Item 5
Annual Report for
Medical Revalidation
2013-2014
Produced by
Mr Declan Flanagan. Responsible Officer
Rayvathi John, Revalidation support manager
Michael Ferguson Revalidation Administrator
Emral Jarrold, acting Revalidation Support Manager
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Annual Board Report for Medical Revalidation
2013-2014
1.
Executive summary
As of the 31st March 2014, 256 doctors were attached to Moorfields Eye hospital for
the purpose of revalidation. This is referred to as having a prescribed connection
with the trust. It is relevant that the approximately 55 Specialist Registrars in the
Trust do not have a prescribed connection with the Trust for appraisal and
revalidation purposes. Annual appraisal of SpR’s [ARCP] is the responsibility of the
London Deanery though Moorfields consultants who are clinical or educational
supervisors have an active role in this process.
Of the 256 doctors the numbers of completed appraisals within the appraisal year
2013-2014 were 207 [80.9%]. This included all Consultants, SAS, Trust fellows,
Locum and honorary doctors.
The Trust submitted a mandatory Revalidation Annual Organisational Audit (AOA)
to NHS England [NHS E] covering the period April 2013 – March 2014. The Trust
received comments on this audit in late July 2014 from NHS England. The report
compares Moorfields performance with the rest of London. 80.9% of all Moorfields
doctors had an appraisal with the reporting period. This compares with 79.5% for
the rest of London and 83.8% for the whole of NHS England. See Appendix C for a
breakdown of this data. The full organisational audit report from NHS England is
available on request.
One hundred doctors have now been successfully revalidated by the Trust.
2.
Purpose of the Paper
As part of the framework for quality assurance and for the purpose of revalidation,
NHS England has requested this Annual Report to cover the period of 2013-2014
together with the compliance statement (Annex D). This follows the completion of
the Annual organisation Audit (AOA) exercise which was submitted in May 2014.
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The paper is intended to provide assurance to the Board that, in line with a number
of self- and external assessments during the course of the year, the trust is fulfilling
all the requirements for revalidation.
3.
Background
Medical Revalidation was launched nationwide in December 2012. The purpose of
the implementation of Revalidation was to strengthen the way that doctors are
regulated, with the aim of improving the quality of care provided to patients,
improving patient safety and increasing public trust and confidence in the medical
system.
The trust has assigned a Responsible Officer, Declan Flanagan, Medical Director
and Clinical Revalidation lead, Miss Alison Davis, Consultant Ophthalmologist to
lead on the implementation and delivery of the Revalidation requirements. With
effect from June 2014, Miss Poornima Rai, Locum Consultant Ophthalmologist has
replaced Miss Davis as Clinical Revalidation lead.
Moorfields Eye Hospital has a statutory duty to support the Responsible Officer in
discharging their duties under the Responsible Officer Regulations1 and it is
expected that provider executive teams (Trust Management Board) will oversee
compliance by:

monitoring the frequency and quality of medical appraisals in their
organisations;

checking that there are effective systems in place for monitoring the
conduct and performance of their doctors;

confirming that feedback from patients is sought periodically so that their
views can inform the appraisal and revalidation process for their doctors;
and

Ensuring that appropriate pre-employment background checks (including
pre-engagement for Locums) are carried out to ensure that medical
practitioners have qualifications and experience appropriate to the role
undertaken.
The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The
General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012’
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The trust submitted an annual Organisational Readiness Self-Assessment (ORSA) in
May 2013; to The NHS Revalidation Support Team (RST). Under the RAG rating
system (Red, Amber, Green) this report received a green rating. This rating reflected
the efforts of the Revalidation team and progress made in implementing actions
which had previously been identified earlier in the revalidation preparation process.
4.
Governance Arrangements and Quality Assurance
A revalidation group had already been established which was made up of the
Medical Director, Clinical Revalidation Lead, Revalidation/HR Advisor and
Recruitment/Revalidation Assistant. In addition the revalidation group is supported
by Trust Audit team.
In October 2012 the Clinical Revalidation lead presented a paper to the Quality and
Safety Committee with an update on the trust’s progress in ensuring readiness for
Revalidation.
An audit was undertaken in March 2013 through our internal audit programme,
KPMG, the outcomes of which has been presented to the Audit Committee in May
2013.
