Postgraduate School of Medicine Quality Management Visit to SOUTH DEVON NHS FOUNDATION TRUST

 

30th May 2014

 

  

 

Postgraduate School undertaking visit: Medicine 

Primary author of report (name and job title): Dr Nicholas Withers, Head of School of Postgraduate Medicine

Local Education Provider visitedSouth Devon Healthcare NHS Foundation Trust (SDHT)

Visit team (names and educational job titles)

Chair

Dr N Withers

Panel members

Bill Lusty – TPD Acute Medicine

  Ray Sheridan – TPD Geriatric Medicine
  Steve Iles – College Tutor, CMT
  Tarek Shirazi – College Tutor, CMT & Gastroenterology rep
  Alison Moody – TPD CMT and Respiratory Medicine
  Ravik Mascarehanas – Rheumatology TPD
  Antonia Brooke – Diabe & Endo TPD

Medical externality

N/A

Lay representative

Mr B Wylie

Programme / Specialty

No. of trainees seen

No. of trainers seen

CMT, Respiratory, Gastro, Diab & Endo, Geriatrics, Rheumatology, Cardiology, Acute,

14

6

Evidence considered prior to review taking place: none

Date visit report ratified by SWPPME

14th July 2014

Date visit report made available to provider

17th July 2014

Date provider ratifies visit report

July 2014

Circulation of this report: PPME Quality Team, SDHT Director of Medical Education

 

Executive Summary

The over-riding theme of this Quality Visit to the South Devon LEP was a culture of very satisfied trainees who recognised that the training and experience of working at the Trust was excellent. This was supported by evidence of keen and dedicated Educational and Clinical supervisors who in the main have undertaken (or are currently undertaking) appropriate training to fulfil their roles.

 The visit was well supported by the local education team and trainee and trainer representatives were available from most specialties either on the day of the visit or by separate meeting when attendance on the day was not feasible. One notable absence from the process was Acute Medicine where it has not been possible to obtain trainee or trainer feedback at the time of writing the report.

The visit highlighted one significant area of concern with regards to supervision of CMT (and Foundation) trainees on the Oncology ward and its potential impact on patient safety. Immediate supervision of these doctors usually falls to a Staff Grade doctor who at the time of the visit was on maternity leave and had not been replaced. Consultant cover for the trainees is via a Consultant of the day telephone, but trainees reported a lack of consistency in response to this method of communication. Furthermore, at times when the Oncology CMT trainee is on Acute Medicine duty, Oncology inpatients are looked after by the Oncology F2 alone with the above inadequate senior cover provision in place. This issue was highlighted to the DME on the date of the visit and by subsequent letter to the DME and Medical Director. An immediate remedial action plan was forwarded to myself by the Clinical Director in Medicine and a further check on the impact of this remediation is currently being undertaken through our quality processes.

 CMT doctors were  very happy with their training aside from the impact of the Acute Medicine blocks on their ability to have consistent exposure to their 4 month specialties. This relates to both in-patient and outpatient experience. It is recommended  that the allocation of new CMT and ACCS approved training posts from August 2014 will enable a rota redesign that will improve this situation.

Trainers had undergone appropriate training  and felt well supported by the Trust and LETB in these roles. The majority of trainers described appropriate time/recognition in their job plans for educational supervision roles, but also reported that realistically they were all working beyond the time described in their job plans for direct clinical care, hence much of their ES/CS work was undertaken in their own/additional work time. Despite this the trainers who were interviewed represented an enthusiastic and dedicated resource who appear to be well supported by the Educational Team at the Trust.

Overall the impression was that of a happy and well satisfied group of trainees and a well- developed training environment supported by well trained and enthusiastic trainers.

  

Key recommendations

Ref

Department / Programme / Specialty

Key recommendation(s)

1

Oncology

 

Immediate action to provide adequate and safe supervision of CMT (and Foundation) Trainees on the |Oncology Ward including immediate cover of absence of Oncology Staff Grade on maternity leave

 2

 

CMT

 

Review of current CMT rotation and the use of blocks within each 4 month post to provide AMU cover. Use of new CMT/ACCS approved training posts to provide 4 month Acute Medicine blocks to lesson impact of Acute Medicine rota on speciality inpatient and outpatient experience

 

3

 

Respiratory

 

Consideration of a more formal pleural ultrasound service (currently very reliant on input from StRs) with recent appointment of new Consultant.

 

4

 

Endocrinology

 

Consideration of including the Year 2 StR in the Endocrine Ward Review rota (with Consultant supervision) to allow on-going exposure and experience in specialty.

 

5

 

CMT/Medicine

 

Review possibility of remote access to online induction modules or more dedicated time for completion of modules in the workplace.

 

6

 

Medicine

 

Review of trainers job plans to ensure consistent time allocated for ES/CS role and that this time is not overwhelmed by increasing clinical workload

 

7

 

Cardiology

 

Review of future provision of training in pacemaker procedures due to constraints with numbers and trainers requirements for their own continuing experience.

 

Areas of good practice

Department / Programme / Specialty

Area(s) of good practice

 

CMT/Acute Medicine

 

The change to all day teaching session has been valued and is highly praised by trainees. Of note Simulation training provided by Acute Medicine Department is excellent.

 

Medicine

 

All trainees are discussed at a monthly meeting of Consultant/supervisors. This enables early detection of any difficulties/struggling trainees and provides good feedback on performance of trainees in GIM

 

Cardiology

 

There is in-built flexibility to the Cardiology StR training which allows for a certain amount of tailored and individualised experience for the trainees.

