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  1. 1. Postgraduate Deanery Foundation QA Visit to Barnsley District General Hospital 2009 Background As part of the Deanery Quality Management systems the Foundation School Director and Deanery QA team visit each Trust (Deanery visiting team). The pre-visit questionnaire from the Foundation Training Programme Director(s) (FTPDs) and survey data form the Foundation School end of post questionnaires (54 responses). Only four F1s and five F2s responded to the PMETB survey. No issues were raised so this data has not been integrated into this report. The visit consists of the FTPD presenting an overview of the strengths and weaknesses of the local programme. The Deanery visiting team then meet some F1s, some F2s and final some Educational Supervisors. Information is then collated and fed back verbally to the Trust and this is followed by this written report. Present Deanery Dr Alasdair Strachan, Foundation School Director Miss Lucy Smith, Training Programme Coordinator Ms Anne Brown, Lay Representative Trust Mr Ray Raychaudhuri, FTPD Ms Julie Brearley, Foundation Administrator Numbers of programme participants meeting Deanery team F1 – 6 F2 – 7 Educational Supervisors - 6 Findings The following sections of this report are set out under the GMC and PMETB’s joint Domains and Standards for training for the Foundation Programme. Domain 1 – Patient Safety Standard The duties, working hours and supervision of trainees must be consistent with the delivery of high quality safe patient care. There must be clear procedures to address immediately any concerns about patient safety arising from the training of doctors. Workload F1s felt that in general there was a lack of middle grade support across the specialties. A&E trainees were happy with the workload and Cardiology had gaps in the rota, with staff grades of variable standards, which they felt meant they missed out on training, they have noticed that /home/pptfactory/temp/20100722114938/barnsley3318.doc
  2. 2. throughout the year there have been improvements, employing more doctors on the ward in Cardiology. They indicated that when the rota was complete, that staffing is fine in Medicine. One trainee in Gastroenterology said they had work from 9am to 5pm on one day without any senior review and consultants only being available over the phone. No F1s felt that any specialties had too much training. Urology, GP, cardiology, surgery and accident and emergency were all felt to have a good balance of teaching to service, whereas medicine was felt to be largely weighted to service, and that there were no real training opportunities and that they had to learn on the job. F2s felt that medicine was only service and no training, that GP and A&E had a good balance between the two. Orthopaedics was highlighted as a good department with potential to have a good balance, but that the gaps in the rota meant it was effectively just a service job. The F2s who had worked in O&G felt that the training in that specialty was more directed at the StRs and SpRs, and that F2s and service posts were left to cover the wards instead of attending. It was noted however that following feedback this appears to be being address and improving. EWTD F1s felt that all rotas were compliant on paper. In orthopaedics and medicine, F1s were staying late. Surgery was felt to be compliant. All the F1s present had completed monitoring forms and did not feel any pressure to put anything other than the hours they worked. In the Deanery survey 24 of the 27 F1s felt their post was EWTD compliant. F2s thought that medicine was not even compliant on paper and they never finish on time. Hours monitoring was abandoned. It was noted that the form stated “hours supposed to work” not “hours actually worked” therefore, the monitoring done before it was abandoned may appear to be compliant. Orthopaedics was not compliant, but the F2s felt that with a full rota, it would be. A&E and O&G were felt to be compliant. ENT is not compliant and has a 2A banding attached to the job. In the Deanery survey 10 of the 27 F2s felt their post was not EWTD compliant. Handover F1s felt that the handover in surgery was effective and well structured, though one trainee commented that trauma and orthopaedic handover was done by ringing the on-call at the end of the day, and if they were in surgery they were told to “leave a note”. Medicine handover was not structured but that it worked well enough. They felt it was their own responsibility to provide an effective handover. F2s felt that surgical and orthopaedic handovers were very good and structured, as was paediatrics. There was no handover in medicine and notes are merely written on the white board for the nurses. O&G has a very informal