Quality Manual - KSS Deanery

KENT SURREY AND SUSSEX DEANERYQUALITY MANUAL

3. The KSS Local Quality Reporting FrameworkThis section provides a brief summary of the KSS local quality reporting framework. Fulldetails are set out in the Graduate Education and Assessment Regulations (GEAR).http://kssdeanery.org/document/gear-version-3Each LEP has a Local Academic Board (LAB), which is chaired by the Director of MedicalEducation (DME) with the Medical Education Manager (MEM) taking up the role ofAcademic Registrar; and a number of Local Faculty Groups (LFGs), one for each specialtyproviding education and training.The LFG is the first tier of local accountability for postgraduate medical education and aneffective unit for its management in LEPs. The LFG is responsible for the quality control ofthe local programme, ensuring the programme meets curriculum requirements, andtracking, supporting and auditing the trainees’ progress. Each LFG reports to the LAB.The LAB oversees the activities of the LFGs, and will aim to deal with any problems orissues arising from the LFGs. This keeps the quality control function of the LEP’s activitiesat a local level. If there is a serious problem that cannot be dealt with at a local level, theLAB will refer to the Deanery. In this way, a local remedy can be applied to any problemarea; KSS has immediate awareness of any unusual circumstances; and the KSS Head ofSchool becomes involved only when it is necessary and appropriate.The KSS Schools and Quality Department receive the minutes from all LFG and LABmeetings and an Annual Report and Review (AAR) from each LAB and LFG. Thesedocuments feed into the Deanery Report to the GMC.4. KSS Policies and ProceduresThe KSS Deanery Quality Management System is governed by a number of policies andprocedures. These are being continuously produced and added to the Quality Manual aspart of an on-going process of document management and control.The approved policies and procedures are stored electronically as part of the Deanery’sQuality management System (QMS), which also includes work instructions andforms/templates as applicable.The KSS Quality Manual is a living document, which is reviewed and updated on acontinual basis.The following section contains links to all the current KSS Policies, Procedures, WorkInstructions, Forms, Templates and Guidance in the QMS. These documents are reviewedon a regular basis. Older versions are stored in the archive section.2

1. Quality Structure and Terms of ReferenceA. KSS Organisational Structure ChartK:\QUALITY MANAGEMENT\QM Documents\Master Documents\KSS Organisational Structure ChartB. Quality Management StructureK:\QUALITY MANAGEMENT\QM Documents\Master Documents\Quality Management StructureC. Quality Management Steering Group Terms of ReferenceK:\QUALITY MANAGEMENT\QM Steering Group Meetings\KSS QMSG Terms of ReferenceD. Quality Management Operational Group Terms of ReferenceK:\QUALITY MANAGEMENT\QM Operational Group\KSS QMOG Terms of ReferenceE. Deanery Board Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\Deanery Board ToRF. Operational Group Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\Operational Group ToRG. Strategic Management Group Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\Strategic Management Group ToRH. Higher Specialty Training Board Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\ Higher Specialty Training Board ToRI. Trainee in Difficulty Committee Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\ Trainee in Difficulty Committee ToRJ. South Thames Foundation School Board Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\South Thames Foundation School Board ToRK. GP School Board Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\ GP School Board ToRL. GP Post Certification School Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\ GP Post Certification School ToRM. Quality Assurance of GP Appraisal Group Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\ Quality Assurance of GP Appraisal Group ToRN. Joint Committee on Quality Management Terms of ReferenceK:\QUALITY MANAGEMENT\QM Documents\Quality Manual\ Joint Committee on Quality Management ToR3

2. Deanery ReportA. Guidance on Producing the KSS Deanery ReportK:\QUALITY MANAGEMENT\Annual Reports\Deanery Report Documents\DR GuidanceB. Deanery Report Production FlowchartK:\QUALITY MANAGEMENT\Annual Reports\Deanery Report Documents\DR Flowchart3. LEP MetricsA. Guidance – Completion of the LEP MetricsK:\QUALITY MANAGEMENT\LEP Metrics\Guidance – Completion of the LEP MetricsB. LEP Metrics TemplateK:\QUALITY MANAGEMENT\LEP Metrics\LEP Metrics templateC. LEP Metrics Signing-off SheetK:\QUALITY MANAGEMENT\LEP Metrics\LEP Metrics Signing-off Sheet4. GMC National Training SurveyA. Process for Administering the GMC SurveyK:\QUALITY MANAGEMENT\GMC Survey 2012\Process for Administering the GMC Survey5. Specialty School Visits to LEPsA. Visiting Procedure – Specialty School Visits to LEPsK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\LEP Visits Procedure version 1.6B. Calendar for School Quality Management Visits to LEPsK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Calendar for School Quality Management Visits to LEPsC. Process for reporting Visits to ProgrammesK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Process for Reporting Visits to ProgrammesD. Visit Report TemplateK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Visit Report Template4

E. Headline Feedback FormK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Headline feedback formF. Action Planning TemplateK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Action Planning TemplateG. DME Self Assessment Pro FormaK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\DME Self Assessment Pro FormaH. Visiting Team Pro FormaK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Visiting Team Pro FormaI. Question PromptK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Question PromptJ. Role of the Lead Visitor – overviewK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Role of the Lead Visitor – overviewK. Visit Feedback Form (LEP)K:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Visit Feedback Form (LEP)L. Visitor Feedback FormK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Visitor Feedback FormM. Visitor Guidance and DeclarationK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Visitor Guidance and Declaration6. Foundation School Visits to LEPsA. Foundation Faculty Visiting ProcessK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Foundation\Foundation Faculty visiting ProcessB. Lead Visitor checklistsK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Foundation\Lead Visitor ChecklistsC. Guidance Notes for Lead VisitorsK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Foundation\Guidance Notes for Lead VisitorsD. Guidance Notes for Lead AdministratorsK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Foundation\Guidance Notes for Lead Administrators5

E. Briefing NoteK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Foundation\Briefing NoteF. Headline Feedback FormK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Foundation\Headline Feedback Form7. Pharmacy VisitsA. Pharmacy Visits ProcedureK:\QUALITY MANAGEMENT\Pharmacy\Pharmacy Visits\Pharmacy Visit ProcedureB. Action Planning Template - PharmacyK:\QUALITY MANAGEMENT\Pharmacy\Pharmacy Visits\Action Planning template - Pharmacy8. GP School Visits to LEPsA. Guidance on the Quality Management of GP Specialty TrainingK:\QUALITY MANAGEMENT\LEP Visits\Visit Documents\Guidance to KSS GP Quality Management process - v59. Contract ReviewA. Contract Review Process 2012/13K:\QUALITY MANAGEMENT\Contract Review\Protocol 2012B. KSS Single ContractK:\QUALITY MANAGEMENT\Contract Review\Contract 2012C. Quality Manual SpecificationK:\QUALITY MANAGEMENT\Contract Review\QM Specification PGMDE 2012D. Education AuditK:\QUALITY MANAGEMENT\Contract Review\CR Education Audit 2012E. Business AnalysisK:\QUALITY MANAGEMENT\Contract Review\Business analysisF. LAB StrategyK:\QUALITY MANAGEMENT\Contract Review\LAB Strategy6

G. Earned Autonomy Verification ReportK:\QUALITY MANAGEMENT\Contract Review\Earned autonomy verification reportH. Blank Verifiers Report 2012K:\QUALITY MANAGEMENT\Contract Review\Blank Verifiers Report 2012I. Action Plan Template 2012K:\QUALITY MANAGEMENT\Contract Review\Action Plan Template 201210. Serious IncidentsA. KSS Serious Incidents PolicyK:\QUALITY MANAGEMENT\QM Documents\Master Documents\KSS Serious Incidents PolicyB. Serious Incident Preliminary Notification FormK:\QUALITY MANAGEMENT\QM Documents\Master Documents\Serious Incident Preliminary Notification Form7

Postgraduate Deanery for Kent, Surrey & Sussex:KSS Deanery Organisational Structure ChartOctober 2012(Professor David Black)Dean DirectorChair of KSS StrategicManagement Group (SMG)EDUCATIONProfessor Zoë PlaydonHead of EducationPHARMACY(SEMMED)Gail FlemingDirector ofPharmacyBUSINESS & SENIORMANAGEMENTChris BirdChief Operating OfficerChair of Business & SeniorManagement Team (BSMT)GENERAL PRACTICEProfessor AbdollahTavabieDeputy Dean Directorand GP DeanDENTALProfessor StephenLambert-HumbleDental DeanFOUNDATIONDr Jan WelchDirector, SouthThames FoundationSchoolSECONDARY CAREDr Kevin KelleherDeputy PostgraduateDean for SecondaryCareCLINICAL LEADERSHIPDr Lindsay HadleyHead of KSS School ofClinical LeadershipDr Clare PenlingtonDeputy Head of EducationKaren AllmanHuman ResourcesAngela FletcherSpecialty WorkforceDr Ian McLeanDeputy GP Dean andHead of KSS GPSchoolSandra ForsterGeneral Practice andDentalRobin GarrettI.T and OperationsMarc TerryFoundation WorkforceKaren GibsonQuality Management

