A Framework of Quality Assurance (FQA)
for Responsible Officers and Revalidation
Ahead of the Curve
RO conference
4 June 2014
FQA - Introduction
•
•
•
•
Objective
Key principles
Background
How the FQA will support Responsible Officers,
Designated Bodies (DBs) and Higher Level ROs
• FQA - Core Standards
• FQA - Core Standards Categories
• FQA – Origins and Development
• FQA - Process
• FQA - Work stream Summary
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FQA - Objective
• The implementation of a framework of quality assurance
(FQA):
• Encompassing all mechanisms by which ROs and DBs
demonstrate to patients, the public, doctors and
organisations that robust, consistent processes to monitor
the performance of doctors are in place and are functioning
effectively.
• Evidence based on the Medical Profession Regulations
(2010, amended 2013) and in associated guidance.
• Designed to help ROs give confidence to their board (or an
equivalent governance or executive group), patients, their
own ROs, that the necessary functioning systems are in
place and that appropriate action is being taken on the
basis of the information they generate.
3 NHS England | Revalidation | FQA
FQA - key principles:
• FQA must support all ROs in fulfilling their statutory duties
• The model is of a single process of monitoring, culminating
in the generation of an Annual Organisational Audit (AOA),
which will feed a report from RO to their board (or an
equivalent governance or executive group) and also the
RO’s appraisal
• The reporting process for ROs must be:
• Streamlined
• Coherent
• Integrated – with other systems of quality assurance
• And minimise disruption and duplication of effort
4 NHS England | Revalidation | FQA
FQA - Background
• The FQA is about implementation of the RO Regulations
(including Revalidation) and comprises:
• A set of ‘core standards’ derived from the regulations and associated
mandatory guidance;
• Quarterly progress reports (appraisal rate)
• An Annual Organisational Audit (AOA);
• An Annual Report Template to help ROs in their reporting of progress
to their DB;
• A statement of compliance (signed by DB board or equivalent
governance or executive group member); and
• It also states that there must be mechanisms in place to
help ROs achieve and demonstrate calibration and
consistency of their decision-making (eg RO and appraiser
networks).
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FQA – the elements: ‘Core Standards’
• The FQA team has identified every item in the RO
Regulations and all the associated mandatory guidance
which must be in place (and which ROs will be expected to
demonstrate)
• These have been compiled into a single list
• Each item has been referenced to the specific point or
section of the regulations or guidance
• Each point of evidence or question of the reporting system
for ROs is derived from the core standards
• Currently shows mandatory and good practice - excellent
practice standards will be gathered and shared over time
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FQA – core standards categories
• The designated body and responsible officer
• Appraisal
• policy, leadership and governance
• capacity and capability
• Monitoring performance and responding to concerns
• policy, leadership and governance
• capacity and capability
• Recruitment and engagement
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FQA – the elements: AOA
• ROs are familiar with RST’s ORSA exercise which
assessed ‘readiness’ for implementing revalidation
• The AOA, based on the core standards, is similar, but
assesses DB progress in implementing revalidation
• For ROs, the AOA provides a means of demonstrable
assurance that systems and processes in their DB meet
nationally agreed standards
• AOA data feeds into RO’s annual report to their board (or
an equivalent governance or executive group) and
submitted to higher-level RO along with a statement of
compliance. These will be collated into a national annual
report. It also feeds into the RO’s portfolio of supporting
information for their appraisal.