handover, there is a handover book, but this is not used. A&E was mentioned as not having any real need for a handover. ENT did not have a handover, without a night team, ENT in then covered by the surgical team. In the Deanery survey 1 of 5 Emergency Medicine, 2 of 3 General Medicine, 4 of 10 Geriatric Medicine and the only respondent in Rheumatology felt handover was not safe or reliable. One of three O&G and 2 of 8 O&T respondents felt the same. Domain 2 – Quality Assurance, Review and Evaluation Postgraduate training must be quality controlled locally by deaneries, working with others as appropriate, but within an overall delivery system for postgraduate medical education for which Deans are responsible. End of Placement Questionnaires A number of F1s missed the deanery survey and did not know about it. They felt that they had the appropriate opportunity to feedback to consultants and to the Deanery via the FTPD. They also were not all aware that they needed to feedback after each placement. /home/pptfactory/temp/20100722114938/barnsley3318.doc
  3. 3. All the F2s present had completed the PMETB survey, but only one had completed the deanery questionnaire. The F2s indicated that there was no mention of having to have evidence of completing the questionnaires as part of their RITAs. In medicine, the F2s felt that they were given weekly opportunities to feedback to consultants, however that sometimes, feedback did not go any further and sometimes they were unreceptive to what was being said. The F2s present felt they also had adequate opportunity to feedback to the deanery via the questionnaire, but that none of them had any particular issues that they felt needed to get in touch with the deanery about. Domain 3 – Equality, Diversity and Opportunity Postgraduate training must be fair and based on principles of equality Equality and Diversity No problems were raised, but both F1s and F2s indicated that they were not aware of what the trust policy was if there were any issues. Bullying and harassment Generally both F1s and F2s had no problems, though one F1 indicated that there were some personality clashes with seniors for two of their colleagues, one of whom had raised the issue, and one they weren’t sure about. Dr Strachan indicated that if there were any issues that these should be discussed with the FTPD. Neither F1s nor F2s were familiar with the trust policy of bullying and harassment, but felt it was common sense as to what to do. In the Deanery survey one felt they had been a victim of discrimination and eight felt they had been intimidated or bullied. Five stated they did not know who to inform if they felt bullied or harassed. Domain 4 – Recruitment, selection and appointment Process for recruitment, selection and appointment must be open, fair and effective The F2s felt that working in Barnsley meant that they were “out of the loop” in terms of what was going on with recruitment and that in other parts of South Yorkshire, their peers had been given more support and advice. They felt that this could be addressed by better communication across South Yorkshire. Domain 5 – Delivery of curriculum including assessment The requirement set out in the curriculum must be delivered and assessed Core Curriculum Teaching F1s felt that the Wednesday teaching sessions were of a variable standard, and Physiological Abnormalities stood out as an interesting teaching session. They had no problems being released for teaching and they were all aware that they had to go to these mandatory teaching sessions, as were the other doctors on the ward which allowed them to be released. F2s enjoyed the teaching at the Simulation Centre in Mexborough and thought it an effective way of learning. Teaching the teachers was over-long, but the content was relevant. Conflicts and complaints received a mixed review, but the F2s recognised that it is a very group dependent course. Again, this was felt to be over-long and though the concepts were applicable they were unsure as to whether the training was useful. F2s had also received one day of audit teaching locally. They felt that they had had some difficulty being released highlighted in A&E and medicine. In the Deanery survey 9 F2s felt they could not attend 70% of their training courses and 13 F2s and 1 F1 felt their education time was not adequately protected. /home/pptfactory/temp/20100722114938/barnsley3318.doc