Postgraduate Deanery for Kent, Surrey & Sussex:KSS Deanery Functional Structure ChartOctober 2012KSS LETBLegal accountabilityto host organisation -CEO of BSUHProfessionallyaccountable to- MD LETB- MD HEE- GMCKSS Deanery BoardMembership includes theLETB MDAccountability to LETBthrough regularcontract performancereview meetingsLondonDeaneryDean DirectorKSS StrategicManagement GroupSTFS BoardKSS Quality Management Steering Group (QMSG)Membership includes the LETB Head of Quality and InformationKSS Trainee in Difficulty GroupCorporateFunctionsDentistryPrimaryCareSecondaryCarePharmacyEducationQualityManagementFoundationHumanResourcesIT andOperationsFinancePrimary CareWorkforceSecondary careWorkforceCareersLibrary &KnowledgeServicesFoundationWorkforce

KSS Deanery Quality Management StructureKSS Quality ManagementSteering GroupTraineesadministrativelymanaged byLondonKSS QualityManagementOperational GroupFoundationSchoolKSS SpecialtySchoolsSpecialty TrainingCommitteesKSS orLondon/KSSDeanery specifieshow LAB shouldbe set up and runLABs and LFGs workaccording to GEARNHS Trust Local Academic Board (LAB)(Manages Quality Control for the Trust)Trust: DME, MEM, MSM, Medical Director, HR, IT, etc.Deanery: Education Adviser and Associate DeanTrainee Rep, Lay MembersTrust decides howmany LFGs arerequired - dependson size of TrustLocal Faculty Groups (LFG)E.g. Foundation Programme, Medicine, Surgery, O&G, Paediatrics,ACCS, GP, Anaesthetics, Psychiatry

KSS DEANERY QUALITY MANAGEMENT STEERING GROUPTERMS OF REFERENCETo design a cost effective quality management system for KSS building on current goodpractice and GMC direction, which is minimally disruptive to service.To implement local effective educational governance with the local education providers.To be the overall Deanery group for quality management standards, policies and problemresolution.To be the Deanery group for final recording and resolution of all issues relating to the approvalof posts and programmes.To consider the wider stakeholder environment and how to involve/inform as appropriate.To lead on future GMC quality assurance visits and to act as a source of expertise totroubleshoot local problems.

KSS DEANERY QUALITY MANAGEMENT OPERATIONAL GROUP (QMOG)TERMS OF REFERENCETo take relevant action on matters arising from the KSS QM Steering Group asrequired.To facilitate communications and joint working across departments in KSS Deanery.To discuss quality management issues as they arise, and devise solutions for approvalby the QM Steering Group.To provide evidence to cost the Operationalisation of QM in KSS.To provide evidence for the specifications of IT/Data Handling systems for QM in KSS.To involve/inform wider stakeholder groups as appropriate.To receive feed-back from the Schools on their QM/C activities.To lead on quality management operational issues and to act as a source of expertiseto troubleshoot local problems.To call together appropriate people as necessary to deal with ad-hoc operational issues.

The Deanery Board will:DEANERY BOARDMEMBERSHIP AND TERMS OF REFERENCEi) promote excellence and innovation in postgraduate education and encourageand develop educational research including development and evaluation ofassessment and learningii)iii)iv)oversee the business planning process for the Deanery as a provider within thecontext of SHA commissioning of postgraduate medical and dental education,undergraduate and post graduate pharmacy education and possible futurenational commissioningadd value to and promote the success of the Deanery as an organisation bothnationally and regionallyassure all stakeholders that work with the Deanery on a regional basis that thework of the Deanery is equitable, in particular, in its allocation of finances, qualitymanagement processes and operational contracting with Local EducationProvidersv) assist the Dean Director in setting strategic direction and effective educationalmanagement capacity and capabilityvi)vii)viii)oversee the Deanery communication strategy in order to ensure engagement ofall stakeholders.take a lead role in the appointment of the senior staffreview the overall performance element of the evidence required by thecommissioner to meet national regulatory standards and local key performanceindicators.Its principal functions are to:i) receive reports from the Dean Director and other Deansii)iii)iv)consider and approve the Deanery strategic direction and business planapprove and review the Deanery financial planreceive and comment on the national workforce plansv) receive and approve the Deanery quality management reportsvi)vii)receive and comment on GMC and other national reportsappoint Appeals Committees as requiredviii)receive and comment on the risk register and escalate any risks to the Brightonand Sussex University Hospitals (BSUH) Board of Directors.K/DO/DD/Documents/Deanery Board/Deanery Board ToR June 2011.doc

The Chair will be responsible for the operation of the Deanery Board, ensuring that it makesan effective contribution to the governance of the Deanery and its pursuit of quality andexcellence. The Chair will work closely with the Dean Director and the Secretary of theDeanery Board and will ensure that key and appropriate issues are discussed by theDeanery Board in a timely manner and that relevant information and advice is madeavailable to the Deanery Board to inform the debate and decision-making process.Membership of the Deanery BoardThe membership of the Deanery Board will comprise:From KSS Deanery: the Dean Director, the GP Dean and the Chief Operating OfficerFrom the Brighton and Sussex Medical School: the Dean or designatedrepresentativeFrom KSS LETB: Managing DirectorFrom a Higher Education Institute: 2 representatives elected from the HEI collegearrangement with a minimum of one place to be reserved for either the University ofKent or the University of SurreyFrom local acute Education Providers: 3 representatives elected through the LEPcollege arrangement based on the 3 counties of Kent, Surrey and SussexFrom the 3 county based Mental Health Trusts: 1 representativeFrom the 3 new county based PCT clusters: 1 representativeAn independent EducationalistThe Deanery Board will meet monthly in the first instance.The Membership of the Deanery Board will be based on the principle of no substitutes.September 2012K/DO/DD/Documents/Deanery Board/Deanery Board ToR June 2011.doc

KSS DEANERY OPERATIONAL GROUPMEMBERSHIP AND TERMS OF REFERENCEPurposeTo provide day-to-day operational support to the Dean Director delivering the business of theKSS Deanery.MembershipDeansDeputy DeansAssociate DeansHeads of SchoolHeads of DepartmentSenior Business ManagersOther members of staff may attend at the request of their Head of Department whendiscussing specific issues.Meeting FrequencyOnce weekly (Friday morning) chaired by the Dean Director or a nominated deputy.Meeting FunctionsTo co-ordinate and put into operation the day-to-day management of the secondarycare function.To co-ordinate, where appropriate, the work of all business functions within theDeanery.To share information of all aspects of Deanery business.To discuss KSS policy and strategy and note the business managers’ meetings thatmakes formal decisions on policies.K/DO/KSS Operational Group/ToR Oct 2012.doc

TERMS OF REFERENCEKSS DEANERY STRATEGIC MANAGEMENT GROUPMEMBERSHIP AND TERMS OF REFERENCEPurposeThe strategy and decision making group for the Deanery.To discuss and plan the strategic direction of the Deanery.Agree the annual business plan and monitor progress against it.To debate and direct the educational direction of the Deanery.Final responsibility for the allocation and use of Deanery funds.Debate and resolution of serious or complex operational issues unresolvedelsewhere.Maintain and discuss a Deanery wide top level risk register.MembershipDean DirectorGP DeanDental DeanDirector, South Thames Foundation SchoolDeputy Postgraduate Dean for Secondary CareChief Operating OfficerHead of EducationHead of PharmacyOther attendees by invitationMeeting FrequencyMeetings held once a month and chaired by the Dean Director.Principles of WorkingA forum in which all strategic leads are equally involved.A forum in which we debate and agree difficult issues, including finance, withoutdoing backroom deals or making autocratic decisions.A forum in which we challenge arguments, but not personalise issues or re-fight oldbattlesA forum in which we try to reach agreement by consensus, but occasionally accept amajority opinion when a decision must be made.A forum where we continually strive to be a coherent organisation with a single frontto the outside world.08 October 2012 revisedK/DO/DD/Meetings/Strategic Management/ToR Oct 2012.doc