This audit identified the need to procure a centralised Revalidation Management
System (RMS) to audit, monitor and capture accurate data for appraisal and
revalidation. The Trust undertook an evaluation of commercially available RMS
systems. A bespoke system from Premier IT was then purchased and has been in
use since 1st April 2014. Training for the RMS was organised over 12 sessions of
1.30 hours per session. In addition support was also provided to cover the individual
appraisal needs for doctors.
The audit also identified the need to confirm that if doctors worked for other
institutions as well as Moorfields that evidence of this work was considered at their
annual appraisal. Doctors are now required to produce this evidence. This evidence
is usually in the form of a letter from the Chief Executive or Medical Director of the
other institution.
In the past year the Trust introduced an electronic incident reporting system. This
gives the Responsible Officer and individual doctor’s access to all incidents in which
they have been named. There is a similar system for complaints.
An internal audit was conducted on the Model Appraisal Guide (MAG) by the
revalidation group in 2013-2014 to ensure the quality assurance of appraisal. The
aim of the audit was to determine whether the medical appraisal process was fit for
purpose. In addition it also aimed to identify the number of doctors who had
completed an appraisal between 1st December 2012 and 1st June 2013.
The outcomes of this Audit will be reported to the Trust Management Board in
August 2014. The revalidation team will in the second cycle address the outcome of
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the audit which will be submitted to Audit team or Quality and safety committee in the
last quarter of 2014-2015.
The Responsible Officer has discussed revalidation of doctors employed by
Moorfields Dubai [MEHD]. The GMC have confirmed that as these doctors are
responsible to the Medical Director of Moorfields Eye Hospital and as they work only
for MEHD that they can be revalidated by the Moorfields Responsible Officer. The
previous Medical Director received training in appraisal to GMC standards to support
this process. Another consultant has recently been trained to fulfil this role until the
new Medical Director is appointed. The Quality and Safety structure in MEHD
recently been strengthened with the appointment of a Quality and Safety officer
responsible for collection of clinical outcome data for clinical audits. This will
strengthen the annual appraisal process. This officer has recently spent a week
working with the Quality and Safety team in London to ensure that clinical quality
assurance is performed to the same standard in MEHD as in London. A member of
the Quality and Safety team will also spend a short period of time in MEHD in August
2014
The Revalidation and Quality & Safety team is providing support to ensure that all
medical staff in the new Moorfields Croydon satellite have training in appraisal and
clinical audit to ensure that they fulfil all the requirements for revalidation.
The Revalidation group are currently in the process of scheduling an Independent
audit by a third party (yet to be agreed) to assess the quality assurance of the
internal Revalidation process adopted by the trust. It is hoped that the findings of
this audit will be presented to the Audit Committee by December 2014. In addition an
internal audit is to be arranged to look at the appraisal process currently used by the
trust.
Weekly meetings are undertaken within the Revalidation group to address any adhoc
issues and concerns that may arise of the Revalidation and appraisal process.
The Trust Responsible Officer is appraised by an external appraiser nominated by
NHS England and his Responsible Officer is Dr Andrew Mitchell of NHS England.
The Responsible Officer {RO] and the Trust Revalidation lead attend regular external
Responsible Officer Network meetings with other RO’s, representatives from the
GMC as well as NHS England.
a.
Policy and Guidance
There is a Medical Revalidation and Appraisal policy as well as a Back on Track
Policy in place these polices was ratified by the Board in March and October 2012
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respectively. These policies were drafted in accordance with the guidance issued by
the GMC and NCAS. The Back on Track Policy was amended in May 2012 to reflect
changes made by the GMC.
Doctors are able to access the polices under
http://mehhome/resources/policies-procedures-and-
guidelines/policies-and-procedures/
5.
a.
Medical Appraisal
Appraisal and Revalidation Performance Data
For 2013-2014, the Trust recorded that out of 256 doctors
completed.
207 appraisals were
Collation of data for audit and reporting during 2013-2014 has been a major
challenge for the team in the absence of any IT Revalidation management system.
Until the system is fully embedded, the Trust is currently monitoring the appraisal
data using a manual process. Prior to the implementation of the Revalidation
management system and during this report period, the Trust has used various
systems to manage the appraisal and revalidation process. For example the doctors
used a PDF version of the appraisal form called Model Appraisal guide (MAG) which
after completion was stored either on the Trust appraisal system or on the
individual’s local drive. The Trust was also engaged with 2 different providers for the
purpose of obtaining colleague and patient feedback, which through a manual
process were updated on an internal database (standard excel spreadsheet). This
experience with different providers was helpful in deciding what comprehensive RMS
to purchase. The spreadsheet also requires regular audit to ensure they are aligned
with all current starters and leaver in the trust (which is sourced from the Trust HR
system).
