there.

T&O

Ensure that there is a planned induction in place and monitor its delivery.

Programme

The role of foundation doctors in completing Treatment Escalation Plan (TEP) forms needs to be clarified and understood by the trainees and those supervising them.

Supervision – clinical and educational (inc. career guidance, feedback)

Day to day clinical supervision was generally described as good or excellent although some variation was acknowledged, usually depending on the registrar. Trainees reported that they could easily get hold of people for support and were clear about the on-call pathway for accessing help. O&G and Neonates were mentioned as being very well supported. The weak area appeared to be day-time support for surgical F1s when their seniors are in theatre, although surgical consultants were described by the F1s as very approachable; the issue was availability. A concern was also raised about the cover for overflow wards where staffing was ad hoc which made it difficult to get plans made for patients.

Trainees knew who their educational supervisor was and managed to meet with them. Assessments were reported as being more difficult to achieve in cardiology, upper GI and colorectal because seniors didn’t appear to have the time to do them.

An example was given of a trainee having to find their own clinical supervisor but this seemed to be a one-off.

 

Area(s) of development

Medicine

Need to ensure robust staffing plan for overflow wards so that patients get the same level of care as established wards.

Surgery

Clarify the pathway for F1s to access help if their seniors are in theatre

Assessments

Cardiology, upper GI and colorectal consultants need to be aware of the trainees’ view that it is particularly difficult to get assessments done. Encourage to find a solution to this.

Training environment (inc. access to educational resources)

The ability to take study leave was thought to be dependent on the job. Some F2s felt that consultants did not understand their entitlement and they had been asked to transfer study leave to a day off.

Trainees would like more clarification about appropriate courses for study leave e.g. are women’s and men’s health course run by the RCGP allowed?

Trainees reported that senior nurses in surgery were very happy to teach procedures e.g. NG tubes.

Trainees would like to be able to experience clinics but it was recognised that this may not be a realistic aim in many F1 posts.

Mention was made of the supportive medical Registrar and the opportunities for presenting and feedback in AMU.

Urology was described as a lovely team, adequately staffed with opportunities for clinic and surgery. The Eating Disorders post was described as having wide and varied learning opportunities.

Trainees said that it was easy to get involved with audits and teaching but one commented that the environment was not particularly supportive/conducive to academic research.

Trainees were positive about the careers management teaching session and had access to 2-3 careers sessions. They said that the careers team was very approachable.

Department / Programme / Specialty

Area(s) of development

Programme

Ensure that clinical supervisors understand the entitlement to study leave as part of the conditions of having a trainee.

Programme

Provide a list of courses that are routinely approved as appropriate for study leave.

Programme

Consider how trainees could be helped to access research opportunities.

Work load

The weekend workload for trainees in medicine appears to have been improved with additional staffing and consultant weekend ward rounds. Trainees still felt they needed more juniors to do the work. The support of nurse practitioners in AMU was acknowledged by the trainees who felt this role would work well on other wards.

There appeared to be issues with training others to take on clinical tasks e.g. it was reported that O&G nurses were trained to cannulate but don’t do it, attempts had been made to train HCAs for cannulation and venepuncture but this had been stopped.

Trainees reported large variations in the workload for surgical posts and said that the rota did not appear to take account of “take” such that workload could vary between 3 and 60 patients. They report that the trainees doing Colorectal as their first post typically stay until midnight and that those who do it in subsequent posts stay until 8pm. Their informal advice to colleagues is not to do Colorectal as their first post.

Trainees in medical posts do not understand how surgical posts appear to get more leave through compensatory rest. Trainees would like to have access to on-line rather than paper-based monitoring.

An example was given of a trainee not being able to take 2-3 days annual leave in Colorectal.

In T&O, significant staffing gaps were reported; 4 or 5 had left since December and were not being replaced until August. This meant that some days, doctors had 40 patients each which meant that not all patients were seen and continuity was disrupted. They said they had been paid extra because of the hours being worked.

The Neonates rota was described as being “10 minutes off being illegal” which meant trainees sometimes worked 14 or 15 hour shifts and that it was impossible to swap duties with others.

The trainees told us that Sharon Booth who did the medical rotas was excellent and made a lot of effort to solve issues.

Department / Programme / Specialty

Area(s) of development

Surgery

Review surgical rota to take account of effect of post-take patients in order to smooth the variation in workload

Colorectal

Review the working hours of the F1 in Colorectal in the August post.

Rotas

Clarify for the trainees why they have compensatory rest in Surgery but not in medicine

Adequate experience / achievement of curriculum competencies

Trainees were unclear as to whether the simulation training was mandatory. There were some problems reported getting the opportunity to complete the female catheterisation procedure, especially for male trainees. However, no trainee has ultimately not been able to find this opportunity.