KSS HIGHER SPECIALTY TRAINING BOARDTERMS OF REFERENCERemit1. To review progress implementing the programmes which serve Higher Specialty Training (HST) inthe KSS region taking account of BSUH and its allied Medical School and Departments, BSMS(as an undergraduate and postgraduate University centre) and extending to the Surrey and KentLEPs and Academic centres.2. To provide internal scrutiny by challenging progress to ensure minimal risk to development of newand existing programmes. Actions from scrutiny should move to the emerging LETB whenappropriate.3. To provide support in overcoming challenges and helping to meet SEC / KSS HST PGMEconsultation recommendations.4. To ensure the Deanery, the Trusts, relevant Academic Institutions and other key stakeholders areall involved in the development of KSS HST Programmes.5. To ensure high quality academic input is enhanced and maintained within KSS HST Programmes.6. To ensure effective Communications are maintained with all Stakeholders7. To champion and progress KSS based Higher Specialty Training Programmes by steering thedelivery of key KSS HST priorities and objectives in negotiation with allied LETBs, AHSNsDeaneries and Schools.8. To ensure alignment in Programme development meets emergent service models and bydelivering expertise to emerging Clinical Commissioning Groups where appropriate.9. To provide guidance and liaison with other allied Lead providers and Deaneries via closecollaborative working10. To take account of National and regional policy decisions relating to PGME delivery11. To comment on future Commissioning options for PGME in the region.12. The KSS HST Board will invite and request attendance from the following colleagues:Membership –Chief Executive, Brighton and Sussex University Hospital NHS TrustChief Executive, East Kent Hospitals University NHS Foundation TrustChief Executive, Royal Surrey County Hospital NHS TrustDean Director, KSS DeaneryChief Operating Officer, KSS DeaneryDeputy Postgraduate Dean for Secondary CareDean, Brighton and Sussex Medical SchoolChief of Medicine - BSUHHead, Division of Clinical Medicine, BSMS (academic representative)Director of Medical Education, Brighton & Sussex University HospitalsDirector of Medical Education, Royal Surrey County Hospital Foundation Trust

Director of Medical Education, East Kent Hospitals University Foundation TrustAssociate Dean (particular responsibility for Brighton), KSS DeaneryHead of School of Medicine, KSS DeaneryHead of ACCS, KSS DeaneryHead of School of Emergency Medicine, KSS DeaneryHead of School of Anaesthesia, KSS DeaneryHead of School of Surgery, KSS DeaneryHead of School of Obstetrics & Gynaecology, KSS DeaneryHead of School of Radiology, KSS DeaneryHead of School of Psychiatry, KSS DeaneryHead of School of Paediatrics, KSS DeaneryHead of school of Ophthalmology KSS DeaneryHead of Medical Workforce, KSS DeaneryConsultant Haematologist (Academic Lead)Associate Director of HR (Medical Personnel & Education), Brighton & Sussex University HospitalsMEM Representative KSSAD-Academia KSSAs required: All KSS Training Programme DirectorsSpecialty Leads from BSUHSpecialty Leads from Kent based TrustsSpecialty Leads from Surrey based TrustsMeetings -Every two months

KSS TRAINEE IN DIFFICULTY COMMITTEETERMS OF REFERENCE1. To act as the decision making body for the management of Trainees in Difficulty handledby KSS Deanery.2. To discuss all Trainees in Difficulty in KSS Trusts, as well as all trainees in the SouthThames Foundation Schools, including those in non-KSS Trusts.3. To offer support and advice to the Heads of Schools in managing Trainees in Difficulty.4. To update ‘The Trainee in Difficulty – A KSS Trainee Support Guide’ on an annual basis.MEMBERSHIP (as at 10 May 2012)David Black (Chair), Dean Director, KSS DeaneryKaren Allman, Head of Human Resources, KSS DeaneryChristine Bridge, Foundation School Manager, South Thames Foundation School (Brighton Office)Geoff Bryant, Head of School of Emergency Medicine, KSS DeaneryChris Carey, Head of School of Anaesthesia and ICM, KSS DeaneryMark Cottee, Associate Director, South Thames Foundation School (Tooting Office)Graeme Dewhurst, Head of School of Medicine, KSS DeaneryDavid Firth, Head of School of Psychiatry, KSS DeanerySarah Flint, Lead for Obstetrics & Gynaecology, KSS DeaneryGail Fleming, Head of Pharmacy (Pharmacy Department), KSS DeaneryAngela Fletcher, Head of Specialty Workforce, KSS DeaneryKevin Kelleher, Deputy Postgraduate Dean for Secondary Care, KSS DeaneryStephen Lambert-Humble, Head of Dental, KSS DeaneryNathan Nathan, GP Associate Dean, KSS DeaneryPeter Martin, Head of School of Paediatrics, KSS DeaneryIan McLean, GP Deputy Dean, KSS DeanerySubir Mukherjee, Head of School of ACCS, KSS DeaneryBeverley Osbourne, Foundation School Manager, South Thames Foundation School (Tooting Office)Martin Parry, Associate Director, South Thames Foundation School (Brighton Office)Simon Quy, Education Adviser, KSS DeaneryJoan Reid, Senior Careers Adviser, South Thames Foundation SchoolHumphrey Scott, Head of School of Surgery, KSS DeaneryAbdol Tavabie, Dean of Postgraduate GP Education, KSS DeaneryMarc Terry, Foundation School Manager, South Thames Foundation School (London Office)Jan Welch, Director, South Thames Foundation School DirectorDavid Yates, Associate Dean for Quality, KSS DeaneryCamilla Sonsken / Philippa Skippage, Head of School of Radiology, KSS DeaneryGeeta Menon, Head of School of Ophthalmology, KSS DeaneryEdward Pickles, School of Anaesthesia representative, KSS DeaneryEmma Wright, Specialist Pharmacist, Pharmacy Department, KSS Deanery

South Thames Foundation SchoolSouth Thames Foundation School BoardTerms of Reference1 PurposeTo enable Kent, Surrey and Sussex Deanery, South London sector of the LondonDeanery, KCL Medical School, St George’s University of London and Brighton andSussex Medical School to develop an overarching vision and direction for the SouthThames Foundation School and ensure it delivers foundation training in accordancewith the national Standards set by the GMC.2 Operational Role• To ensure the school has appropriate and co-ordinated processes andprotocols in place in order to deliver and monitor foundation training.• To co-ordinate recruitment, assessment and appeals policy and processespolicy within the school and with London Deanery.• To ensure there are shared and robust quality control processes to supportthe GMC quality assurance requirements.• To review and agree expenditure for the management and administration ofthe school within the national financial arrangements.• To ensure appropriate liaison with London Deanery and North ThamesFoundation Schools.• To make South Thames appointments, as appropriate, to the Londonfoundation training board.Note: A quorum (requiring representation from both deaneries and the foundationschool) would be required for the board to make formal decisions.2.1 Frequency & Timing of Meetings• 4 times per year usually in September, December, March and June• 3pm usually Tuesdays2.2 Membership• Postgraduate Dean Director for KSS (Chair)• Postgraduate Dean for London• GP Dean for South London• GP Dean for KSS• Foundation School Director• Foundation School Associate Director (Brighton)• Foundation School Associate Director (Tooting)• Principal St Georges, University of London• Dean of King’s College, London, School of Medicine• Dean of Brighton & Sussex Medical School• KSS Chief Operating Officer• KSS Head of Foundation Workforce• KSS Head of Education• London Foundation Programme Manager• Representatives from Medical Directors x 2 (1 KSS / 1 South London)• Representatives from Clinical Tutors x 2 (1 KSS / 1 south London)• Representative of F1 doctors• Representative of F2 doctors• Additional co-opted members as requiredwww.stfs.org.ukPage 1 of 1Updated: October 2012

KENT SURREY & SUSSEX DEANERYGENERAL PRACTICE SPECIALTY SCHOOL BOARDCONSTITUTION & TERMS OF REFERENCEDoc AA. INTRODUCTION1. The name of the Committee shall be the KSS General Practice SpecialtySchool Board (GP School Board)2. The Terms of Reference shall be reviewed annually in May, or at other times ifnecessary.Management of the Postgraduate School of General Practice EducationThe school has an Executive Board which is the strategic and operational unit of thePostgraduate School of General Practice. There is representation on the Board fromeach of the programmes within the school. The Dean of Postgraduate GP Education isthe Chair of the Executive Board. The Head of the GP School will be the Deputy GPDean. The Executive Board also has representatives from the RCGP, LMC, GPspecialty trainees, trainers, lay and university.DeanPostgraduateGeneralPracticeEducationGPDeanGP School Board(ARCP)Annual ReviewCompetenceProgressionHead of GP School & DeputyDean(TSC)Trainer Selection& ReselectionCommitteeProgrammeDirectorsLMC &RCGPRegionalRepresentativeHead ofCurriculum &AssessmentGP TrainerRepresentativeOthers,Trainee, Lay& UniversityA programme is a subset of the school within the deanery. Programmes areorganised geographically and developed to be sensitive to local needs. Eachprogramme has GPStRs (trainees in years ST1, ST2 and ST3), is supported by GPProgramme Directors and provides a variety of training placements, in hospital,community settings and general practice. All the programmes in the KSS healtheconomy together form the GP School. An individual programme will deliver the GPcurriculum in a way congruent with local health needs, resources and expertise.Induction is a programme responsibility and it is important that trainees have aninduction to the School, Trust and clinical specialty whether general practice orhospital. The first year induction is particularly important. .KSS GP Specialty School Board, Constitution & TOR v2131 st March 2008

