Performance and Resources Board meeting, 17 November 2015
Agenda item:
7
Report title:
Quality Assurance Programme 2016
Report by:
Sunil Kapur, Acting Assistant Director of Quality Assurance and
Continuous Improvement team, skapur@gmc-uk.org,
0161 923 6654
Action:
To consider
Executive summary
At its meeting on 22 September 2015, the Performance and Resources Board approved the
Quality Assurance Strategy. Aim three of the Strategy was to develop a Corporate Quality
Assurance Programme.
The Quality Assurance Programme 2016 adopts a risk based, proportionate approach to
assurance and has taken account of assurance and management checks already in place
across the GMC.
Recommendations
The Performance and Resources Board is asked to approve the Quality Assurance
Programme 2016 at Annex A.
Performance and Resources Board meeting, 17 November 2015
Agenda item 7 – Quality Assurance Programme 2016
Requirement
1
Aim three of our Quality Assurance (QA) Strategy is for the Quality Assurance and
Continuous Improvement team (QA&CI) team to ‘conduct corporate reviews to
provide assurance to GMC’s management teams on cross cutting and high risk
operational processes’. This will aid in providing assurance that our key operational
processes and decision making meets specified requirements and standards, which
are set out in our policy and guidance documents and our operational procedures.
This work has now been planned and documented in our Quality Assurance
Programme for 2016.
2
The Quality Assurance Programme adopts a risk based, proportionate approach to
assurance. The programme is at Annex A.
Approach
3
In developing the Programme we have considered operational processes and
decisions which:
a Are currently subject to assurance by the QA&CI team, the majority of which are
conducted for the Fitness to Practise Directorate.
b May be subject to future review by the Professional Standards Authority (PSA).
c Have been recommended for review by Internal Audit.
d Have been requested for review by a senior, directorate manager (including
Medical Practitioners Tribunal Service (MPTS)) or appeared on a directorate
assurance map.
4
Previous QA results and the level of assurance and management checks already in
place were also considered in developing the Quality Assurance Programme. This is in
line with our QA Strategy of adopting a proportionate and risk based approach to
quality assurance. As a result it is proposed to reduce the frequency of existing
assurance activity in Fitness to Practise from quarterly to six monthly. Previous
assurance results and the implementation of peer review has shown that process
controls are mature, well established and that the quality of decision making and case
management is high. However, the reduction in existing assurance is balanced by the
inclusion of new assurance activities for processes or operational functions that have
not previously been subject to regular review within the directorate.
5
The QA team have also worked closely with the Assistant Director of Audit and Risk
Assurance to ensure that operational QA activities complement the work of the
Internal Audit team.
2
Performance and Resources Board meeting, 17 November 2015
Agenda item 7 – Quality Assurance Programme 2016
6
The methodology used to produce the Quality Assurance Programme is an interim
approach for 2016. It is envisaged that future work programmes will be informed by
the implementation of the QA Strategy; in particular the development of directorate
QA plans and the results of our European Framework for Quality Management
assessment, which will give the QA team a more holistic picture of key operational
processes and future assurance requirements across all directorates. These results
can also be used to determine the future frequency and type of assurance activity.
7
In developing the Quality Assurance Programme we have also considered corporate
projects. The QA&CI team will provide support to the new corporate complaints
process, the Investors in People accreditation process and it is also proposed that we
will support the development of assurance processes for the MPTS. We are also
aware of a potential requirement to adapt as the change programme is initiated.
8
The scope of assurance for some directorates is still to be determined, so a number
of working days have been allocated in the Quality Assurance Programme. This is the
case for the Education and Standards, Strategy and Communication and Resources
and Quality Assurance directorates.
QA Reviews
11 It’s envisaged that the QA&CI team will undertake two types of assurance activity;
quality control audits and operational process reviews. Quality control audits will
review the outputs (including decisions) of a process to ensure they comply with
agreed standards and operational guidance. Audits will be conducted on a sample
basis with a minimum of 85% confidence level. This means that 85 out of 100
samples will reflect the results of the whole population. Operational process reviews
will involve an assessment of the maturity of a process, its controls and measures.