  4. 4. Departmental Teaching F1s indicated Cardiology, GP and Care of the Elderly all had good specialty teaching, with Accident and Emergency having very good teaching. Other medical specialties (other than cardiology and care of the elderly) was not rated highly. Teaching in surgery was believed by the F1s to be non- existent, but that trauma and orthopaedics teaching was average. In F2, paediatrics, medicine, GP, A&E, O&G had good specialty training. Orthopaedics had not had any yet, but that there was an intention to have lunchtime teaching but the “teachers” were not available. Surgery had three or four sessions in August 2008, but then they petered out. Assessments and Feedback In the Deanery survey 14 of the 54 respondents felt they did not receive regular feedback from their Educational or Clinical Supervisor. The F1s present felt that the only issue with assessments was finding time for consultants to complete them. Their e-Portfolios were assessed at the end of F1 by a formal meeting with the FTPD. F2s felt that assessments were easier to do when they were on paper and that the educational supervisors need to be better at using e-Portfolio for it to be effective, some were unable to release mini-PATs for them to review. In orthopaedics and medicine the F2s felt that it was difficult to get seniors to watch procedures, but that it very much depends on the consultant and the specialty. In the Deanery survey 11 of the 54 respondents stated they had difficulty to complete their assessments. Adequate Experience F1s were asked if they felt adequately prepared for a job as an F2. One F1 had had no medical jobs as an F1 and had not experienced continuity of care (rotation: general surgery, urology, A&E). One trainee had also done eight months of geriatric medicine (four months at Doncaster and four months at Barnsley). Twenty four of twenty seven F1s in the Deanery survey felt they had had exposure to an appropriate case load and mix. F2s felt in general that they were given a lot of responsibility in Barnsley which they feel stands them in good stead for ST. Twenty of twenty seven Fs in the Deanery survey felt they had had exposure to an appropriate case load and mix In the Deabery survey 49 of the 54 respondents felt they had improved their clinical skills. Domain 6 – Support and development of trainee, trainers and local faculty Trainees must be supported to acquire the necessary skills and experience through induction, effective educational supervision, an appropriate workload, personal support and time to learn. Support, training and effective supervision must be provided for Foundation doctors. Support, training and effective oversight must be provided for local faculty Foundation Programme Induction F1s thought that the induction at the start of their F1 year was good, but that inductions mid-way through the year were non-existent. The F1s felt that a lot of induction was done during their two week shadowing period, but that it would have been much more effective in their induction week. Trust Induction Those trainees present who had moved between trusts said that the mid-year inductions on moving trusts did not exist. F2s said the hospital induction was very good, but that they were inducted with the STs and /home/pptfactory/temp/20100722114938/barnsley3318.doc
  5. 5. registrars and so some of the information given was not applicable to them. Departmental Induction F1s felt that general surgery and trauma and orthopaedics had effective inductions but that in medicine they were very much “thrown in at the deep end”. For the practices attended, the GP inductions were very thorough. In the Deanery survey 21 of 27 F1s felt they had a satisfactory departmental induction. F2s felt that A&E had a good, three-day structured induction, that O&G made a good effort but that certain people were unavailable, so some sessions were cancelled. In medicine, F2s concurred with F1s and felt they were also “thrown in at the deep end”. In the Deanery survey 23 of 27 F2s felt they had a satisfactory departmental induction. Educational Supervision of Foundation doctors All the F1s and F2s present said they had met with their Educational Supervisor within the first month of their placement. Though Dr Strachan indicated that the Deanery encourages mid point reviews (and they are essential if there are problems), the F1s felt that some consultants did not like doing them as they are not mandatory. Overall, the F1s felt the education supervision was of a good standard. In the Deanery survey 26 of the 27 F1s stated they had had their meetings and their portfolio had been reviewed. Overall F2s thought that educational supervision was good, however in paediatrics, their was a lot of duplication doing assessments online and on paper, and that the trainee working in O&G did not have any effective meetings with their educational supervisor and that it was often difficult to find them and arrange meetings and assessments. In the Deanery survey 24 of the 27 F1s stated they had had their meetings their portfolio had been reviewed. Clinical Supervision of Foundation doctors F1s felt that