B. TERMS OF REFERENCE:1. To advise the SEC Strategic Health Authority and its WorkforceManagement structure (KSS Deanery), and appropriate academic andhigher education institutions:• To deliver the education and training of general practitioners to meet the RoyalCollege of General Practitioners and Postgraduate Medical and EducationTraining Board (PMETB) agreed curricula; to the standards set out by PMETB,and to promote excellence in all aspects of the work of the School.• To implement the new MMC training programmes• To manage transitions and rotations within the programmes and to manage entryto the specialty training posts in line with nationally agreed guidelines cocoordinatedby the National Recruitment Office for General Practice.• To ensure appropriate support for trainees in General Practice programmes whoare training to be general practitioners• To ensure that the delivery of training enhances the quality and safety of patientcare for today’s and tomorrow’s patients and produces specialists fit to meet theneeds of the NHS and with the skills to be able effectively to contribute to futurechanges in the health service .• To meet workforce and patient needs by training fit for purpose generalpractitioners - including ensuring that all trainees gain the organisational skills,e.g. team working, leadership, change management, business management -necessary for their role as future general practitioners able to work effectively incomplex organisations and able to lead and implement change in the primary caresetting.• To monitor the quality of training; to evaluate and review local quality controlmeasures and reports and ensure these are used to drive continual improvementto meet the standards that will be set by the Royal College of GeneralPractitioners and the PMETB• To monitor possible discriminatory affects of any policies or procedures and steeraction to promote diversity and equality of opportunity.• To take part in the selection and recruitment of doctors in training to generalpractice training programmes and to contribute to the development of selectionmethodology• To maintain effective formative and summative assessment processes - includingthe annual review of training and the process for the recommendation of theaward of CCT• To work with the KSS Deanery to recognise and to assess trainees in difficultyand provide them with necessary support and to implement appropriate remedialaction.• To manage the career development of trainees in general practice• To develop academic training programmes for Academic Clinical Fellows and forClinical Lecturers and to promote academic training for all trainees• To promote excellence and innovation in training and in training methods and toencourage and develop educational research including development andevaluation of assessment methodologies• To work with the KSS Head of Libraries and Knowledge Management to develop,promote and implement knowledge access and “e” learningKSS GP Specialty School Board, Constitution & TOR v2231 st March 2008

• To maintain and progress faculty development and advise the KSS Deanery ofdevelopment needs and methodology for addressing these• To implement procedures and practices to supports trainees who wish to trainflexibly and/or who require reasonable adjustments to programmes andplacements.• To respond to national initiatives including those from the Department of Health,the Royal College of General Practice and the PMETB and advise the Dean ofPostgraduate of GP Education on their local development and implementation.2. Quality Management of GP Specialty training Programmes and GP Trainers:• To maintain and expand a database of GP specialty training programmes, GPTrainers and training Practices, and to be responsible for the future shape andcontent of these programmes and placements.• To approve and re-approve GP Trainers in accordance with criteria established bythe RCGP/PMETB and developed by the Board.• To approve and re-approve those Practices suitable to participate in the Doctors’Retainer Scheme.3. Provision of Education:• To advise on the provision of GP Specialty training Programmes, ensuring abalanced programme of experience to meet the individual training needs of eachtrainee doctor.• To advise on the appointment and reappointment of GP Programme Directors• To advise on the provision of, and requirements for, training for various items ofservice of statutory significance, such as Child Health Surveillance, Out of Hourstraining provision, Minor Surgery and Family Planning.• To advise on the development needs of GP educationalists (including potentialGP Trainers) with an emphasis on enabling them to provide an appropriateenvironment for training the trainees for whom they provide supervision.• To advise on the provision of a careers advisory service in General Practice toinclude information, advice and counseling.• To advise on multi- and inter-professional learning and teaching opportunities fordoctors in General Practice.• To be responsible for the appointment of the members of Trainer SelectionCommittees, GP Programme Directors Appointments Committee, Annual Reviewof Competence Progression Panel..• To supervise the management of study leave budget for GPStRs.• To supervise the management of the GP Retainer Scheme.• To contribute to the KSS Deanery Business Plan,• To supervise the management of the annual appraisal of the GP Deanery,Programme Directors and GP Trainers.• To supervise the appointments and membership of Appeals Committees for GPTrainer Appointments, GP Retainer Practice Accreditation, Membership of the GPRetainer Scheme, Management of Summative Assessment.4. Research and Audit, and Service Issues:• To advise on training in audit and research methods, and management training forGeneral Practice for doctors in training for General Practice and to identifyopportunities for multidisciplinary initiatives.KSS GP Specialty School Board, Constitution & TOR v2331 st March 2008

C. PRINCIPAL FUNCTIONS OF THE BOARD:• Receives and comments on report from the Head of GP School• Ratifies or varies recommendations for GP Trainer and Programme Directorsmade by appropriate Selection/Appointment Committees.• Approves hospital placements selected for GP training after consideration ofDeans' Visits Reports and the KSS Deanery Quality Assurance Group• Receives and comments on reports by the responsible Associate GP Dean onAnnual Review of Competences Progression (ARCP).(or reports from panels)• Receives and comments on RCGP/PMETB documentation.• Receives and comments on report from GPStR Sub Committee.• Appoints Appeals Committees in relation to GP Trainer and Programme Directorsappointments, and the process of the ARCP and Summative Assessment intransition.• Agrees and publishes Criteria for Appointment & Reappointment of GP Trainersand Programme Directors based on recommendations published byRCGP/COGPED.• Agrees and publishes Criteria for the Selection of hospital placements for GPTraining in accordance with recommendations published by RCGP/COGPEDD. MEMBERSHIPEx Officio Members Postgraduate Medical Dean or his/her representative Dean of Postgraduate General Practice Education or his/her deputies Associate Deans of Postgraduate General Practice Education Professors of General Practice or Primary Care in the deanery orrepresentatives Medical Educationalist - specialist knowledge would be sought on specificassignments as required. A Lay Representative who will also have the responsibility of chairing theTrainer Selection Committee.Representative Members:MembershipPostgraduate GP Dean – ChairRepresentation from local faculties ofRoyal College of GeneralPractitionersNon Executive Director (SEC)Representatives from GP ProgrammeDirectors – one per countyMedical Director of PCTGP Trainee Representatives (ST1,2&ST3)Appointment ProcessNominated by KSS DeaneryNominated by the Faculties of RoyalCollege of General PractitionersNominated by SECNominated by each countyNominated by SECFrom the GP Trainees CommitteeKSS GP Specialty School Board, Constitution & TOR v2431 st March 2008

Lay/Patient RepresentativeBrighton & Sussex Medical SchoolAcademic RepresentativeRepresentative from allied clinicalprofessionRepresentation from LMCsDirector of Medical Education/ClinicalTutorSelected from Lay Chairs panelNominated by Head of Primary CareBSMSRepresentative of UniversityNominated by SECNominated by LMCsNominated by DME/Clinical TutorsCommitteeBoard MembersRepresentative members will be expected to serve for an initial period for three years,renewable at the discretion of the appointing organisation.The Board shall have the power to co-opt additional members to fulfill specific timelimitedfunctions.A member should send a deputy if unable to attend.If an officer steps down before the end of their term, their replacement will entitled toserve for an initial period for three years, renewable at the discretion of the appointingorganisation.Observers will be as follows: Deanery Staff as appropriateE. STANDING ORDERS1. Board Meetings:The Board will normally meet four times a year. The Board is expected to meetas often as necessary to complete its business.Meetings will normally be held on Deanery premises.The Chairman will ensure that agendas and papers for meetings are circulatedelectronically to all members to arrive at least five working days before themeeting.One third of members shall constitute a quorum.Elections to office and changes to the constitution may only be made ifdeclared on the agenda.Decisions of the Board will normally be reached by consensus of opinion;voting may be resorted to in certain matters at the discretion of the Chairman.In such cases, motions should be proposed and duly seconded by members ofthe Board, and decisions will be reached by a simple majority vote of memberspresent. In the event of a tie, the Chairman of the meeting will have a second(or casting) vote.KSS GP Specialty School Board, Constitution & TOR v2531 st March 2008