Resources
12 It is important to ensure that we have the flexibility to vary the Quality Assurance
Programme if new emerging issues are identified. However, amendments will need to
be considered alongside the limited resources within the centralised QA&CI team. Any
amendments to the Programme will be subject to approval by the Director of
Resources and Quality Assurance, and significant changes will be reported to the
Board at the next available meeting.
Reporting
13 Final reports will normally be sent to an Assistant Director (AD). Where an audit or
review reports on any decisions made by an AD the report will be sent to the
Director. Summary reports on the findings and themes emerging from our assurance
activity will be presented to the Board and the MPTS Committee as appropriate. We
are currently working to develop our reporting requirements and ensure that our
reporting arrangements are streamlined.
3
Performance and Resources Board meeting, 17 November 2015
7 – Quality Assurance Programme 2016
7 - Annex A
Quality Assurance Programme 2016
Performance and Resources Board meeting, 17 November 2015
Area for review
Source
Agenda item 7 – Quality Assurance Programme 2016
Scope
Resources Frequency
/days per
audit
Comments
Fitness to Practise Directorate
Triage decisions
Case Examiner (CE) –
Post investigation
decisions
Existing Fitness to Practise
(FTP) quality control audit.
Audit based on a sample of
enquiry decisions made.
Professional Standards
Authority (PSA) area for
review.
Audit results recorded in
Siebel.
FTP request for assurance
Quality Assurance (QA) and
Continuous Improvement
(CI) team to prepare report.
Existing FTP quality control
audit.
Audit based on a sample of
CE decisions made.
PSA area for review.
Audit includes review of first
and second CE decisions.
FTP request for assurance.
10 days x 4 Twice a year.
Quality Q1 and Q3
Assurance
Officers
(QAOs)
Audit at 85%
confidence level *.
Approximate sample
size per audit is 162
enquiries.
25 days X 5 Twice a year.
QAOs Q2 and Q4
Audit at 85%
confidence level.
Approximate sample
size per audit 156
cases.
Audit results recorded in
Siebel.
*
Confidence level refers to the reliability placed on the sample result. An 85% confidence level means that 85 out of 100 samples will reflect the results of the whole population.
A2
Performance and Resources Board meeting, 17 November 2015
Area for review
Source
Agenda item 7 – Quality Assurance Programme 2016
Scope
Resources Frequency
/days per
audit
Comments
QA&CI team to prepare
report
Case Examiner – CE
IOP
Existing FTP quality control
audit.
Audit based on a sample of
decisions made.
PSA area for review.
Audit results recorded in
Siebel.
FTP request for assurance.
8 days X 2
QAOs
Twice a year.
Q1 and Q3.
Audit at 90%
confidence level.
Sample size per audit
approx. 66 cases.
6 days X 2
QAOs
Two per year. Audit at 85%
Q2 and Q4
confidence level.
Sample size per audit
48 cases.
6 days X 2
QAOs per
audit
Twice a year.
Q1 and Q3
QA&CI team to prepare
report
Investigation Manager
IOP
Existing FTP quality control
audit.
Audit based on a sample of
decisions made.
PSA area for review.
Audit results recorded in
Siebel.
FTP request for assurance.
QA&CI team to prepare
report
Voluntary Erasure
decisions
Existing FTP quality control
audit.
Audit based on a sample of
decisions made.
PSA area for review.
Audit results recorded in
Audit at 85%
confidence level.
Sample size per audit
38 cases.
A3
Performance and Resources Board meeting, 17 November 2015
Area for review
Agenda item 7 – Quality Assurance Programme 2016
Source
FTP request for review
Scope
Resources Frequency
/days per
audit
Comments
Siebel.
QA&CI team to prepare
report
Rule 28 decisions
Existing FTP quality control
audit.
Audit based on a sample of
decisions made.
FTP request for assurance.
Audit results recorded in
Siebel.
6 days X 1
QAO
Twice a year.
Q2 and Q4
Audit at 85%
confidence level.