generally, clinical supervision was fine, but one F1 raised the issue of spending full days on ward 28 on their own with no senior review. In the Deanery survey 5 of the 27 F1s did not feel they could contact the duty consultant with ease. The F2s felt that in A&E, medicine and O&G there was adequate clinical supervision both day and night. In the Deanery survey 25 of the 27 F2s felt they could contact the duty consultant with ease. Six felt they were not well supported by their senior colleagues. Pastoral support No issued were raised and trainees felt they could speak to the educational supervisor or the FTPD if necessary. Careers support F1s struggled to remember having any careers advice, but vaguely recalled some in the Wednesday lunchtime sessions. F2s had attended a good session careers and felt they had had information covering a number of specialties, but as mentioned, they felt out of the loop with recruitment to specialty training. Study Leave No issues were raised. Support for Local Faculty 1. Foundation Training Programme Directors The FTPD felt he had appropriate support from the FSD and DPGMDE. /home/pptfactory/temp/20100722114938/barnsley3318.doc
  6. 6. 2. Educational Supervisors Those present felt that SPA time was not consistent across the trust. Dr Strachan emphasised that 0.25PA is supposed to be crystallised into educational supervisors’ job plans for each trainee they supervise. Concerns were raised by ESs that this may be reduced to 0.15PAs. ESs felt adequately supported by the FTPD. They did however indicate that they were unclear about renewing their training as an ES and when they should be renewing this. They felt lots of courses were available, but they were unsure which they should be attending. Dr Strachan explained how the number blended e-learning for educational supervision works and how often this should be done. The ESs felt that those foundation trainees starting mid way through the year in the trust were at a disadvantage and that the inductions for them were not very good mid-year. There were no issued raised about releasing trainees, provided they gave the relevant notice. Trainees are made very aware that the onus is on them to get this notice, especially in A&E. E-portfolio received a mixed review from the ESs, but it was agreed that it is an excellent tool when used properly and makes review a very open process and ESs can monitor their trainees before specific meetings and throughout placements. ESs raised the issue of foundation trainees taking lots of sick leave and also about non- completion of initial, mid-point and end of placement reviews due to trainees not arranging meetings and taking responsibility for their training. ESs would appreciate feedback from the deanery as to how effective their work is and how they can improve, Dr Strachan said this may come from the deanery questionnaire. Overall, the ESs said they were very impressed by the standard of F1s and F2s. Domain 7 – Management of Education and Training Education and training must be planned and maintained through transparent processes which show who is responsible at each stage. Supporting Doctors in Difficulty Domain 8 – Educational Resources and Capacity The educational facilities, infrastructure and leadership must be adequate to deliver the curriculum. Facilities F1s felt there are good access to computers and the library, however it would be good to have computers on the ward and have the facility to electronic discharges. F2s said computer and library facilities were fine. Domain 8 – Outcomes The impact of standards must be tracked against trainee outcomes and clear linkages should be reflected in developing standards. The outcomes of F1 and competencies for the Foundation programme are published. All doctors should meet these outcomes and competencies before successfully completing the Foundation programme. Trainee completion rates – to be completed Of those present, five out of the six F1s would recommend their rotations to others. The one who would not indicated that the problem was not associated to the Barnsley rotation, but others outside of this trust. It was however felt that in the urology rotation, there was not really anything to do and /home/pptfactory/temp/20100722114938/barnsley3318.doc