Subcommittees or Working Groups may be set up by the Board; membershipwill be agreed by the Board, with an individual member identified to lead andreport back to the main Board.2. Deanery Support for Board:A member of the Postgraduate General Practice Education staff will act asSecretary to the Committee.Reimbursement of travel expenses at public transport rate will be paid formembers attending committee meetings.3. Role of Chair:The Chair shall be responsible for the operation of the Board, ensuring that itmakes an effective contribution to the governance of the School and its pursuit ofquality and excellence. The Chair will work closely with the Head of School andthe Secretary on Board business and will ensure that key and appropriate issuesare discussed by the Board in a timely manner and that relevant information andadvice is made available to the Board to inform the debate and decision-makingprocess.4. Role of Head of School:The Head of School provides leadership for the School. He reports to the Boardregularly on both the delivery and quality of training and the School’s pursuit ofexcellence. He will provide information about the process of training andaggregated information on outcomes. The information provided must enable theBoard to assess and monitor progress and to advise on direction, policies andstrategy.The Head of School will be responsible for producing an annual report of theSchool’s activities and achievements which will be approved by the School Boardand presented to the Deanery’s Quality Management Committee.5. Role of Members:The role of members of the Board will be to consider the key strategic andmanagement issues facing the School in carrying out its educational governanceand quality assurance functions.Member will take collective responsibility for the Board’s decisions.Members will contribute to the formation of strategy by bringing a range of differentperspectives and experiences. Members are responsible for taking decisions thatsupport the School’s purpose, not simply the interests of their parent or nominatingorganisation.Members will be expected to attend regularly, inform themselves appropriately andinvolve themselves actively in discussions and decision making.Whilst the nominated members are not expected formally to represent theirorganisations or nominated bodies, they will provide the opportunity for the viewsof relevant stakeholders to be considered. They may also be asked to seek theviews of the nominating group.The Boards members may be asked to take specific roles if required by the Boardor the GP School to support their work.KSS GP Specialty School Board, Constitution & TOR v2631 st March 2008

6. Quorum:Meeting will be quorate if at least one-third of the Board is present including theHead of School or nominated deputy and at least one nominated member.7. Voting:The Board will not routinely be required to vote but may be asked to vote oncertain matters requiring an executive decision.At the discretion of the Chair, all questions put to the vote shall be determined byoral expression or by a show of hands, unless the Chair decides otherwise.Decisions made by formal vote will be determined on a majority vote which will berecorded. Proxy votes will not be accepted. Where joint members attend together,the vote of only one member will be accepted.8. Record of Attendance:The names of the Chair and members present will be recorded. Any member failsto attend without sending a deputy; their parent organisation will be informed.9. Open and Closed Business:The main business of the Board will concern strategy, educational governance,quality assurance/management and the pursuit of excellence. It is envisagedappeals to the GP School Board may be part of the appeal process for individualtrainees exercising a right to appeal in accordance with Deanery policy. Suchappeals will normally be held by a sub-committee of the Board and traineemembers will not be present. Should the full Board need to discuss mattersrelating to individual trainees, the trainee representative will not be present.When matters concerning an individual trainer or other individuals are discussedby the Board, the Chair will determine the appropriateness of the presence ofindividual Board members.Confidential issues relating to individuals will not form part of publicly accessibleminutes of meetings.10. Minutes:The minutes of the meeting will be drawn up by the Board Secretary and submittedfor agreement at the next meeting and signed by the Chair.Draft minutes and action points will be circulated within three weeks of eachmeeting.When agreed, the minutes (except for records of closed parts of the meeting) willbe made available on the Deanery website.11. Confidentiality:Board members and any staff of the Deanery attending shall not reveal or discloseconfidential information including papers marked ‘In Confidence’ or minutesheaded ‘Items taken in Closed Session’, without the permission of the Chair. Thisapplies to the content of any discussion as well as papers and records.KSS GP Specialty School Board, Constitution & TOR v2731 st March 2008

12. Risk Register:The Head of GP School will ensure that the Boards maintain a risk register and aprocess for identifying and quantifying risks and liabilities13. Recording of interests:Board members will be required, on appointment, to declare any interests ofrelevance to the School Board. Such interests may include:Directorships of private companies seeking to do business with the DeaneryConnections with voluntary organisations contracting for NHS servicesIf members have any doubt about the relevance of an interest, this should bediscussed with the Board Chair who may bring it to the attention of the DeanDirector.If a conflict of interest is identified during the course of a Board meeting, the Boardmember concerned should declare such an interest and withdraw from the meetingand play no part in the relevant discussion or decision.February 2008KSS GP Specialty School Board, Constitution & TOR v2831 st March 2008

Doc EKENT SURREY & SUSSEX DEANERYGENERAL PRACTICE CPD SCHOOL BOARDCONSTITUTION & TERMS OF REFERENCEA. INTRODUCTION1. The name of the Committee shall be the KSS General Practice CPD SchoolBoard (GP CPD School Board).2. The Terms of Reference shall be reviewed annually in May, or at other times ifnecessary.Management of the Post-Certificate School of General Practice Education:The School has an Executive Board which is the strategic and operational unit of thePost-Certificate School of General Practice. There is representation on the Board fromeach of the programme areas within the school.The Dean of Postgraduate GP Education is the Chair of the Executive Board. TheHead of the Post-Certificate School will act as deputy in his absence. The ExecutiveBoard also has representatives from the RCGP, LMC, PCTs in SEC SHA, GP Tutors,KSS Remediation Services, KSS Associate Deans, Mentors and Appraisers.DeanPostgraduateGeneralPracticeCPD School BoardQAWGHead of Post-Cert SchoolKSS RemediationservicesGP TutorsLMC &RCGPRegionalRepresentativesPCTRepresentativesAppraisers andMentorsOthers, Lay &UniversityContinuing Professional Development – CPDThe Post-Certification GP School is committed to the promotion of PersonalDevelopment Plans (PDPs) linked to the annual NHS appraisal process. PCT clinicalgovernance provides a framework to monitor, review and raise the quality of caredelivered by the GPs on their medical performers list. GP appraisal lies at theeducational end of the spectrum of clinical governance processes. The appraisalprocess contributes to the overall clinical governance framework as it providesassurances that GPs are planning and reviewing their CPD in a structured way. GPsKSS GP CPD School Board, Constitution & TOR v3 1 of 10 Oct 2009

can include in their appraisal folder reflections on their clinical governance relatedactivities. PCTs can also inform the appraisal process by providing where appropriate,information to GPs which can inform their own needs assessment and inform theirpersonal and practice development planning.Appraisal and CPD are closely linked. Appraisal provides doctors with an opportunityto demonstrate the CPD they have undertaken, reflect on what they have learned fromit, and plan their CPD for the following year. The learning needs identified by GPs intheir personal development plans (PDPs) as part of their appraisals should inform theeducation and support that is available and accessible to them.Re-certification and re-licensing are being developed by the GMC and The RoyalCollege of General Practitioners to produce the unified process of revalidation, withenhanced appraisal at its core.The Post-Certification GP School and CPD Board will work in collaboration with thePCTs in KSS to prepare GPs for revalidation and to encourage high qualityprofessional development.The Post-Certification GP School will develop the following services:• Enhanced appraisal service. Working in partnership with our PCTs the Schoolis developing Appraisal Development Centres which will provide training andupdating for new and existing appraisers and PCT personnel, preparing themfor the changes required for Revalidation.• Support for appraisers. In addition to the Appraisal Development Centres theSchool will use the GP Tutor network to provide learning sets for the appraisernetwork and will train lead appraisers to support their colleagues.• GP Tutors will also help their PCTs organise protected learning time for GPsand practice staff and will ensure GPs in their area are fully informed about theRevalidation process. They will continue to act as a focus for educationalactivity and support in their localities, including support for local commissioninginitiatives.• The School will also collaborate with PCTs on the development of local supportand performance improvement training for GPs identified through the appraisalsystem as needing local remediation or rehabilitation.• The School will be responsible for the further development of the KSSMentoring programme which offers additional support for GPs through a one toone, confidential relationship with a respected GP peer. This service isavailable to all GPs in KSS and can help with career planning and personaldevelopment as well as supporting GPs with individual or practice-basedconcerns.• The School will also support GP Refreshers, those returning to general practiceafter a career break, and will try to support GPs through the transition fromtrainee to independent GP by encouraging learning sets for salaried doctors.KSS GP CPD School Board, Constitution & TOR v3 2 of 10 Oct 2009

