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  4. Leadership and management for all doctors
  5. Maintaining and improving standards of care

Leadership and management for all doctors

Maintaining and improving standards of care

Reflecting on your practice

All doctors

22

You should regularly reflect on your own performance, your professional values and your contribution to any teams in which you work. You should ask for, and be prepared to act on, feedback from colleagues and patients, including through the outcomes of audits, appraisals and performance reviews (see paragraphs 30 - 32), and through patient complaints and comments.

30

You should be familiar with the individual performance review process in all the organisations in which you work.

31

You must take part in annual appraisals and you must make sure that your appraisal covers your whole practice, including any non-clinical roles.

32

If you hold a licence to practise, you must take part in revalidation.

Doctors with extra responsibilities

23

Leading by example, you should promote and encourage a culture that allows all staff to contribute and give constructive feedback on individual and team performance. You should make sure that systems are in place to achieve this.

Ensuring high standards of care

24

Early identification of problems or issues with the performance of individuals, teams or services is essential to help protect patients.

All doctors

25

You must take part in regular reviews and audits of the standards and performance of any team you work in, taking steps to resolve any problems.

26

You should be familiar with, and use, the clinical governance and risk management structures and processes within the organisations you work for or to which you are contracted. You must also follow the procedure where you work for reporting adverse incidents and near misses. This is because routinely identifying adverse incidents or near misses at an early stage, can allow issues to be tackled, problems to be put right and lessons to be learnt.

27

You must follow the guidance in Good medical practice 5 and Raising and acting on concerns about patient safety 4 when you have reason to believe that systems, policies, procedures or colleagues are, or may be, placing patients at risk of harm.

5

General Medical Council (2013) Good medical practice London, GMC.

4

General Medical Council (2012) Raising and acting on concerns about patient safety London, GMC

Doctors with extra responsibilities

28

If you have a management role or responsibility, you must make sure that systems are in place to give early warning of any failure, or potential failure, in the clinical performance of individuals or teams. These should include systems for conducting audits and considering patient feedback. You must make sure that any such failure is dealt with quickly and effectively.

29

If you are managing or leading a team, you should make sure that systems, including auditing and benchmarking, are in place to monitor, review and improve the quality of the team's work. You must work with others to collect and share information on patient experience and outcomes. You must make sure that teams you manage are appropriately supported and developed and are clear about their objectives.

Performance review and revalidation

All doctors

30

You should be familiar with the individual performance review process in all the organisations in which you work.

31

You must take part in annual appraisals and you must make sure that your appraisal covers your whole practice, including any non-clinical roles.

32

If you hold a licence to practise, you must take part in revalidation.

Doctors with extra responsibilities

33

You must make sure that staff you manage, including doctors in sessional and other non-training posts, have enough time to prepare for their appraisals or performance reviews and that they have the opportunity to complete them fully and on time.

34

You must be honest and objective and keep to the principles of equality and diversity when appraising or assessing colleagues' performance. This includes when assessing trainees during the Annual Review of Competence Progression (ARCP) or other equivalent process. The safety of patients and the public could be put at risk if you make false, exaggerated or incomplete comments about another professional's competence or experience.

35

You should support staff you manage to complete learning and development activities identified by appraisals or performance reviews.

36

If you appraise or assess colleagues, you should make sure that you have the appropriate knowledge and skills. You should make sure that any staff you manage who also carry out appraisals have the knowledge and skills to do so, and are given regular feedback on how they perform this role.

37

If you are responsible for designing and delivering services, you should make sure that there is an appropriate appraisal or performance review process in place and that staff understand and follow it. You should also make sure that there are ways of dealing with any problems that appraisals bring to light. If the appraisal process includes clinical academic staff, you should make sure it follows the Follett principles.6 

6

Follett B, Paulson-Ellis M (2001) A review of appraisal, disciplinary and reporting arrangements for senior NHS and university staff with academic and clinical duties London, Department for Education and Skills.

38

If you are a responsible officer within a designated body, you will have extra responsibilities as set out in the relevant regulations7 and you must take account of any guidance produced by the departments of health8 or your organisation.

7

Medical Profession (Responsible Officers) Regulations 2010 (which cover England, Wales and Scotland) or the Medical Profession (Responsible Officers) Regulations (Northern Ireland) 2010.

8

Department of Health (England 2010) The Role of the Responsible Officer - Closing the gap in Medical Regulation - Responsible Officer Guidance (pdf), Department of Health. Department of Health, Social Services and Public Safety (2011) Confidence in care: Guidance on the role of responsible officers for doctors and employers (pdf) Belfast, Department of Health, Social Services and Public Safety. At the time of printing, no additional guidance had been published by the departments of health in Scotland and Wales.

Keeping up to date

All doctors

39

You must keep your skills and knowledge up to date in all areas of your work, whether in a clinical or non-clinical setting.

40

You must keep up to date with, and follow, the laws and statutory codes of practice relevant to your particular responsibilities and location9 and you should get expert advice when you need it. You must be familiar with the relevant guidelines and developments that affect your work and use them to help you with your practice.

9

For example, you must be familiar with the Equality Act 2010, Data Protection Act 1998 and relevant employment legislation.

Information governance

41

Doctors need accurate, up-to-date and accessible information to deliver good and safe care to patients. Patients need to understand how information about them will be collected, stored and used and how their confidentiality and privacy will be protected. Good information governance systems can help to achieve this and contribute to providing high quality and safe care. They can also provide valuable information to allow teams and services to improve the quality and safety of care they deliver. All doctors have a role to play in contributing to these systems.

All doctors

42

You must keep accurate and clear patient records following the advice in Good medical practice.5 You should make sure that non-clinical records you keep, including financial records, are clear, accurate and up to date.

5

General Medical Council (2013) Good medical practice London, GMC.

43

You must follow the guidance in Confidentiality:good practice in handling patient information on protecting information and disclosing information for patient care or secondary purposes.10 

10

General Medical Council (2017) Confidentiality: good practice in handling patient information London, GMC.

44

You should be familiar with, and follow, the confidentiality, data protection and record management policies and procedures where you work and know where to get advice on these issues.

Doctors with extra responsibilities

45

If you are responsible for managing patient records or other patient information, you must follow the specific guidance for managers on protecting information set out in Confidentiality:good practice in handling patient information.11 

11

General Medical Council (2017) Confidentiality: good practice in handling  patient information London, GMC, paragraphs 128 - 130 (Records management and retention).

46

You must make sure that any other records you are responsible for, including financial, management or human resources records, or records relating to complaints, are kept securely and are clear, accurate and up to date.

47

You must make sure that records you are responsible for are made, stored, transferred and disposed of in line with the Data Protection Act 1998 and other relevant legislation.