  7. 7. that the ward was run by a senior registrar. They did not feel that they had particularly learnt anything, but it did give time to do extra curricular audits etc. F2s would recommend A&E, orthopaedics, paediatrics, GP, O&G and surgery, but not medicine. In the Deanery survey 10 of the 54 respondents would not recommended their posts to junior colleague. These were Emergency Medicine (1 of 4 responses), General Internal Medicine (1 of 3 responses), Geriatric Medicine (3 of 10 responses), O&G (1 of 3 responses), O&T (2 of 8 responses) and the only resonse from Rheumatology. Notable Practice This section of the report draws together some areas of notable practice identified in the findings of this report. 1. Most of the F1s and F2s present would recommend their jobs to others. F2s felt very prepared for ST training due to the responsibility they have been given in Barnsley. 2. As with the 2008 visit, there are some good examples of handover in some specialties and the Deanery would again like to encourage this across the trust. 3. The trainees had all had their initial and final Educational Supervision meetings, with most having midpoint meetings. They valued these constructive meetings. Requirements 2008 Condition 1 The most obvious issue was the high workload that the Foundation doctors experience. This not only effected the attendance (and thus reduced the quality of data to the team) but adversely effects training. The F1s felt that their surgical post was nearly all service and struggled to find any examples of training. Although the two F2s who attended the meeting felt the service /training ratio was acceptable the PMETB survey reflected a problem with long hours etc. Action – The Trust needs to devise a plan to improve the work intensity. An interim report needs to be submitted outlining this plan by May 2009. Outcome – Surgery had training now. Medicine has heavy workload with little training. F1s not having appropriate support needs addressing especially for Ward 28. Interim evidence needed from Deanery survey to show training occurring in Medicine and F1s supported. Thus the Trusts needs to ensure trainees complete the survey. Condition 2 The F1 surgical posts contained little teaching in any format. The trainees would appreciate any teaching, be it ward round, bedside or more formal. Action - This needs addressing for the coming posts and feedback from trainees showing an improved situation by February 2009. Outcome- Still needs addressing. Evidence of teaching needed by February 2010. /home/pptfactory/temp/20100722114938/barnsley3318.doc
  8. 8. Condition 3 The attending trainees did not complain of bullying but it was a problem in the PMETB survey. This needs addressing with some urgency. Action – an action plan addressing this must be submitted to the School by February 2009. Outcome – some evidence of bullying and harassment. Evidence of appropriate training needed e.g. MIAD training numbers for next School visit. Condition 4 A number of trainees were not aware who they should confide in with problems. This may also impact on the reporting of bullying. This needs clarifying to trainees so they are all aware. Outcome – trainees still unclear. Need to address and produce evidence for next School visit. Condition 5 Induction was not well thought of by the trainees. The F2s felt the Trust Induction did not cover all the necessary issues. The F1s who joined part way through the year had poor inductions from the Trust, Foundation and their specialty. A review of many of these processes is needed. Outcome – In general induction seemed improved expect for those for trainees joining part way through the year. In Medicine There does not seem to be a departmental induction in Medicine. This needs resolving and details of the induction sent to the Foundation School as soon as it is resolved. Condition 6 The clinical supervision of the surgical F1s was not always available when needed. The PMETB survey revealed concerns about the F1s working beyond their competencies. The Trust needs to ensure that this is improved for the next visit. Outcome – partially resolved. See above. Condition 8 Career advice for F1s needs improving with some urgency. Outcome - resolved /home/pptfactory/temp/20100722114938/barnsley3318.doc
  9. 9. Requirements 2009 This section of the report draws together requirements identified in the report, which must be considered by the Trust and by the Foundation School. A plan must be provided to address these concerns, the outcomes of which will be audited on the next visit unless otherwise stated. Condition 1 Many issues from 2008 have been resolved but many are outstanding. These need resolving (see above). Condition 2 PMETB response was very low. Evidence of completion of end of placement questionnaires, PMETB survey and deanery questionnaires were not reviewed at end of year RITAs. Next year completion of these will be mandatory and evidence of submission must be assessed as part of the RITA process. Condition 3 Educational supervisors job plans should be crystallised to ensure appropriate time is set aside for educational supervision. Action – report to Deanery regarding future direction needed by December 2009. Trust Response /home/pptfactory/temp/20100722114938/barnsley3318.doc