• The School will adopt new procedures to encourage effective CPD for GPs asneeded in response to the further evolution of Revalidation as defined by themain regulatory bodies.B. TERMS OF REFERENCE:1. To advise the SEC Strategic Health Authority and its WorkforceManagement structure (KSS Deanery), Primary Care Trusts, andappropriate academic and higher education institutions:• To deliver the education and training of GP Tutors, Appraisers and LeadAppraisers to meet the Royal College of General Practitioners and GeneralMedical Council’s agreed criteria and standards for Revalidation and to promoteexcellence in all aspects of the work of the School.• To implement the new GP Appraisal Support Programme through collaborationwith individual PCTs and in response to the working of the Quality Assurance ofAppraisal Working Group (QAWG).• To implement the KSS Mentoring Programme to support GPs who request a peerled,confidential support programme.• To ensure appropriate support for CPD for GPs in SEC SHA area through the GPTutor network and through the promotion of effective protected learning time forGPs and their staff.• To ensure that the delivery of training enhances the quality and safety of patientcare for today’s and tomorrow’s patients and maintains and supports GPspecialists, ensuring they are fit to meet the needs of the NHS and with the skillsto be able effectively to contribute to future changes in the health service.• To meet workforce and patient needs by ensuring CPD promotes “fit for purpose”general practitioners – including the development of both clinical andorganisational skills, (e.g. team working, leadership, change management,business management), necessary for their role as general practitioners able towork effectively in complex organisations and able to lead and implement changein the primary care setting.• To monitor the quality of appraisal; to evaluate and review local quality controlmeasures and reports and ensure these are used to drive continual improvementto meet the standards that will be set by the Royal College of GeneralPractitioners and the GMC.KSS GP CPD School Board, Constitution & TOR v3 3 of 10 Oct 2009

• To monitor possible discriminatory affects of any policies or procedures and steeraction to promote diversity and equality of opportunity.• To take part in the selection and recruitment of appraisers and mentors and tocontribute to the development of selection methodology.• To work with PCTs and KSS Deanery to recognise and to assess GPs indifficulty and provide them with necessary support and to implement appropriateremedial action.• To promote excellence and innovation in appraisal methods and training ofappraisers and mentors and to encourage and develop educational researchincluding development and evaluation of assessment methodologies.• To work with the KSS Head of Libraries and Knowledge Management to develop,promote and implement knowledge access and “e” learning.• To implement procedures and practices to support sessional doctors and helpthem organize effective CPD and prepare for revalidation.• To respond to national initiatives including those from the Department of Health,the Royal College of General Practice and the GMC and advise the Dean ofPostgraduate of GP Education on their local development and implementation.2. Quality Management of GP Appraisal and Appraiser Training:• To maintain a database of GP Appraiser, Lead Appraisers and GP Tutors and tobe responsible for the future shape and content of their training programmes andon-going skills development in response to the criteria and standards of theRCGP and GMC.• To assist PCTs with the selection and re-approval of GP Appraisers inaccordance with criteria established by the RCGP/GMC and developed by theBoard.3. Provision of Support for GP Education:• To advise on the provision of GP support for CPD across KSS, ensuring abalanced spread of GP Tutors to meet the individual needs of each locality.• To advise on the appointment and reappointment of GP Tutors.• To approve and re-approve those Trainers and Practices suitable to participate inthe Doctors’ Refresher Scheme.• To advise on the development needs of GP educationalists (including potentialGP Tutors and Appraisers).KSS GP CPD School Board, Constitution & TOR v3 4 of 10 Oct 2009

• To advise on the provision of a careers advisory service in General Practice toinclude information, advice and counseling.• To advise on multi- and inter-professional learning and teaching opportunities fordoctors in General Practice.• To be responsible for the appointment of the members of GP Tutor AppointmentCommittee.• To supervise the management of the GP Refresher Scheme.• To contribute to the KSS Deanery Business Plan.• To supervise the management of the annual appraisal of the Deanery GP Tutors.4. Research and Audit, and Service Issues:• To advise on training in audit and research methods, and management training forGeneral Practitioners and to identify opportunities for multidisciplinary initiatives.• To encourage research and evaluation of all programmes supported by the Post-Certification GP School.C. PRINCIPAL FUNCTIONS OF THE BOARD:• Receives and comments on report from the Head of Post-Certificate GP School.• Ratifies or varies recommendations for GP Tutors made by appropriateAppointment Committees.• Approves recommendations for Appraisal Support Programme made by Post-Certificate School and QAWG.• Receives and comments on reports by the School on work undertaken by the GPTutor network.• Receives and comments on RCGP/GMC documentation concerned withappraisal, CPD and Revalidation.• Receives and comments on report from QAWG.• Agrees and publishes Criteria for Appointment & Reappointment of GP Tutorsbased on recommendations published by RCGP/GMC.D. MEMBERSHIPKSS GP CPD School Board, Constitution & TOR v3 5 of 10 Oct 2009

Ex Officio Members• Postgraduate Medical Dean or his/her representative• Dean of Postgraduate General Practice Education or his/her deputies• Associate Deans of Postgraduate General Practice Education• Professors of General Practice or Primary Care in the deanery orrepresentatives• Medical Educationalist - specialist knowledge would be sought on specificassignments as required.• A Lay Representative who will also have the responsibility of chairing theTutor Appointment Committee.Representative Members:MembershipPostgraduate GP Dean – ChairHead of Post-Certificate SchoolAssociate Dean RepresentativeRepresentation from local faculties ofRoyal College of GeneralPractitionersNon Executive Director (SEC)Representatives from GP Tutors – oneper countyResponsible Officer Representatives –One from each county.PCT Appraisal representatives – onefrom each countyGP Appraiser RepresentativeLead Appraiser RepresentativeMentoring RepresentativeLay/Patient RepresentativeAcademic RepresentativeRepresentative from allied clinicalprofessionRepresentation from LMCsAppointment ProcessNominated by KSS DeaneryNominated by KSS DeaneryNominated by KSS DeaneryNominated by the Faculties of RoyalCollege of General PractitionersNominated by SECNominated by each countyNominated by SECNominated by QAWGFrom the Appraiser networkFrom Appraiser networkNominated by Mentors.Selected from Lay Chairs panelRepresentative of UniversityNominated by SECNominated by LMCsBoard Members:KSS GP CPD School Board, Constitution & TOR v3 6 of 10 Oct 2009

Representative members will be expected to serve for an initial period for three years,renewable at the discretion of the appointing organisation.The Board shall have the power to co-opt additional members to fulfill specific timelimitedfunctions.A member should send a deputy if unable to attend.If an officer steps down before the end of their term, their replacement will entitled toserve for an initial period for three years, renewable at the discretion of the appointingorganisation.Observers will be as follows:• Deanery Staff as appropriateE. STANDING ORDERS1. Board Meetings:• The Board will normally meet four times a year. The Board is expected to meetas often as necessary to complete its business.• Meetings will normally be held on Deanery premises.• The Chairman will ensure that agendas and papers for meetings are circulatedelectronically to all members to arrive at least five working days before themeeting.• One third of members shall constitute a quorum.• Elections to office and changes to the constitution may only be made ifdeclared on the agenda.• Decisions of the Board will normally be reached by consensus of opinion;voting may be resorted to in certain matters at the discretion of the Chairman.In such cases, motions should be proposed and duly seconded by members ofthe Board, and decisions will be reached by a simple majority vote of memberspresent. In the event of a tie, the Chairman of the meeting will have a second(or casting) vote.• Subcommittees or Working Groups may be set up by the Board; membershipwill be agreed by the Board, with an individual member identified to lead andreport back to the main Board.2. Deanery Support for Board:A member of the Postgraduate General Practice Education staff will act asSecretary to the Committee.Reimbursement of travel expenses at public transport rate will be paid formembers attending committee meetings.3. Role of Chair:The Chair shall be responsible for the operation of the Board, ensuring that itmakes an effective contribution to the governance of the School and its pursuit ofquality and excellence. The Chair will work closely with the Head of School andKSS GP CPD School Board, Constitution & TOR v3 7 of 10 Oct 2009

the Secretary on Board business and will ensure that key and appropriate issuesare discussed by the Board in a timely manner and that relevant information andadvice is made available to the Board to inform the debate and decision-makingprocess.4. Role of Head of School:The Head of School provides leadership for the School. He reports to the Boardregularly on both the delivery and quality of appraisal and CPD, and the School’spursuit of excellence. He will provide information about the process of appraisaland aggregated information on outcomes. The information provided must enablethe Board to assess and monitor progress and to advise on direction, policies andstrategy.The Head of School will be responsible for producing an annual report of theSchool’s activities and achievements which will be approved by the School Boardand presented to the Deanery’s Quality Management Committee.5. Role of Members:The role of members of the Board will be to consider the key strategic andmanagement issues facing the School in carrying out its educational governanceand quality assurance functions.Member will take collective responsibility for the Board’s decisions.Members will contribute to the formation of strategy by bringing a range of differentperspectives and experiences. Members are responsible for taking decisions thatsupport the School’s purpose, not simply the interests of their parent or nominatingorganisation.Members will be expected to attend regularly, inform themselves appropriately andinvolve themselves actively in discussions and decision making.Whilst the nominated members are not expected formally to represent theirorganisations or nominated bodies, they will provide the opportunity for the viewsof relevant stakeholders to be considered. They may also be asked to seek theviews of the nominating group.The Boards members may be asked to take specific roles if required by the Boardor the GP School to support their work.6. Quorum:Meeting will be quorate if at least one-third of the Board is present and thefollowing members are in attendance• Head of School or nominated deputy• At least one PCT appraisal representative• At least one representative from the LMCs and / or RCGP Faculties• At least one representative from the KSS Tutor and / or Mentoringnetwork7. Voting:The Board will not routinely be required to vote but may be asked to vote oncertain matters requiring an executive decision.At the discretion of the Chair, all questions put to the vote shall be determined byoral expression or by a show of hands, unless the Chair decides otherwise.KSS GP CPD School Board, Constitution & TOR v3 8 of 10 Oct 2009