Department / Programme / Specialty

Area(s) of development

Simulation training

Confirm with the trainees that simulation training is mandatory

Teaching – local, regional and study leave

The visitors recognise the difficulties planning an educational programme that suits all needs. However, the formal teaching programme would benefit from review and trainee involvement in its development. While the education team reported that the programme is planned for the year, the trainees said that it lacked organization and gave presenters too little time to prepare. There are longstanding differences of opinion of how and when the programme should run e.g. F1s reported that alternating the day isn’t helpful (e.g. can’t arrange departmental teaching if you don’t know what days the F1s will be at generic teaching) and F2s would prefer full study days rather than fortnightly 2hr sessions and say that the break in the session is unnecessary. F1s said that it would be helpful in some cases to have teaching from senior trainees rather than consultants as they knew better what they needed. Trainees were bleeped by the education team to remind them to attend.

Excellent examples of departmental teaching were reported, such as in Plastics, Psychiatry, Neonates, Respiratory, GP Learning Sets and Geriatrics and in Gastro where there was weekly teaching and a journal club, but in some departments trainees felt that formal and informal teaching was lacking. Some trainees said it was impossible to attend 70% of the trust-wide teaching due to leave and rota patterns and that videoed teaching would help.

Department / Programme / Specialty

Area(s) of development

Programme

Review the timing, content and order of the programme with the trainees to improve their “buy-in”. The F1s told us that they would propose a programme to the education team.

Programme

Ensure that trainees are aware of e-learning options to make up for sessions genuinely missed

Departmental Teaching

Review the extent of departmental teaching for foundation trainees. Extending the provision across departments would enhance the training experience

Undermining, bullying and harassment

No concerns were raised with the visiting team. There were numerous comments about the trust being a friendly and supportive place to work.

Additional comments / feedback

Clinical supervisors typically take on the educational supervisor role for their first trainee of the year. Trainers were happy with this arrangement rather than fewer of them having more trainees. Supervisors reported that trainees are good at making the initial contact but usually need to be chased for meetings later in the year. Some supervisors do not chase their trainees at all. A couple of supervisors routinely saw their trainees for a mid-point review. The trainers found the last CS meeting difficult as it came too early in the post.

Several trainers said they wanted more training in the eportfolio. The general feedback was that they did not find the e-portfolio useful as a tool, although one supervisor said it was helpful when they had a trainee who was having problems. There were complaints that the CS could not view their trainee’s SLEs although the rationale for this was explained. Several commented that the eportfolio times out too quickly without saving a draft.

Trainers recognised that they needed to be on very safe ground if they were to write negative comments about a trainee. The potential use for multiple consultant reports to feed into the CS report was emphasised in the discussions.

Trainers had time in their job plans for the ES role but said that this time was not protected, there was a squeeze on it by the trust and that time for clinical supervision was not recognised.

Most trainers were aware of the Deanery careers service. They knew who to contact if they were managing a trainee with difficulties. They felt supported by the education team and said their response was good, they had been actively helped and they knew structures were in place even if they didn’t often use them. They commented that they would like more involvement with Occupational Health: we discussed including this request in the original referral. Trainers would like more feedback from the education team about their management of trainees with difficulties.

All recognised the importance of having an education building again and the team located there.

Department / Programme / Specialty

Area(s) of development

Supervision

Encourage the good practice for clinical supervisors to review all trainees mid-post.

Supervisor training

Develop an e-portfolio session as part of faculty development training

 

Education team to feedback to supervisors regarding their management of trainees with difficulties.

 

 

 

Visit Panel Chair Declaration

This completed report is a true and accurate account of the discussion that I participated in or were reported to me from this visit.

The key recommendations have been identified within this report have been identified with good faith.

I can confirm that any areas of significant concern and that have a direct impact upon patient safety have been brought to the attention of the relevant Director of Medical Education (or equivalent), responsible Medical Director and Executive Lead for Quality at Health Education South West Peninsula Postgraduate Medical Education.

Chair name:

 

GEORGIA JONES

Chair educational role:

 

HEAD OF PENINSULA FOUNDATION SCHOOL

Date of signature:

 

11 June 1014

 

 

 

 

 

 

 

HealthEducationSouthWestPeninsula Postgraduate Medical Education Declaration

I as signatory on behalf of Health Education South West, Peninsula Postgraduate Medical Education can confirm that the information and associated recommendations provided via this report have been reviewed and deemed appropriate for the purpose as stated.

Recommendations contained within this report have been documented as part of the quality management processes of Health Education South West Peninsula Postgraduate Medical Education and where appropriate will be reported to the General Medical Council (GMC) as required.

Name:

 

Dr Martin Davis

HESWPPME educational role:

 

Associate Dean for Quality

Date of signature:

 

3rd September 2014