Sample size per audit
12 cases
2 days X 1
QAO
Twice a year.
Q1 and Q3
Audit at 90%
confidence level
Sample size 8 cases.
New audit/process.
QA&CI team to prepare
report
Notify employer
decisions
Existing FTP quality control
audit.
Audit based on a sample of
decisions made.
Possible PSA area for
review.
Audit results recorded in
Siebel.
FTP request for assurance.
QA&CI team to prepare
report
A4
Performance and Resources Board meeting, 17 November 2015
Area for review
Adverse Information
Case Review Case
Examiner decisions
Source
Agenda item 7 – Quality Assurance Programme 2016
Scope
Existing FTP quality control
audit.
Audit based on a sample of
decisions made.
Possible PSA area for
review.
Audit results recorded in
Siebel.
FTP request for assurance.
QA&CI team to prepare
report
Existing FTP quality control
audit.
Audit based on a sample of
decisions made.
FTP request for assurance.
Audit results recorded in
Siebel.
Resources Frequency
/days per
audit
Comments
6 days X 5
QAOs
Twice a year.
Q2 and Q4
Audit at 85%
confidence level.
Sample size 126 cases.
5 days X 2
QAOs
Twice a year.
Q1 and Q4
Audit at 85%
confidence level.
Sample size 30 cases.
15 days X 3
QAOs
Twice a year.
Q2 and Q4
Audit at 90%
confidence level due to
changes in process.
Sample size to be
determined.
QA&CI team to prepare
report
Disclosure and Barring
decision audit
Existing FTP quality control
audit.
Audit based on a sample of
decisions made.
FTP request for assurance.
Audit results recorded in
Siebel.
QA&CI team to prepare
A5
Performance and Resources Board meeting, 17 November 2015
Area for review
Agenda item 7 – Quality Assurance Programme 2016
Source
Scope
Resources Frequency
/days per
audit
Comments
report.
Provisional enquiry
decision audit
New request for assurance
by FTP.
Possible PSA area for
review
Thematic audit to review the 5 days X 1
process, guidance and a
QAO
sample of decisions.
Once in Q1
Results will determine
the frequency and type
of future assurance
activity such as peer
review
Flagged on FTP Assurance
Map
Case Review – AR
decision
Existing FTP quality control
audit however this audit
has not been completed
since 2014 due to process
changes.
Thematic review Performance
New request for review
Audit at 90%
confidence level due to
new process. Sample
size to be determined.
Thematic review of the
process, guidance and a
5 days X 2
QAOs
Two per year. Audit at 90%
Q2 and Q4
confidence level due to
changes in process.
Sample size to be
determined.
10 days X 2
Once.
Timescales to
Review to be
developed following
A6
Performance and Resources Board meeting, 17 November 2015
Area for review
Agenda item 7 – Quality Assurance Programme 2016
Source
Assessment – case
review team, FTP
from FTP
Thematic review Health Assessments
Rule 12
Scope
Resources Frequency
/days per
audit
Comments
sample of decisions.
QAOs
be confirmed. completion of CI
Estimate Q3/ project.
Q4.
Area highlighted on FTP
assurance map.
Recommended
independent review
following implementation
of new process.
Review of the new
processes and assurances
put in place within the
Associates and Appraisal
Team.
10 days X 2
QAOs
Once in Q3.
Review scope to be
developed following
completion of CI
project.
New request for review.
Review of assurance
requirements.
10 days X 2
QAOs
Once in Q2
Review scope to
include findings and
recommendations
following the recent CI
project.
20 days x 2
QAOs
Once in Q1
Links to request for
development of peer
review process for
registration decisions;
which will be picked up
CI and QA support flagged
in local system review.
Registration and Revalidation Directorate
Registration. Assistant
Registrar (ARs)
decisions
New request from
Registration and
Revalidation Directorate.
New area for possible
Review of the current
processes and decision
making by Registration ARs.
A7
Performance and Resources Board meeting, 17 November 2015
Area for review
Source
Agenda item 7 – Quality Assurance Programme 2016
Scope
Resources Frequency
/days per
audit
future PSA review.