The manual process also relies heavily on the available resource (both internal and
external) to update the information on a regular basis. This arrangement also, has a
restricted functionality on producing details on appraisal information or being able to
produce a report to identify reasons for incomplete appraisal, appraisals output not
signed, etc.
The new revalidation management system in use since May 2014 will make it much
easier to manage the appraisal process and audit the quality of the process.
See Extract from AOA report-Appendix A submitted to NHS England in May 2014
on the appraisal undertaken in the trust.
b.
Appraisers
Additional appraisers have been recruited to ensure that each appraiser has a
manageable workload. Training by accredited external providers has been provided
for all new appraisers and refresher training for some of the existing trainers.
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As of March 2014, 46 trained appraisers were engaged in the process of Medical
appraisal up to revalidation standard.
The trust also organised top-up training for existing appraisers on the 15th October
2013 to 16th December 2013 and 23 appraisers in total attended these session. This
training was organised to ensure the knowledge and skills remain up-to-date within
the GMC’s requirement.
The trust has been continuously recruiting new Medical appraisers to balance the
proportion of the appraiser and appraise ratio and ensure that the workload for each
appraiser remains manageable.. Further training has been organised in July 2014
and although outside the period covered by this report a total of 56 appraisers have
now been trained.
The revalidation group intends to set up an appraiser network to offer ongoing
support to appraisers and the details of this network are yet to be finalised.
c.
Access, security and confidentiality
The trust has an implemented framework of Information Governance to ensure all
the information held on staff members are complaint with the Data protection and
confidentiality, information security and information quality on an annual basis.
d.
Clinical Governance
The trust has an established team and system to record all incidents and complaints
through Risk and safety team. The report and details are available if requested to all
staff so that they are able to provide the data at the time of their appraisal.
The trust also has a dedicated Audit team to assist the doctors and contribute to their
clinical performance by auditing to the revalidation standards.
Clinical Governance and Clinical Audit meetings are held on a regular basis to offer
support, training and updates to doctors. This is to enhance their professional
development and ensure compliance with the requirements of the trust and
professional bodies.
There were 57 doctors that required Revalidation during the reporting year 201320414. 100% Revalidation Recommendations were completed on time and
below is the split:
Positive recommendations - 55
Deferrals requests - 2
Non engagement notifications –N/A
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Reasons for all missed or late recommendations-N/A
See Audit of revalidation recommendation-Appendix B
Although outside the period covered by this report a total of 102 doctors have now
been revalidated as of 26th August 2014. 43 more have dates to revalidate by the
end of March 2015.
6.
Recruitment and engagement background checks
The Trust has a dedicated Human Resources team to ensure the Recruitment and
Pre-employment checks are in place before the employee commences with the
Trust. These checks also ensure collection of revalidation information if appropriate
from previous employers.
The Trust HR team ensures that all staff are only appointed to the post once the
following pre-employment checks are undertaken.
Identity check
Qualification check
Occupational Health Clearance
DBS
3 recent references
Right to work in the the UK
Information Governance Training
Name of last responsible officer
Reference from last responsible officer
Revalidation due date
7.
Monitoring Performance
The performance of each clinical service is monitored against 3 core clinical
outcomes which are benched marked against published external outcomes.
Doctors are required to produce at least one audit annually to recognised standards
of their clinical outcomes covering a key area of their practice for their appraisal.
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8.
Responding to Concerns and Remediation
The trust has a Back on Track policy which is based on the guidelines provided by
GMC and National Clinical Assessment Service (NCAS). The guidelines from the
policy are used when required when responding to concerns about a doctor or when
remediating a doctor.
The trust used the Back on Track policy for guidance in January 2013 to help a
doctor return in an honorary capacity and worked closely with the GMC to support
the doctor. However upon advice of the GMC this doctor’s honorary contract was
terminated.
9.
Risk and Issues
The recorded average medical appraisals undertaken within secondary care during
2013-14 is 80%. Moorfields for the same period has recorded 81% which is
marginally above the NHS average for appraisal.
The Revalidation team are continually tasked with identifying those doctors who
have not yet had their appraisals due to maternity leave, illness, appraisal dates not
set and leave dates imminent. During the last quarter of 2013-2014, some such
cases were identified and postponements of their revalidation or appraisal were
agreed by the Responsible officer.
