Postgraduate School of Radiology Quality Management Visit to Royal Devon and Exeter NHS Foundation Trust

 

Date:  7th May 2014

  

PostgraduateSchool undertaking visit:  Clinical Radiology

Primary author of report: Dr Tom Sulkin, Head of School

Provider visited:Royal Devon and Exeter NHS Foundation Trust

Date(s) of visit: Wednesday 7th May 2014

Visit team (names and educational job titles)

Chair

Dr Tom Sulkin, Consultant Radiologist, Truro and Head of School

Panel member 1

Dr William Mukonoweshuro, Consultant Radiologist, Plymouth and TPD

Panel member 1

Dr Mark Puckett, Consultant Radiologist, Torbay and TPD

Panel member 2

Dr Priya Suresh, Consultant Radiologist, Plymouth and RCRCollege Tutor

Panel member 3

Mr Joseph Campbell, School Manager, HEE SW

Panel member 4

Dr Janice Ash-Miles, Consultant Radiologist, Bristol and RCR Regional Educational Adviser

Lay representative

Maria Harding

Programme

No. of trainees seen

No. of trainers seen

Radiology

Four

Seven

Evidence considered prior to review taking place: Questionnaires were sent to all trainers and trainees (none returned prior to visit), hours monitoring report.

Date visit report ratified by HESW – Peninsula

25th June 2014

Date visit report made available to provider

25th June 2014

Date provider ratifies visit report

22nd July 2014

Circulation of this report: PPME Quality team, Director of Medical Education, RD&E

 

Executive Summary

The South West offers training based at the PeninsulaRadiologyAcademy, one of only three radiology academies in the country. The Peninsula Radiology Academy is close to Derriford Hospital in Plymouth and is the only purpose-built facility for the training of radiology trainees of its type in the world. Trainees split their training time between the Academy and clinical radiology departments in Barnstaple, Exeter, Plymouth, Torbay and Truro. Placements are for one year.

The Postgraduate School of Radiology holds 61 NTNs. In 2013-14 8 trainees were based in Exeter (3 ST2, 1 ST3, 1 ST4 and 3 ST5). In addition, one ST5 trainee based in Barnstaple has undertaken on call in Exeter. In 2014-15 ST1 trainees will rotate to all clinical sites (with the exception of Barnstaple) for the first time. This will increase trainee numbers in Exeter.

Trainees described the radiology department in Exeter as ‘a popular placement’ that they would ‘recommend to a colleague’. The visiting team found that radiology training in Exeter is delivered by a team of enthusiastic educational and clinical supervisors who provide comprehensive senior support and supervision for all trainees.

‘Exeter is a much enjoyed and popular placement with lots of examples of good practice in learning and training.  The educational team from Head of School through to Clinical Tutor and educational supervisors are motivated and interested’ (Dr Janice Ash-Miles, RCR Regional Educational Adviser).

There is an appropriate balance between service and training. Trainees are given well judged opportunities for independent practice commensurate with level of training

Examples of good and best practice are included in the report and will be disseminated to other training centres through the School Board. 

Recommendations include the need for an urgent review of the on call rota.

Dr Tom Sulkin, Consultant Radiologist, Truro and Head of School

 

Key recommendations

1

Examples of good and best practice should be shared with other localities through the School Board.

2

The trainees’ on call rota should be urgently reviewed to ensure it is safe. A revised rota should be implemented for the start of the new training year in September 2014.

3

Consultants unable to provide adequate support and supervision for trainees should be provided with appropriate feedback and where necessary alternative supervision should be put in place for the start of the new training year in September 2014 .Adequate support and supervision is particularly important out of hours.

 

Dr Tom Sulkin, Head of School

 

 

Areas of good practice

Department / Programme / Specialty

Area of good practice

Department of Radiology, Royal Devon and ExeterHospital, Exeter, SW Peninsula Postgraduate School of Clinical Radiology

Apart from two areas of concern – the extent of the on-call duties and the non-engagement of one or two consultants – Exeter is a much enjoyed and popular placement with lots of examples of good practice in learning and training. The educational team from Head of School through to Clinical Tutor and Educational Supervisors are motivated and interested. There are many examples of good practice.

