Quality Assurance of Appraisal

1. Quality Assurance of Appraisal GP Appraisal Meeting June 16th 2005 Dr Di Jelley Appraisal and Revalidation Advisor Post Graduate Institute

2. Contact Details • Collingwood Surgery North Shields Tel 01912571779 • Email di.jelley@nhs.net

3. Summary • What is appraisal for ?-a brief history • Quality assurance of GP appraisal -high level indicators --specific criteria • The importance of Form 4s • Linking Personal and practice development plans • How can the Deanery help?

4. Appraisal in the commercial sector • Management tool in industry and commerce for many years • Annual review of performance-often linked to target-setting and pay awards • Usually done by immediate ‘boss’ in hierachical management structure • Many organizations now use 360 degrees approach

5. Intended benefits of Appraisal • Improvement in individual and organization’s performance • Better communication channels • Capability increased with more knowledge and skills • Enhances ‘organizational culture’-morale,working relationships,teamwork • Human resources better managed

6. Appraisal in education • Introduced as ‘compulsory’ in 1988 Education Act- • Dual role-increasing teacher accountability and promoting professional development • Patchy implementation-mostly due to resources • Some evidence of benefit when linked to observation and constructive feedback

7. Trethowan(1991) Managing Schools with Appraisal • “Appraisal as a one-off inspection of and assessment is false, shallow and often counter-productive. As a natural summary of all that has been achieved in the teacher’s year , it is the most powerful motivator ever developed.”

8. Health Service Appraisal -secondary care • Established within NHS management to improve individual performance and enhance service quality • Evidence of benefit difficult to establish due to confounding variables • Appraisal in nurse training grades perceived as helpful-again outcomes difficult to measure

9. GP Appraisal –initial statements of purpose [1] • “Appraisal for GPs is a professional process of constructive dialogue, in which the GP being appraised has a formal structured opportunity to reflect on his or her work, and to consider how his or her effectiveness might be improved. The primary aim of appraisal is to help GPs consolidate and improve upon good performance, aiming towards excellence.” . [DoH 2002]

10. GP Appraisal –initial statements of purpose[2] • “It is not the primary aim of appraisal to scrutinise doctors to see if they are performing poorly…but it can help to identify reductions in performance at an early stage , and also to recognise factors which may lead to a reduced level of performance, such as ill health” DoH 2002

11. Appraisal of GPs and other PHCTeam professionals • Most of the health professional have had some form of appraisal in place for years • GPs one of the last professional groups to introduce appraisal • Why is GP appraisal so different ?-between peers, non-hierachical etc-also because of the links to revalidation

12. Revalidation-GMC guidance • “Revalidation requires each doctor to demonstrate that they remain fit to practise on a 5 yearly basis • The doctor must show they are participating in an appraisal scheme based on Good Medical Practice [with submission of required evidence] • Certification must also be provided to confirm the GP complies with local Clinical Governance requirements, + is free from any ‘fitness to practise’ concerns.

13. The changing perspective of the GMC • Initial statements that “ participation in five appraisals” would be sufficient to lead to revalidation • Concern, fuelled by Shipman Inquiry, that a poor or deceitful doctor could engage satisfactorily in annual appraisal • Additional safeguard of PCT ‘sign off’-but not clear if this will this satisfy CMO’s review group [post Shipman 5]

14. Quality assurance of appraisal • Can only quality assure a process if we clearly understand its aims • In the commercial sector, education and most health professions, appraisal is hierachical, and is about managing performance • In GP aim of appraisal established as developmental and formative, but increasingly being seen more as a critical component of revalidation and performance review

15. Audit Commission-review of performance management (1994) • Three key principles for success • 1.Clear specification of values + objectives • 2.Communication and consultation between appraisees and appraisers. • 3.Evaluation of outcomes • -Appraisal is often seen as unhelpful if these principles are not observed

16. QA for Doctors-National Clinical Governance Support Team • Expert group has met twice in last three months • Following broad areas have been agreed as a framework to quality assure appraisal • Will not be formally ratified until CMO’s review group reports [?September 2005]

17. Quality assurance of GP appraisal –high level indicators • Organisational indicators -appraisal seen as fully integrated with all other systems of quality improvement • Appraiser skills and training -adequate selection , training and ongoing support for appraisers. • Appraisal interview- challenging and effective process , with verifiable supporting evidence and robust PDP • Systems and infrastructure are effective and ensure that all GPs are appraised annually

18. QA[1]-Organisational Ethos • Evidence of commitment- adequate resources, clear plan , annual report to PCT Board, organisational response to identified needs • Evidence of QA-compliance with national standards-annual PCT self-assessment and 3 yearly external review + feedback • Evidence of integration-clinical governance, education and CDP, risk management, underperformance etc

19. QA[2] Appraiser skills and training • Formal recruitment, selection + initial training process for appraisers • Effective support and development group • Appraisers have ongoing training and performance review-annual review of their form 4s with feedback • Appraisers receive feedback from their appraisees

20. QA[3]- Appraisal Interview • Evidence that the interview is challenging and effective-review of PDP-change of appraisal pairings after 3 years • Verifiable supporting evidence-core portfolio which includes both patient and colleague feedback-support to appraisers on reviewing the evidence • Storage of PDPs in line with national guidelines

21. QA[4] Systems and Infrastructure • Dedicated core management structure • Administration of appraisal system efficient and supportive of appraisee, adequate preparation time, choice of appraiser etc • Form 4s signed and stored securely • Arbitration system for complaints • Training on appraisal toolkit provided • All performers appraised annually

22. What else? • The importance of Form 4s-for appraisees, appraisers and PCTS • Linking personal and practice development plans • What is going on now with QA-can the Deanery help?

23. The importance of Form 4 • Form 4 summarises the appraisal discussion and outlines the agreed action points-core document for revalidation • It should highlight areas where evidence is absent or insufficient to guide appraisees towards provision of adequate evidence for revalidation • Form 4 provides continuity of information between different appraisers • Provides information on development needs of GPs for PCT • It is a ‘proxy’ measure of appraiser skills

24. From personal to practice development plans • Appraisal is a very individual process, but most GPs work as part of a team • Individual learning plans should integrate within the broader practice development plan to avoid duplication and maximise effective use of time • Sharing key outcomes in Form 4s or PDPs helps this integration process

25. How can the Deanery support PCTs deliver robust appraisal? • Clarify links between appraisal, under-performance and revalidation after CMO’s review of Shipman 5 is published • Offer an external QA review to any PCT that wishes this. • Help GPs prepare for revalidation? • Continue to support GP appraiser training and refresher courses • What else?