The Revalidation team identified that most of the doctors who had not yet identified
an appraisal date were temporary or short term contract holders. These were mostly
trust Fellows who are employed for approximately 1 year from outside UK and do not
wish to undertake an appraisal or be revalidated as there are no implications for
them to practise in their home country after the termination of contract.
The Trust employs over 90 Clinical Fellows. These are either UK ophthalmologists
who have completed their SpR training or have come from abroad for further
subspecialty training. The Revalidation team has stressed the importance of annual
appraisal to GMC standards to this group and provided additional training and
support for them.
Associate Specialists are recognised nationally as a group that have had a low rate
of annual appraisal in the past. For this reason the Responsible Officer and the
revalidation team have supported them in preparing for appraisal. In addition 2
Associate Specialists from Moorfields attended a training day for them run by the
London Deanery.
Moorfields has a substantial number of consultants with research roles and
responsibilities with the Institute of Ophthalmology and other institutions. They are
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required to have annual joint clinical and research appraisals with clinical and
research appraisers. The Revalidation Management system is being modified to
facilitate this.
The trust creates awareness of the requirements and support in place for annual
appraisal and revalidation during medical induction. Continuous support is also
offered to all staff particularly clinical fellows and associate specialists by their
services and the Revalidation team to ensure that they are all appraised to
revalidation standards.
Temporarily appointed fellows, i.e. those on fixed term contracts should be listed on
the Trust risk register for the purpose of annual appraisal and revalidation.
10.
Corrective Actions, Improvement Plan and Next Steps
As mentioned above within the Revalidation group there has been an appointment of
a new Clinical Revalidation lead Mrs Poornima Rai, Locum Consultant
Ophthalmologist commenced these additional duties in June 2014. The new RMS
system Premier IT was introduced in April and went live in May 2014, appropriate
training has and is continually being provided.
Future Plans

To continue to develop and improve the new RMS by introducing
additional features to replace the current manual forms which are used
(Clinical declaration of practice elsewhere and appraisal form) .

The Clinical Revalidation lead will identify ‘Revalidation representatives’
from individual services and satellites to ensure the smooth operation
of revalidation within the service and address queries and support
revalidation.

A new support network system for all trained appraisers will be created
to keep appraisers up to date with changes in revalidation, RMS
improvements. The objective of this network is also to ensure that
appraisers are supported and offered assistance where needed.

Modify the RMS system to facilitate joint clinical and research
appraisals for clinicians with research roles in the Institute of
Ophthalmology and other research institutions.

All the doctors who have not had appraisals or who have missed
appraisal dates have now been identified using the RMS system. This
will allow close monitoring of the appraisal progress of all doctors and
provision of support if nay doctors are missing their appraisals.
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11.
Conclusion and recommendation
Medical Revalidation is now in its 2nd year of implementation. A robust supporting
structure has been developed and implemented in Moorfields for all doctors. 57
doctors successfully revalidated in 2013 – 2014, and since the start, 100 doctors
have been successfully revalidated. There were only two deferrals both for justifiable
reasons.
A number of self-assessments, and an external audit, have shown that Moorfields
has undertaken all the necessary action to fulfil its responsibilities for revalidation.
An action plan, overseen by Dr Poornima Rai, Revalidation Lead, and supported by
a dedicated resource in the HR team, will ensure that Moorfields remains fully
compliant with all aspects of revalidation.
Additional development needs have been identified to ensure that doctors continue
to be supported to collect and provide evidence for their mandatory quinquennial
revalidation. Section 10 describes these developments that are required over the
next year.
This report will be reviewed by the higher level responsible officer, Dr Andrew
Mitchell of NHS England, and discussed at the Moorfields Responsible Officer’s
annual appraisal.
The Trust board is asked to approve the ‘statement of compliance’ Annex D
confirming that the organisation, as a designated body, is in compliance with the
regulations.