Dr Janice Ash-Miles, RCR Regional Educational Adviser

 

Radiology training in Exeter is delivered by a team of enthusiastic Educational and Clinical Supervisors who provide comprehensive senior support and supervision for all trainees. All have engaged with appropriate educational training provided by the School, Deanery or RCR. Training activities are recognised in consultant job plans.

Junior trainees are also well supported by senior trainees.

 

The College Tutor (Dr John Apsey) is enthusiastic and provides excellent trainee focussed support for all trainees. Trainees’ timetables are flexible and ensure that training opportunities meet the requirements of the RCR curriculum and provide opportunities to develop sub-specialty interests.

 

The clinical timetables for trainees in Exeter provide a broad range of experience across most subspecialties. As a result of the comprehensive nature of the clinical services provided subspecialty training in musculoskeletal radiology and Interventional Radiology are particularly strong.

 

Trainees have their own office and on call room with access to books and journals. They also have good access to reporting PACS workstations and PCs.

The radiology department in Exeter is well designed with all modalities available in a single department. This facilitates multimodality and cross-specialty training.

 

The Biopsy and Drainage (BAD) lists provide an excellent opportunity for trainees to gain experience in non-vascular IR.

 

As a result of the balance between general and specialist radiology services and the enthusiasm for teaching and training the Clinical Radiology Department in Exeter offers excellent broad based core training in general radiology with excellent opportunities for subspecialty training. The latter complement opportunities available at other localities to ensure comprehensive curriculum delivery across the training scheme.

 

There is an appropriate balance between service and training. Trainees are given well judged opportunities for independent practice commensurate with level of training

 

The trainees run the departmental discrepancy meeting – this is an area of excellent practice allowing trainees to be involved in discrepancy reporting in a blame free and educational setting.

 

 

Summary of the visit

Patient safety inc. handover and induction

The weekend on call rota for trainees presents a potential patient safety issue.

There are robust systems for handover between on call radiologists out of hours.

Department / Programme / Specialty

Area of development

 

Induction for trainees is co-ordinated by the College Tutor. In common with all localities on the training scheme rotation between academy and clinical blocks can present difficulties in ensuring all trainees receive all necessary training. Opportunities exist for the provision, by LEPs, of mandatory training that is transferrable between localities across the region.

Trainees work a continuous duty period from 9am on Friday to 5pm on Sunday.  This comprises a normal working day on Friday followed by on call. The panel was informed that hours monitoring in 2013 was compliant with the New Deal and the EWTD. In 2014 however, of the 7 trainees who participated in hours monitoring 5 signed a disclaimer stating that the post was compliant rather than completing a diary. The trainees present seemed unaware disclaimers had been signed. The two diaries submitted were not analysed on the grounds that the sample size was small.

Despite the results of the hours monitoring the trainees universally reported that the weekend on call shift was excessively onerous. Although they are non-resident the practical implication of the fact that they do not live close to the hospital and the nature of out of hours imaging services means they are unable to leave the hospital site. While the volume of work is not excessive, the relatively continuous phone calls and low grade activity means trainees find they are unable to rest sufficiently during the shift. This inevitably impacts on the quality of their work. There are opportunities for the on call trainee to hand over on call duties to a resident consultant on Saturday and Sunday morning, but arrangements are ad hoc and the period of handover is short. Some trainees seemed reluctant to hand over on call duties despite being invited to do so.

The panel was unanimous in its view that the weekend on call rota for trainees should be changed. Currently the shift is too long with insufficient opportunity for meaningful rest. As this is potentially a safety issue the rota should be revised as a matter of urgency.

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

By day clinical supervision is excellent and valued by all the trainees.