Decisions made by formal vote will be determined on a majority vote which will berecorded. Proxy votes will not be accepted. Where joint members attend together,the vote of only one member will be accepted.8. Record of Attendance:The names of the Chair and members present will be recorded. Any member failsto attend without sending a deputy; their parent organisation will be informed.9. Open and Closed Business:The main business of the Board will concern strategy, educational governance,quality assurance/management and the pursuit of excellence.When matters concerning a specific GP, Tutor, Appraiser, Mentor or otherindividuals are discussed by the Board, the Chair will determine theappropriateness of the presence of individual Board members.Confidential issues relating to individuals will not form part of publicly accessibleminutes of meetings.10. Minutes:The minutes of the meeting will be drawn up by the Board Secretary and submittedfor agreement at the next meeting and signed by the Chair.Draft minutes and action points will be circulated within three weeks of eachmeeting.When agreed, the minutes (except for records of closed parts of the meeting) willbe made available on the Deanery website.11. Confidentiality:Board members and any staff of the Deanery attending shall not reveal or discloseconfidential information including papers marked ‘In Confidence’ or minutesheaded ‘Items taken in Closed Session’, without the permission of the Chair. Thisapplies to the content of any discussion as well as papers and records.12. Risk Register:The Head of GP School will ensure that the Boards maintain a risk register and aprocess for identifying and quantifying risks and liabilities13. Recording of interests:Board members will be required, on appointment, to declare any interests ofrelevance to the School Board. Such interests may include:• Directorships of private companies seeking to do business with the Deanery• Connections with voluntary organisations contracting for NHS servicesIf members have any doubt about the relevance of an interest, this should bediscussed with the Board Chair who may bring it to the attention of the DeanDirector.KSS GP CPD School Board, Constitution & TOR v3 9 of 10 Oct 2009

If a conflict of interest is identified during the course of a Board meeting, the Boardmember concerned should declare such an interest and withdraw from the meetingand play no part in the relevant discussion or decision.February 2009KSS GP CPD School Board, Constitution & TOR v3 10 of 10 Oct 2009

Doc AConstitution/Terms of Reference/MembershipKSS Quality Assurance of GP Appraisal Working GroupKENT, SURREY, SUSSEX (KSS)Quality Assurance of GP Appraisal Working Group (QAWG)CONSTITUTIONA. INTRODUCTION1. The name of the Committee shall be the KSS Quality Assurance of GP AppraisalWorking Group (QAWG)2. The Terms of Reference shall be reviewed annually in May, or at other times ifnecessaryBBACKGROUNDThere is great variation amongst primary care trusts as to how the GP appraisalprocess is delivered and quality assured. This was confirmed in the recent survey ofPCTs and GP Tutors across the region. Appraisal will be an integral component ofrelicensing and recertification when the changes to professional regulation of doctorsare implemented in 2009 and beyond (revalidation process). Therefore, we need todevelop a model or models of quality assurance to deliver consistency in relation tothe quality of the GP appraisal process across the health economy.In addition, clinical governance provides a framework for NHS trusts and PCTs tomonitor, review and raise the quality of care delivered by doctors in their employ oron their performers list. GP appraisal lies at the educational end of the spectrum ofclinical governance processes. The appraisal process contributes to the overall clinicalgovernance framework as it provides assurances that GPs are planning and reviewingtheir CPD in a structured way. PCTs (England) can also inform the appraisal processby providing, where appropriate, information to GPs which can inform their ownneeds assessment and inform their personal and practice development planning. Whenrelicensing is introduced as part of the revalidation process, PCTs will compileinformation about the performance of individual GPs which the responsible officer islikely to share with GP appraisers – national directions about how the relicensingprocess will work are awaited.C. TERMS OF REFERENCE1. Advice to PCTs and South East Coast NHS :-1.1 To aim for development of a model or models for the quality assurance of GPAppraisal across SEC.KSS QAWG TOR (final version).doc 8th December 08Page 1

Constitution/Terms of Reference/MembershipKSS Quality Assurance of GP Appraisal Working Group1.2 To create a forum for consolidation and further development of a robustquality assurance process for GP appraisal.1.3 To share resources including expertise and findings from PCTs’ activities intoGP appraisal e.g. selection of GP appraisers, reselection, initial training andupdating of GP appraisers, training of PCT staff key to the GP appraisal andrelicensing processes, detection and clarification in relation tounderperformance of doctors and feedback process1.4 To share information relating to GP appraisal, giving and receiving feedbackto PCTs1.5 To support PCTs with their GP appraisal work on individual basis, inparticular helping them to deal with performance issues uncovered in appraisaland equally providing appropriate appraisal opportunities for those subject toperformance review.1.6 To facilitate improvement in practice in the selection and reselection of GPappraisers (ie test communication skills and report writing abilities). Provideon going support and training for GP appraisers, PCT Lead appraisers, leadadministrative staff.1.7 To monitor the quality of GP appraiser training; to evaluate and review localquality control measures and reports and ensure that these are used to drivecontinuous improvement to meet the standards that will be set by the RoyalCollege of General Practitioners and the GMC for recertification andrelicensing respectively.2. The KSS Deanery will:2.1 Identify trends in the quality assurance of GP appraisal.2.2 Develop the shared learning across the QAWG on all aspects of GP appraisal.2.3 Pilot or put into practice initiatives related to revalidation locally andnationally as opportunities arise e.g. the national tools – multisource feedback,RCGP managed CPD scheme of CPD credits.2.4 Help with local sector meetings to look at QA process in PCTs.2.5 Share and work with “hot topics” relating to GP appraisal, derived from withinthe group, as a means of promulgating good practice.2.6 Facilitate delivery of appraiser training and development across the healtheconomy.2.7 Recognise and share good practice derived from within the group andnationally; link to national leadsKSS QAWG TOR (final version).doc 8th December 08Page 2

Constitution/Terms of Reference/MembershipKSS Quality Assurance of GP Appraisal Working Group2.8 Facilitate provision of a careers advisory service for general practice in connectionwith PCTs including information, advice and counselling targeted on doctors whoneed it such as those who wish to return to practice or take a career break or seekto diversify their medical careers.3. PCTs will:3.1 Be represented and share their appraisal activities in the QAWG meetings.3.2 Contribute and take part in agreed QA processes.3.3 Collate information and share with the QAWG on matters such as selection ofGP appraisers, basic training, appraisers training needs, assessment andappraising the appraisers, indemnity of GP appraisers3.4 Develop a system of needs assessment for GP appraisers with an emphasis onenabling them to provide an appropriate challenging but supportive role in GPappraisal process, working closely with the PCT’s responsible officer forrevalidation.3.5 Take part in piloting the agreed national tools into different aspect of GPappraisal and revalidation process including form 4 analysis and use of toolsfor making judgement.3.6 The Medical Performers list needs to be reviewed every three years and thatGPs should declare issues in appraisal.4. Research and Audit, and Service Issues:KSS Deanery staff will advise the QAWG on:4.1 Training in audit and research methods, and management training for generalpractice and doctors in training for General Practice and to identifyopportunities for multidisciplinary initiatives.DPRINCIPAL FUNCTIONS OF THE GROUP IN RELATION TO:1. GP Appraisal processIn essence, agree standards and processes for best practice in the quality of theappraisal process; by agreement with individual PCT monitor that quality standardsare adhered to in operation of GP appraisal in individual PCTsReceives and comments on reports from the PCT staff Appraisal Leads, andPCT responsible officers (when appointed); indicate strengths, andweaknesses that PCTs may plan to rectifyReceives and comments on reports from the PCT GP appraiser leads; indicatestrengths, and weaknesses that PCTs may plan to rectifyKSS QAWG TOR (final version) .doc 8th December 08Page 3