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Extract from AOA report-Appendix A
Submitted to NHS England on the year April 2013 – March 2014
ONLY DOCTORS WITH WHOM THE DESIGNATED BODY HAS A
Number
PRESCRIBED CONNECTION AS AT 31 MARCH 2014
of Doctors
Consultants (permanent employed consultant medical
staff including honorary contract holders, NHS, hospices,
and government /other public body staff. Academics with
honorary clinical contracts will usually have their
responsible officer in the NHS trust where they perform
123
their clinical work)
Staff grade, associate specialist, specialty doctor
(permanent employed staff including hospital practitioners,
clinical assistants who do not have a prescribed
connection elsewhere, NHS, hospices, and
31
government/other public body staff)
Temporary or short-term contract holders (temporary
employed staff including locums who are directly
employed, trust doctors, locums for service, clinical
research fellows, trainees not on national training
schemes, doctors with fixed-term employment contracts,
91
etc)
Other doctors with a prescribed connection to this
designated body (depending on the type of designated
body, this category may include responsible officers,
locum doctors, and members of faculties/professional
bodies. It may also include some non-clinical
management/leadership roles, research, civil service,
doctors in wholly independent practice, other employed or
contracted doctors not falling into the above categories,
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etc)
TOTAL The difference between the number of doctors
and the number of completed appraisals is the number
256
of missed or incomplete appraisal
Completed
Appraisals
Percentage of
appraisal
undertaken
107
87%
24
77%
69
76%
7
64%
207
81%
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Audit of revalidation recommendation-Appendix B
Revalidation recommendations between 1 April 2013 to 31 March 2014
Recommendations (inclusive deferrals) completed on time (within the GMC
recommendation window)
57
Late recommendations (completed, but after the GMC recommendation
window closed)
0
Missed recommendations (not completed)
0
TOTAL
57
Primary reason for all late/missed recommendations
None
For any late or missed recommendations only one primary reason must be
identified
No responsible officer in post
N/A
New starter/new prescribed connection established within 2 weeks
of revalidation due date
N/A
New starter/new prescribed connection established more than 2
weeks from revalidation due date
N/A
Unaware the doctor had a prescribed connection
N/A
Unaware of the doctor’s revalidation due date
N/A
Administrative error
N/A
Responsible officer error
N/A
Inadequate resources or support for the responsible officer
role
N/A
Other
N/A
Describe other
TOTAL [sum of (late) + (missed)]
0
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Audit of concerns about a doctor’s practice- Appendix C
Concerns about a doctor’s practice
High
level
Medium
level
Low
level
Total
Number of doctors with concerns about their
practice in the last 12 months
Explanatory note: Enter the total number of
doctors with concerns in the last 12 months. It is
recognised that there may be several types of
concern but please record the primary concern
0
0
0
0
Capability concerns (as the primary category) in
the last 12 months
0
0
0
0
Conduct concerns (as the primary category) in
the last 12 months
0
0
3
3
Health concerns (as the primary category) in the
last 12 months
0
0
0
0
Remediation/Reskilling/Retraining/Rehabilitation
Numbers of doctors with whom the designated body has a prescribed
connection as at 31 March 2014 who have undergone formal remediation
between 1 April 2013 and 31 March 2014
1
Other Actions/Interventions
Local Actions:
Number of doctors who were suspended/excluded from practice between 1
April and 31 March:
Explanatory note: All suspensions which have been commenced or completed
between 1 April and 31 March should be included
0
Duration of suspension:
Explanatory note: All suspensions which have been commenced or completed
between 1 April and 31 March should be included
Less than 1 week
1 week to 1 month
1 – 3 months
3 - 6 months
6 - 12 months
0
Number of doctors who have had local restrictions placed on their practice in
the last 12 months?