Department / Programme / Specialty

Area of development

 

Arrangements for film checking are ad hoc. At present trainees do not experience any difficulties getting their work reviewed and checked as necessary. It may be necessary to introduce more formal arrangements as the number of junior trainees increases.

Out of hours there is sometimes confusion about which examinations can be supervised by the consultant on call and which cannot. This usually revolves around complex specialist imaging, not within the field of expertise of all consultants. Sometimes this imaging has been requested by a tertiary referral centre. The situation could be clarified through clear written guidance for trainees or by taking advice from the on call consultant ad hoc. Trainees should be clear with referring clinicians when an appropriate specialist investigation or opinion is not available out of hours.

There was concern about the level of clinical supervision provided by one or two of the consultants. They were not mentioned by name. During the day this is not a patient safety issue as alternative senior supervisors are available, but this could become a safety issue out of hours. The individuals concerned should be made aware of the need to be available for advice as required by the trainees. If a consultant is unable to provide adequate support and supervision for trainees they should not be involved in training and should not supervise trainees out of hours.

Training environment (inc. access to educational resources

Department / Programme / Specialty

Area of development

Department of Radiology, Royal Devon and ExeterHospital, Exeter, SW Peninsula Postgraduate School of Clinical Radiology

In common with trainees at other localities compensatory days off before and after on call shifts can have an adverse impact on training by limiting learning opportunities (they miss out on planned and ad hoc learning opportunities). It is important that trainees rotate their on call days to limit the impact on specialty training opportunities that take place relatively infrequently

As a result of senior trainees leaving early to take up fellowship posts gaps in the on call rota have arisen. These are being covered by internal locum shifts. The impact of resultant additional compensatory days off on individual trainee’s training and learning opportunities should be carefully monitored.

Work load

No concerns were raised regarding excessive workload.

Department / Programme / Specialty

Area of development

 

The senior trainees would benefit from booked US lists.

Adequate experience / achievement of curriculum competencies

Department / Programme / Specialty

Area of development

 

There are limited training opportunities in breast radiology, paediatric radiology and nuclear medicine. This and the spiral nature of curriculum delivery in Exeter may result in knowledge gaps for core trainees at ST1-3 level. It is important that any gaps in training are clearly identified at the end of attachment ES appraisal and carried forward as learning objectives into the next year.

Subspecialty training at ST4-5 in breast radiology, paediatric radiology and nuclear medicine can be provided at other centres on the training scheme; trainees and ES are aware of this.

The spiral curriculum delivery in Exeter can present trainees with difficulties in achieving sufficient experience with individual trainers to inform core curriculum sign offs to level 4. This could be addressed through close clinical and educational supervision coupled with judicious use of the flexible timetabling available in Exeter.

 

Teaching – local, regional and study leave

Trainees have good access to study leave. All leave is well co-ordinated between the trainees, the radiology department in Exeter and the RadiologyAcademy in Plymouth.

Department / Programme / Specialty

Area of development

 

There are good opportunities for 1:1 training although core trainees would value formal tutorials and teaching sessions if these can be arranged.

Limited funds for study leave are an on going problem for radiology trainees at all localities.

Bullying and harassment

Trainees did not raise any concerns regarding bullying or harassment.

Department / Programme / Specialty

Area of development

Additional comments / feedback

Department / Programme / Specialty

Area of development

 

There are limited opportunities in Exeter to establish and complete research projects. To some extent this reflects the fact that many trainees work on research projects during their Academy blocks in Plymouth. A requirement to conduct research has recently been added to the RCR curriculum. In response, the School of Radiology is in the process of establishing a region wide research network. It is hoped that the research network will result in the recruitment of consultant supervisors from all localities to support and oversee trainees’ research.

 

 

 

Visit Panel Chair Declaration

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

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

I can confirm that any areas of significant concern 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:

 

Dr Tom Sulkin

Chair educational role:

 

Head of School

Date of signature:

 

July 2014

 

 

 

 

 

 

 

Health Education SouthWest 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 have been reviewed and deemed appropriate for the purpose as stated.

The 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:

 

22nd July 2014