Specialist Applications
- decisions
New request from
Registration and
Revalidation Directorate.
and supported via
directorate QA plan.
Thematic review.
20 days x 2
QAOs
Once in Q1
Results will determine
the frequency and type
of future assurance
activity such as peer
review
Review of the current
processes and decision
making by Registration ARs.
20 days X2
QAOs
Once. Q2
Results will determine
the frequency and type
of future assurance
activity such as peer
review.
To be determined.
20 days X2
Once in Q3
New area for possible
future PSA review.
Revalidation decisions
New request from
Registration and
Revalidation Directorate.
Comments
Education and Standards
To be determined
A8
Performance and Resources Board meeting, 17 November 2015
Area for review
Source
Agenda item 7 – Quality Assurance Programme 2016
Scope
Resources Frequency
/days per
audit
Comments
QAOs
MPTS
MPTS (subject to
committee approval)
New request from MPTS to
support quality assurance
development.
Scope of QA review to be
determined by MPTS
committee in Feb 2016.
30 days x 2
QAOs
(estimated)
TBC. Work to
commence
Q1
To be determined.
20 days X 2
QAOs
Once in Q3
To be determined.
20 days X 2
QAOs
Once in Q4
Report to be presented
to MPTS Committee.
Resources and Quality Assurance
To be determined
Strategy and Communications
To be determined
A9
Performance and Resources Board meeting, 17 November 2015
Area for review
Agenda item 7 – Quality Assurance Programme 2016
Source
Scope
Resources Frequency
/days per
audit
Comments
Office of the Chair and Chief Executive
Thematic review Corporate Complaints
New process.
Pre ISO review.
Internal request from
Project Manager/Head of
Section.
To be
determined.
Once in Q3
Review to follow ISO
requirements.
Timescale to support
2017 accreditation.
Supports ISO
accreditation.
Corporate Complaints
– peer review
development cross
directorate
New process.
Internal request from
Project Manager/Head of
Section.
Supports ISO
accreditation.
Development of peer review 25 days x 1
for all directorate complaints QAO.
teams.
Corporate
Complaints,
Project
Manager.
Once
Cross Cutting and Programme/Project Support
Thematic review - Risk
management
framework –
Internal audit
Follow up on
recommendation (June
recommendations made by
2015) for risk management internal audit on risk
10 days X 2
QAOs
Once in Q4
Changes to the risk
management process
will take place in the
A10
Performance and Resources Board meeting, 17 November 2015
Area for review
crosscutting review.
Thematic review English Language
testing. FTP and
Registrations.
Source
Agenda item 7 – Quality Assurance Programme 2016
Scope
processes to be reviewed
as part of QA work
programme.
management processes.
Internal audit completed in
2014. Focused on
readiness for changes.
Thematic review of
guidance, decision making
and local assurances for
Registration concerns raised
during the application
process.
FTP assurance map
identified area for
additional assurance.
Resources Frequency
/days per
audit
(estimated)
first half of 2016
therefore it’s proposed
the review takes place
in Q4 2016.
Thematic review.
Review guidance, decision
making and local assurances
in FTP.
Sample of decisions to be
reviewed. Reported via
excel.
QA&CI team to prepare
report.
15 days X 2
QAOs
allocated
(estimate)
Comments
Once in Q2
Review to be
developed.
The 2014 Internal
audit was to obtain
assurance that the
arrangements put in
place to accommodate
newly received legal
powers were adequate
and the powers were
applied in a fair and
consistent manner.
This review will look at
the decision making
associated with this
guidance in
Registration and FTP
A11
Performance and Resources Board meeting, 17 November 2015
Area for review
Source
Agenda item 7 – Quality Assurance Programme 2016
Scope
Resources Frequency
/days per
audit
Comments
directorates.
Investors in People
(IIP) – Quality
Assurance support.
Support to the project
team on IIP with particular
support to Quality
Assurance.
To be determined.
To be
determined.
Ongoing from
Q1
A12