• A process of independent verification will be introduced to
8 NHS
England | Revalidation
| FQA
support
ROs in
demonstrating performance
FQA Process
Governance
RO Monitors
DB Progress
HR
Appraisals
Recommendations
GMC Data
Monthly
Quarterly
Report
Quarterly
Annual
Regional
RO
AOA exercise
RO Report
to DB
Board*
Higher
Level
RO
Independent
Verification
ERIB
RPB
QCRC
NHSE
Board
DB Board*
Approval
* Or Director or Executive
Team as applicable
Minister
Compliance
Statement
9 NHS England | Revalidation | FQA
700 Reports
4 Reports
1 Report
Governance
Boards
Outcomes/benefits
NHS
England
Provides;
Designated
bodies need to;
Outcomes/ benefits
Quarterly report
Submit data to
Regional Teams
Helps ROs maintain systems to support measurement of
appraisal rates
Annual
Organisational
Audit (AOA)
Submit via upload
portal provided with
AOA electronic return
Provides a means of demonstrable assurance that systems
and processes in the DB meet nationally agreed standards
Board Report
Table at the relevant
governance committee
Support RO in ensuring sufficient resources and support are
provided. Ensures the organisation is reminded of the
requirements of the RO Regulations
Helps provide assurance that DBs are meeting the
Review another DB’s
requirements of the RO Regulations. Develops understanding
systems & processes
of best practice and provides mechanism for ensuring
Receive feedback on
consistency
your
revalidation
10 NHS | Presentation to [XXXX Company] | [Type Date]
systems & processes
Independent
Verification
Making the most of the FQA
• Establish & maintain systems and processes for
revalidation to meet requirements for FQA e.g.
appraisal rate reporting
• Tailor to the needs of the organisation e.g. Board
report
• Ensure the organisation understands the
requirements of the RO Regulations
• Arrange an external quality assurance review, by
peer review or through an independent
organisation and submit report to support
independent verification
11 NHS | Presentation to [XXXX Company] | [Type Date]
Suggestions for challenge by Boards (1)
Non-executives of designated bodies may wish to
constructively challenge their boards by asking:
• What integrated systems are in place for
monitoring doctors’ performance?
• How does the organisation support staff-grade
doctors and associate specialists, recognising
good practice, encouraging and supporting
development and learning?
• What are the annual percentages for completed
appraisals for each grade of doctor?
12 NHS | Presentation to [XXXX Company] | [Type Date]
Suggestions for challenge by Boards (2)
• What systems are in place for monitoring the
impact of the organisation’s implementation of the
regulations on equality and diversity issues?
• How is the quality of medical appraisals assured?
• How is the quality of medical recruitment checks
assured?
• How many doctors have required remediation in
year?
• How is this remediation supported and funded?
13 NHS | Presentation to [XXXX Company] | [Type Date]
Suggestions for challenge by Boards (3)
• How is patient input to feedback on doctors
obtained?
• How are current systems for patient feedback
used for input into appraisals?
• How are quality improvement activities required
for appraisal used to support the organisation’s
priorities?
• What percentage of revalidation
recommendations have had to be deferred and
why?
• How is the organisation meeting its statutory duty
to support the RO in implementation of the
14 NHS | Presentation to Ahead of the curve. National ROs conference | [4 June 2014]
regulations?
Independent verification
• to provide assurance that there are robust systems in place
to underpin the statutory responsibilities of the responsible
officer
• minimum of once per revalidation cycle for each designated
body.
• undertaken by the higher level responsible officer’s team
• desk top review of evidence and a visit to the responsible
officer at the designated body if required
• to identify and disseminate good practice
• ROs may provide evidence to support independent
verification through a report from an external QA review
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External quality assurance review
• Guidance and sample specification available
• Ensure it is carried out by independent personnel
• Based on core standards
• Submit full report to higher level RO’s team
• Share examples of good practice through RO
networks
• Develop an action plan to meet standards where
necessary
Want to know more? Attend the workshop this
afternoon
16 NHS | Presentation to [XXXX Company] | [Type Date]
Discussion points
• Does your designated body’s systems and
processes align with the FQA? If not what
changes are required? How will you make these
changes?
• Can you make the reporting process as slick as
possible? (quarterly reports and AOA)
• Does your Board (or equivalent) understand the
requirements of the RO Regulations? If not what
can you do?
• What mechanisms do you have for learning from
other similar designated bodies?
17 NHS | Presentation to [XXXX Company] | [Type Date]
Discussion points
• Do you have identified people with responsibility
for specific core standards?
• What examples of good practice / innovations can
you share with others?
18 NHS | Presentation to [XXXX Company] | [Type Date]