Principle 4 – Organisations deliver the processes required to support revalidation for doctors, AAs and PAs, and to identify and respond to concerns as they emerge
Outcome 4a. Your board has appointed the required individual(s) to make revalidation recommendations
- appoints or nominates a responsible officer (RO) for doctors, and an individual to make revalidation recommendations for AA/PAs (these may be the same person)3
- appoints a replacement RO or AA/PA recommender as soon as possible, when necessary. For example where your RO or AA/PA recommender leaves, or is absent from work due to ill-health.
- provides its RO, and/or AA/PA revalidation recommender, with sufficient funding and resources, to enable them to effectively carry out their responsibilities.
- ensures its RO, and/or AA/PA revalidation recommender, are appropriately trained to undertake their responsibilities, and supports them to regularly participate in available peer networking opportunities for these roles.
- ensures its RO/revalidation recommender(s) have access to the range and quality of information they need to carry out their role
Outcome 4b. Appraisal for doctors, AAs and PAs is delivered in line with GMC requirements for revalidation, and other national and local requirements
Your organisation ensures appraisers are appropriately appointed and trained.
Your organisation ensures all doctors, AAs and PAs:
- receive an annual appraisal which covers their whole scope of practice, including any work undertaken outside of your organisation during the appraisal period.
- are clear which appraisal requirements are set by the GMC for revalidation, and those which are a local requirement.
- are supported to collect the required supporting information by being given access to relevant data and systems, educational and development activities, and sufficient time to participate in annual appraisal effectively.
Your organisation takes account of the potential impact of breaks in practice (for example due to parental or sick leave), on a doctor’s, AA’s or PA’s ability to meet the revalidation requirements in supporting them through appraisal.
Your organisation ensures that information from a doctor, AA or PA’s whole scope of practice feeds into their appraisal discussion. Whole scope of practice includes all work the individual undertakes which requires registration (and for doctors a licence to practise), and may include information from medical practice undertaken outside of your organisation, such as in the independent or voluntary sector.
Your organisation’s appraisal system is subject to quality assurance including gathering feedback from appraisees, monitoring appraisers' performance and resources to support appraisers.
Your organisation ensures any relevant outputs from the appraisal system are integrated into wider clinical governance arrangements.
Your organisation has policies and processes in place to manage doctors, AAs and PAs who are not engaging in appraisal and other clinical governance processes.
Outcome 4c. Revalidation recommendations are made in line with GMC requirements.
Your organisation monitors revalidation recommendations for doctors, AAs and PAs to ensure they are made in accordance with the GMC’s protocol for making recommendations.
You tell doctors, AAs and PAs promptly about the revalidation recommendation made about them. You discuss the reasons for recommendations before they are submitted, particularly where the recommendation is to defer or for non-engagement.
Outcome 4d. Processes support the early identification of concerns, and their effective management
Your organisation has processes in place to monitor the conduct and performance of all doctors, AAs and PAs that work in your organisation.
Your organisation provides guidance for appraisers on appropriately escalating concerns that may arise from the appraisal discussion.
Performance information about doctors, AAs and PAs, such as clinical indicators relating to patient outcomes and information from complaints and significant events, is regularly reviewed. You address any issues identified, such as variations in individual performance or between clinical teams.
Your organisation proactively responds to concerns locally, with referrals to the GMC made where and when appropriate. Specialty or other central or local advice is taken where appropriate from, for example:
- Medical Royal Colleges and Faculties
- GMC’s Outreach team
Your organisation’s investigations into concerns about doctors, AAs and PAs take into account the . These principles help ensure impartial and effective investigations, and complement national level requirements and guidance.
Your organisation ensures doctors, AAs and PAs’ compliance with any GMC or local conditions imposed on them or undertakings agreed with GMC is monitored.
Outcome 4e. Processes are in place to appropriately handle and share information relating to clinical governance arrangements for doctors, AAs and PAs.
Records relating to all clinical governance processes are accurately and securely maintained, in line with all relevant data protection legislation and the 4.
Information about any concerns involving a doctor, AA or PA that could impact on patient safety or public confidence are shared with the relevant RO, SP, or AA/PA revalidation recommender as soon as they arise. This should be done in line with the GMC’s information sharing principles, and includes where the doctor, AA or PA concerned is on a short-term or temporary contract.
Outcome 4f. Necessary pre-employment checks are undertaken for doctors, AAs and PAs before they start work.
Your organisation undertakes the following checks for all doctors, AAs and PAs working in your organisation (whether they are employed, contracted, in training, working with practising privileges, hired or volunteering), and ensures that these checks are comprehensive, accurate, and in keeping with statutory and other requirements:
- The individual holds the appropriate registration, and for doctors a licence to practise, for their post or practice. You should not rely on checks from previous employment, because a professional’s registration and licence status can change.
- Verifying identity and language checks have taken place, and undertaking these checks if it can’t be verified.
- Ensuring appropriate references are obtained and checked.
- Granting and monitoring of practising privileges is undertaken where necessary, to ensure that doctors, AAs and PAs are working within their competency area.
- The individual has appropriate insurance or indemnity arrangements in place.
- Collecting and publishing doctors, AAs and PAs’ declarations of conflicts of interest. These declarations should be updated on an ongoing basis as required.
Your organisation ensures induction arrangements are in place for all doctors, AAs and PAs.
3 The legislation underpinning revalidation for AAs and PAs had not been finalised at the time of writing.
4 Although not a statutory requirement in all four countries of the UK, all four countries have chosen to have Caldicott/Personal Data Guardians.