 

GIM

 

New StRs shadow the on-call GIM StR for a couple of hours at either end of a shift. This is highly valued and helps trainees to be more confident and familiar with processes prior to staring on the on-call rota.

 

Rheumatology

 

Rheumatology ES was praised for excellent supervision and support

 

Endocrinology

 

Excellent and well- structured educational supervision

 

Geriatrics

 

Training is flexible and tailored to individuals experience and future training needs

 

Respiratory

 

A well supported and flexible training programme suited to both ST3s and those in their final year.

 

Gastroenterology

 

Excellent supervision with good experience in Endoscopy .

 

 

Summary of the visit

Patient safety inc. handover and induction

A major concern regarding supervision of CMT and F2 on the Oncology ward in the absence of the Oncology Staff Grade was reported at the visit. This was immediately escalated to the DME on the day of the visit and by subsequent letter to the MD and DME

Department / Programme / Specialty

Area(s) of development

Oncology/CMT

Immediate action requested to ensure adequate and safe supervision for Oncology trainees in CMT and Foundation, appropriate support and input for Oncology inpatients and adequate cover for maternity leave of current Oncology Staff Grade.

 

CMT

Trainees described some issues with on-line induction programmes which were not accessible outside the Trust. If remote accessibility is not feasible then trainees require  allocated time to complete this training

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

 

The trainees interviewed were all very satisfied with the level and expertise of educational and clinical supervision within the Trust. It is clear from the compliments for many trainers that the team of supervisors within Medicine are enthusiastic, motivated and highly skilled in these roles.

In the Departments where trainers were interviewed Consultants in the ES and CS roles have undergone or are undergoing the appropriate training programmes in accordance with GMC guidance. Most trainers felt that there was recognition of the role in their job plans but that overall workload meant they did not have enough time to dedicate to the role

 

Department / Programme / Specialty

Area(s) of development

Medicine

Review of all ES and CS job plans to ensure that there is consistent recognition of these roles and time freed up to allow roles to be undertaken.

Training environment (inc. access to educational resources

Trainees reported an excellent culture of learning and supervision within the Trust. The Education centre is well resourced with helpful staff

Department / Programme / Specialty

Area(s) of development

 Medicine

No significant issues flagged other than remote access to online induction modules as described above

Work load

Most trainees thought that their roles were busy but workload was not excessive. Some StRs commented that the GIM rota was busy but manageable, others thought that the GIM StR role involved too much clerking and not enough time to supervise more junior doctors’ work- this discrepancy may reflect GIM StRs at different points in their Higher Specialist Training. In some specialties there were minor concerns (both from trainers and trainees) regarding the impact of the GIM rota on specialty training

CMT trainees reported they were busy but had good experience. There is no time in their normal working day to undertake QI/Audit work which is in the main done in their own time.

One Respiratory trainee highlighted a significant  (and increasing) workload in pleural ultrasound and procedures, the burden of which falls mainly on the two StRs

Department / Programme / Specialty

Area(s) of development

 

CMT

Review of day to day workload and incorporation of time for audit/QI within this

 

Respiratory

Review of workload of pleural work and consideration of a formalised pleural clinic/rota once new Consultant in place.

Adequate experience / achievement of curriculum competencies

Specialty training in the main highlighted no significant concerns with gaining of appropriate experience or competencies both within specialties and and GIM. The Endocrine Year 2 Trainee does not take part in the daily inpatient review of Endocrine problems which was thought to be a lost opportunity to gain further experience/exposure in the subspecialty.

The Cardiology trainer interviewed highlighted a future potential issue with pacemaker training brought about by minimum number of procedures required for training and the minimum number required by trainers/service providers to ensure they fulfil their own requirements for maintaining competencies.

CMT doctors reported difficulty in attending the required number of OPD clinics required in CMT curriculum.

Department / Programme / Specialty

Area(s) of development

 

Endocrine

Consideration of adding Year 2 trainee to the daily Endocrine review rota to allow continued exposure/training in the Specialty

 

Cardiology

Trainees to liaise with TPD re numbers issue for training trainees whilst still undertaking adequate number of procedures themselves to remain validated and competent in the procedure as trainers.

 

CMT

Review of attendance at OPD in each specialty for CMT trainees and to build on this process with redesign of rota as previously described above.

Teaching – local, regional and study leave

Trainees did not report any difficulties with obtaining study leave. StRs reported satisfaction with Regional Specialty and GIM training days.

CMT trainees were very complimentary of the recently introduced local training days and the simulation training provided by the Acute Medicine Team.

Several trainees mentioned difficulty in attending the Medical Grand Round on a Monday which is always a very busy day on the wards following the week-end break

Department / Programme / Specialty

Area(s) of development

 

Medicine

Attendance at Medical Grand Round by juniors should be reviewed and if this is an issue consideration to moving date away from a Monday should be given.

Undermining, bullying and harassment

There were no issues or concerns raised in this area.

Additional comments / feedback

Overall, the team were very impressed with the level of dedication and expertise in training and the high levels of trainee satisfaction in all areas.

 

 

 

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 has 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:

 Dr Nick Withers [Signature removed for website]

Chair educational role:

 

Head of Postgraduate School of Medicine

Date of signature:

 

 

 

 

 

 

 

 

Health Education South West Peninsula 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 has been reviewed and deemed appropriate for the purpose as stated.

That 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 [Signature removed for website]

HESWPPME educational role:

 

Associate Dean for Quality

Date of signature: