Principle 4 – Organisations deliver processes required to support medical revalidation and the evaluation of doctors’ fitness to practise

This checklist is a tool to support the delivery of clinical governance processes that underpin medical revalidation, and the evaluation of doctors’ fitness to practise.

4a. Appointing a responsible officer

Your organisation’s board appoints a responsible officer.

Description

If your organisation is a designated body it must:

  • appoint or nominate a responsible officer and appoint a replacement as soon as manageable when necessary. For example where your RO leaves, is under investigation, or absent from work due to ill-health.
  • provide its RO with sufficient funding and resources, to enable them to effectively carry out their statutory responsibilities.

Your organisation ensures its RO is appropriately trained to undertake their responsibilities, and is given support to regularly participate in local RO network activities that provide shared learning opportunities and support consistency of approach.

Prompts

  • How does your organisation ensure its RO is able to deliver all aspects of their statutory functions as defined in the RO regulations?
  • How do you make sure your organisation’s RO has sufficient resources to undertake their statutory role?
  • How does your organisation ensure its RO has the quality of information they need to carry out their statutory duties (including to inform revalidation recommendations to the GMC)?
  • How has learning from your RO’s participation in local RO network activities improved local processes and provided assurance on the consistency of their approach?

4b. Medical appraisal

Your organisation’s board ensures medical appraisal is delivered in line with GMC and other national and local requirements.

Description

Your organisation ensures all doctors requiring an annual appraisal receive one and it covers the whole of a doctor’s practice including any work undertaken outside of your organisation during the appraisal period.

Your organisation ensures doctors are clear which appraisal requirements are prescribed by the GMC for the purpose of revalidation:

Your organisation ensures doctors are supported to collect the required supporting information by being given access to relevant data and systems  and sufficient time to participate in annual appraisal  effectively. This includes locum doctors, doctors in training and clinical academics, for example.

Your organisation ensures doctors taking breaks in practice due to maternity/paternity or sick leave, for example, are supported through appraisal and revalidation.

Your organisation’s appraisal system is subject to quality assurance, including monitoring of appraisers' performance.

Your organisation ensures doctors have the opportunity to feedback on the quality of the appraisal process and discussion.

Your organisation ensures outputs from the appraisal system are integrated into wider clinical governance systems.

Prompts

  • How does your organisation monitor whether all doctors requiring annual appraisal have been appraised?
  • How does your organisation identify barriers to participation in appraisals and the steps taken to remove those barriers?
  • What policies and processes does your organisation have in place to manage doctors who are not engaging in appraisal and other clinical governance processes?
  • How does your organisation make sure information relating to a doctor’s practice from other organisations informs their whole practice appraisal?
  • How do you assess whether doctors have adequate resources to support their appraisal (such as sufficient time and access to the information needed) including educational and development activities?
  • How does your organisation quality assure its appraisal process to identify opportunities for reducing the burden on doctors in terms of preparing for appraisal and collecting supporting information?
  • How does your organisation manage and monitor the performance of appraisers and the resources needed to support them?
  • Does your organisation’s guidance for appraisers include how to appropriately escalate patient safety concerns (including concerns about colleagues) that may as part of the appraisal discussion?
  • How does your organisation ensure there are no unintended barriers for doctors participating in learning and education activities?

4c. Revalidation recommendations

Your organisation’s board ensures revalidation recommendations are made in line with GMC requirements.

Description

Your organisation ensures revalidation recommendations for doctors are made in accordance with the GMC’s protocol for making recommendations.

Doctors are told promptly about the revalidation recommendation made to the GMC about them. The reasons for recommendations are discussed before they are submitted, particularly where the recommendation is to defer or for non-engagement.

Your organisation ensures revalidation continues to deliver benefits by considering how best to track its impact over time.

Prompts

  • How does your organisation monitor revalidation recommendations to ensure they are made in accordance with the appropriate guidance?
  • Does your organisation compare recommendation rates, for example, deferral rates with similar organisations to identify whether there are any differences and if there are differences explore why?
  • Does your organisation monitor the number of late recommendations?
  • How has your organisation improved the revalidation recommendation process? For example, how does it learn from revalidation decisions around deferral and non-engagement?
  • What steps does your organisation take to make sure revalidation recommendations are fair, transparent, based on all the relevant evidence, and have been discussed with the doctors concerned in a timely manner?

4d. Responding to and managing concerns

Your organisation’s board ensures processes for responding to and managing concerns including monitoring the ongoing fitness to practise of doctors are in place.

Description

Your organisation has systems in place to monitor the conduct and performance of doctors including locum doctors, doctors in training and clinical academics, for example.

Your organisation ensures performance information about doctors (including clinical indicators relating to outcomes for patients) is regularly reviewed and issues identified (such as variations in individual performance, and between clinical teams). It also ensures steps are taken to address any issues identified. 

Your organisation proactively responds to concerns locally, with referrals to the GMC made by the RO where and when appropriate. Speciality or other central or local advice is taken where appropriate from, for example:

Your organisation’s investigations into concerns about doctors take into account, where appropriate, the GMC’s principles of a good investigation. These key principles help to ensure investigations into concerns about doctors are objective and effective. They are intended to supplement and complement existing requirements and guidance in place at a national level.

Your organisation ensures doctors’ compliance with any GMC or local conditions imposed on them or undertakings agreed with GMC is monitored. 

Prompts

  • What processes does your organisation have in place to address issues identified relating to the conduct and performance of doctors, including, locums, doctors in training and clinical academics for example?
  • How does your organisation make sure information derived from complaints and significant events other performance data held by the organisation, is regularly reviewed and feeds into the monitoring of the conduct and performance of doctors?
  • How does your organisation ensure advice from external sources is considered early when responding to emerging concerns?
  • What areas for learning and improvement has your organisation identified from the triangulation of outputs from different clinical governance processes?

Questions relating to the GMC’s principles of a good investigation

4e. Sharing information

Your organisation’s board ensures there are processes are in place to handle and share information relating to clinical governance systems for doctors appropriately.

Description

Your organisation makes sure records are accurately and securely maintained in line with all relevant data protection legislation and the Caldicott principles. This includes:

  • records relating to pre-employment checks, medical revalidation, and appraisal, and systems supporting these processes. 
  • local investigations and management of concerns.

Timely sharing of information is an essential component of robust clinical governance. Any organisation using the services of a doctor must inform that doctor’s responsible officer of any concerns that could impact on patient safety or public confidence as soon as they arise. This should be done in line with the GMC’s information sharing principles.

Prompts

  • How do you make sure that records are accurately and securely maintained in line with relevant data protection legislation and guidance?
  • How does your organisation make it is complying with information sharing principles?
  • How does your organisation monitor the effectiveness of its information sharing processes (for example, sharing information with other organisations in which your doctors work)?

4f. Pre-employment checks

Your organisation’s board ensures the necessary checks are in place for doctors before they start work.

Description

Your organisation ensures the following arrangements are in place across the medical workforce (whether they are employed, contracted, in training, working with practising privileges, hired or volunteering):

  • Making sure doctors working in your organisation have the appropriate registration, and a licence to practise, for their type of post or practice. 
  • Verifying identity and language checks have taken place, and undertaking these checks if it can’t be verified. 
  • Ensure appropriate references are obtained and checked
  • Granting and monitoring of practising privileges is undertaken where necessary. 

Your organisation should not rely on registration and licence checks undertaken for previous employment or by another organisation, as a doctor’s registration and licence status can change.

It’s important doctors working in your organisation have appropriate insurance or indemnity

Your organisation ensures there are induction arrangements (particularly those to support doctors new to the UK - the GMC holds regular Welcome to UK Practice events, for example) in place for all doctors including locum doctors and doctors in training. 

Prompts

  • How do you make sure that pre-employment, and other pre-contract checks undertaken for your medical workforce (including locums) are comprehensive, accurate, and in keeping with statutory and other requirements?
  • How do you make sure that arrangements to grant and monitor practising privileges where relevant are robust?
  • What induction arrangements does your organisation have in place and how does it monitor their effectiveness?
  • How do you know doctors working in your organisation have the appropriate insurance or indemnity?