3
GMC Actions: Number of doctors who:
Number
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Were referred by the patients to GMC between 1 April and 31 March
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Of these referral were not substantiated by the GMC and had no
conditions placed on their practice, by the GMC or undertakings agreed
with the GMC between 1 April and 31 March
9
Had their registration/licence suspended by the GMC between 1 April
and 31 March
0
Were erased from the GMC register between 1 April and 31 March
0
National Clinical Assessment Service actions:
0
Number of doctors about whom NCAS has been contacted between 1 April and
31 March:
For advice
2
For investigation
0
For assessment
0
Number of NCAS investigations performed
0
Number of NCAS assessments performed
0
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Comparison of Moorfields Appraisal rates with rest of sector and NHS England
Appendix D
Same sector:
2013/14 AOA indicator
SECTION 2: Appraisal
Your
organisation’s
response
Your organisation’s
response
There is a medical appraisal policy,
with core content which is compliant
with national guidance, that has been
ratified by the designated body's
board
(orofan
equivalent
Number
doctors
with governance
whom the
or
executivebody
group)
designated
has a prescribed
connection on 31 March 2014 who
Consultants
had a completed annual appraisal
between 1 April 2013 - 31 March
2014
Staff grade, associate specialist,
speciality doctor
Doctors on Performers Lists
Doctors with practising privileges
Temporary or short-term contract holders
Other doctors with a prescribed
connection
Total number of doctors who had a
completed annual appraisal
Yes
Your organisation’s
response and (%)
calculated appraisal
rate
Acute
hospital/secondary
care
foundation
trust
DBs
sector:
No. in
of DBs
in
102 and
same sector
(%) that said
‘Yes’
92 (90.2%)
All
sectors:
Total DBs:
No. of DBs in
ALL
sectors and
645
(%) that said
‘Yes’
590 (91.5%)
107 (87%)
Same
sector
appraisal
rate
87.1%
ALL
sectors
appraisal
rate
86.3%
24 (77.4%)
78.2%
78.6%
0 (0%)
100.0%
91.6%
0 (0%)
0.0%
74.2%
69 (75.8%)
46.8%
53.9%
7 (63.6%)
51.3%
67.0%
207 (80.9%)
79.5%
83.8%
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Statement of Compliance -Annex D
Designated Body Statement of Compliance
The Trust Management Board of Moorfields Eye Hospital has carried out and submitted
an annual organisational audit (AOA) of its compliance with The Medical Profession
(Responsible Officers) Regulations 2010 (as amended in 2013) and can confirm that:
1. A licensed medical practitioner with appropriate training and suitable capacity
has been nominated or appointed as a responsible officer;
Comments: Yes
2. An accurate record of all licensed medical practitioners with a prescribed
connection to the designated body is maintained;
Comments: Yes
3. There are sufficient numbers of trained appraisers to carry out annual medical
appraisals for all licensed medical practitioners;
Comments: Yes 56 a ratio of 5-1 which exceeds the GMC guidance of 1-6
4. Medical appraisers participate in ongoing performance review and training /
development activities, to include peer review and calibration of professional
judgements (Quality Assurance of Medical Appraisers or equivalent);
Comments: Yes by feedback from appraises with refresher training provided by
the Trust every few months [July 2014]
5. All licensed medical practitioners either have an annual appraisal in keeping with
GMC requirements (MAG or equivalent) or, where this does not occur, there is
full understanding of the reasons why and suitable action taken;
Comments: Yes. Some doctors retired completely from practice at the end of
March 2014 so did not do an appraisal. A significant number of Clinical Fellows
returned to their home countries in the reporting period. They no longer have
licences to practice in the UK so did not have an appraisal. Some Clinical
Fellows joined the Trust from abroad in the second half of this reporting period
and had not yet had an appraisal by end of the reporting period. They can now
be identified on the RMS system and will have an appraisal as will as all other
doctors within one year of starting in the Trust.
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6. There are effective systems in place for monitoring the conduct and performance
of all licensed medical practitioners, which includes [but is not limited to]
monitoring: in-house training, clinical outcomes data, significant events,
complaints, and feedback from patients and colleagues, ensuring that
information about these is provided for doctors to include at their appraisal;
Comments: Yes. A significant improvement early in 2014 was the introduction
of a electronic incident reporting system. This provides all doctors with a record
of all incidents in which they have been named. This must be discussed at their
appraisal. The Responsible Officer, the risk management team and the
Revalidation team also have access to this data. This compliments a similar
existing system for complaints in which doctors are named
7. There is a process established for responding to concerns about any licensed
medical practitioners fitness to practise;
Comments: Yes
8. There is a process for obtaining and sharing information of note about any
licensed medical practitioners’ fitness to practise between this organisation’s
responsible officer and other responsible officers (or persons with appropriate
governance responsibility) in other places where licensed medical practitioners
work;
Comments: Yes, the form is referred to as F2 - Declaration of Other Clinical
Practice and F3-Appraisal information
9. The appropriate pre-employment background checks (including pre-engagement
for Locums) are carried out to ensure that all licenced medical practitioners have
qualifications and experience appropriate to the work performed; and
Comments: Yes
10. A development plan is in place that addresses any identified weaknesses or
gaps in compliance to the regulations.
Comments: See section 10 Corrective Actions, Improvement Plan and Next
Steps
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Signed on behalf of the designated body
Name: _ _ _ _ _ _ _ _ _ _ _
Signed: _ _ _ _ _ _ _ _ _ _
[chief executive or chairman a board member (or executive if no board exists)]
Date: _ _ _ _ _ _ _ _ _ _
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