Constitution/Terms of Reference/MembershipKSS Quality Assurance of GP Appraisal Working GroupReceives and comments on reports by the responsible KSS Associate GPDeans and Life Long Adviser on GP appraisal process; plan for needs forremediation and reskilling of doctors about whom there are identified concernsin relation to their performance, or conductReceives and comments on RCGP/GMC documents; subsequently advise orimplement new regional systems and processes for appraisal in respect ofrevalidationAgrees and publishes criteria for appointment & reappointment of GPappraisers based on recommendations published by RCGP/GMC and theNational Revalidation Support Group; oversee that criteria are put intopractice at invitation of respective PCTsAgrees and publishes criteria for the selection process of GP appraisers inaccordance with recommendations published by RCGP/GMC and the NationalRevalidation Support Group.2. CPDIn essence, advise PCTs about the implementation of the RCGP’s managed CPDscheme and how appraisers make judgements about the CPD contents of GPs’appraisal folders in line with the new CPD credit based system; monitor that qualitystandards are adhered to in operation of the GP credit based system within appraisal -in individual PCTs by invitationReceives and comments on report from GP Deanery.Receives and comments on report on CPD from the Convenor of the GP TutorWorking Group.E. MEMBERSHIP1. Membership will be as follows:1. PCT Members:• GP Appraisal Lead from each PCT• Responsible officer (when appointed) or manager/ administrative support leadfor appraisal from each PCT2. Deanery members:• Dean of Postgraduate General Practice Education or his/her deputy• Associate Deans of Postgraduate General Practice Education• Lifelong learning adviser• Deanery staff as appropriate3. Representative MembersLocal Medical CommitteesRCGP1 person from each LMC1 person from each RCGP FacultyKSS QAWG TOR (final version) .doc 8th December 08Page 4

Constitution/Terms of Reference/MembershipKSS Quality Assurance of GP Appraisal Working GroupSouth East & South West Thames) appointed bythe FacultiesGP Tutor1 person from each county4. Observers will be as follows:4.1 The QAWG shall have the power to co-opt additional members to fulfilspecific time-limited functions.4.2 A member should send a deputy if unable to attend.5. QAWG Officers5.1 The chair will be the Dean of Postgraduate General Practice Education.5.2 If a representative steps down before the end of their term, their replacementwill be entitled to serve for an initial period for three years, renewable for onefurther term.6. QAWG Members6.1 Representative members will be expected to serve for an initial period forthree years, renewable at the discretion of the appointing organisation.F. STANDING ORDERS1. QAWG Meetings1.1 The QAWG will normally meet four times a year: February, May, Septemberand December. The Group is expected to meet as often as necessary tocomplete its business.1.2 Meetings will normally be held on Deanery/SHA premises.1.3 The Chair will ensure that agendas and papers for meetings are circulated toall members to arrive at least five working days before the meeting.1.4 One third of members across the spread of represented organisations shallconstitute a quorum.1.5 Decisions of the group will normally be reached by consensus of opinion;voting may be resorted to in certain matters at the discretion of the Chair. Insuch cases, motions should be proposed and duly seconded by members of thegroup, and decisions will be reached by a simple majority vote of memberspresent. In the event of a tie, the Chair of the meeting will have a second (orcasting) vote.KSS QAWG TOR (final version) .doc 8th December 08:Page 5

Constitution/Terms of Reference/MembershipKSS Quality Assurance of GP Appraisal Working Group1.6 Subcommittees or working groups may be set up by the group; membershipwill be agreed by the QAWG, with an individual member identified to leadand report back to the main Group.2. Deanery Support for QAWG2.1 A member of the GP PGME staff will act as secretary to the Group.2.2 Reimbursement of travelling expenses at public transport rate will be paid forrepresentative members attending QAWG meetings. LMC and RCGPrepresentatives will receive a contribution to their locum expenses.3. Role of QAWG Chair:3.1 Will chair the meetings of the QAWG.3.2 Will promote and support collaborative working between PCTs andstakeholders.3.3 Will be ultimately responsible for the operation of the quality assuranceframework for GP appraisalKSS QAWG TOR (final version) .doc 8th December 08:Page 6

(updated 3 May 2012)AGREED PROPOSAL FOR A JOINT DEANERY COMMITTEE ON QUALITY MANAGEMENTOF TRAINING BETWEEN LONDON AND KSSBackground1. Both deaneries recognise that training and trainees will continue to cross SHA/localprovider boundaries as part of future programmes of training.2. Both deaneries/SHAs have to assure the GMC there are comprehensive qualitymanagement arrangements in place which local education provider will want to have theminimum number of bodies, ideally one, overseeing their quality management andcontrol arrangements.3. Both deaneries have already agreed we continue the current position where eachdeanery takes responsibility for posts and the educational environment within theirgeographical area.Initial Terms of Reference of the Joint Deanery Committee1. To discuss and share current quality management arrangements within the twodeaneries.2. To look for areas of agreement over commonality of process both now and in the future.3. To share reports, results and information on issues that have arisen from QualityManagement arrangements taking place within home deanery boundaries that mightaffect trainees in a programme being managed by another Lead Provider/Deanery.4. To act as a source of joint support and trouble shooting for “difficult or wicked” problems.5. To ensure that all such problems are escalated to the relevant Postgraduate Dean orResponsible Officer in a timely fashion.6. To share and log information about all trainees in difficulty that cross-deaneryboundaries.7. To keep the GMC informed of all activities, usually through the Deanery Report (DR) ofeach organisation. Both deaneries will agree the joint exception reporting in DRsinvolving cross-boundary programmes.8. Terms of Reference to be annually reviewed.Membership1. The deans responsible for postgraduate Secondary Care education from London andKSS.2. The Directors of the London Foundation School and the South Thames FoundationSchool.3. The Associate Dean for Quality in KSS and the two Trust liaison deans in South London.4. The Quality Managers of both Deaneries.5. The General Practice Deans of both Deaneries.6. KSS Education Department representative, as required.7. A Foundation trainee representative, alternating annually between Deaneries.8. A Specialty trainee representative, alternating annually between Deaneries.Meetings1. The group will meet three times per year, alternating meeting venue between KSSDeanery, STFS and London Deanery offices.2. The group will elect its own chairman on an annual basis

(updated 3 May 2012)3. The Quality Managers of the two Deaneries will be responsible for administering theCommittee. Primary administrative responsibility will normally alternate so that theadministrating manager comes from the other deanery from that of the chair.

Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT DEPARTMENTGuidance on producing the KSS Deanery ReportThe Deanery Report (DR) is the mechanism by which the Deanery provides assurance to theGMC that it is managing the quality of training in line with the GMC’s standards.This document provides an overview on completing the KSS Deanery Report, and should be readin conjunction with the GMC Document, “Deanery Report 2010-2011: Guidance for Deaneries”.All deaneries are expected to report on Foundation, Specialty, and GP Training Programmeswithin their DR. The GMC expects all actions to be mapped against the standards, as indicated inthe Deanery Report Template.Deaneries are required to demonstrate progress on actions included in the July 2011 action planupdate and notify the GMC of any new actions that arose after the submission of the July 2011update, while informing them of how the deanery is meeting standards.This revised report template maintains the principle of exception reporting, which means thatdescribing routine management activities is not necessary. Instead, the focus should be on:a. Key areas of achievement and good practice during the previous yearb. Key areas where improvement is needed to maintain standardsc. Action planned (with specific timescales) to resolve issues or concerns or to disseminate goodpractice.Examples of exception reporting for each area have been provided in the DR template, which hasbeen divided into three worksheets:a. Published itemsIt is important that deaneries are able to publicly demonstrate the improvements they aresecuring in the quality of postgraduate medical education and training, therefore items listed onthis sheet will be published on the GMC website. The report must contain open actions from theJuly 2011 Action Plan Update. Deaneries should also include new or other relevant items.b. Confidential itemsIt is important that deaneries are transparent in their role in quality managing medical educationand training; however, there will be a number of potential concerns or issues that require furtherexamination or evidence. This sheet enables deaneries to keep the GMC informed aboutpotential concerns or issues that are currently being investigated and are yet to be substantiated.c. Good practice itemsGood practice should include exceptional examples which have potential for wider disseminationand development, or a new approach to dealing with a problem from which other partners mightlearn.

Completing the ReportThe Deanery Report template is saved as a shared document on the K Drive under Genshare(see link above).The KSS Document “DR Flowchart” provides an overview of timelines and responsibilities forcompleting the report.The Quality Department is required to populate the shared report template with issues and goodpractice as identified in the LAB AARs, together with actions taken or planned to address theissues / disseminate good practice.The Foundation, GP and Specialty Schools are required to populate the shared reporttemplate with issues and good practice as identified in the School Reports, together with actionstaken or planned to address the issues / disseminate good practice.The Education Department is required to populate the shared report template with issues andgood practice as identified in the Contract Review Reports, together with actions taken orplanned to address the issues / disseminate good practice.The Quality Department is required to populate the shared report template with issues and goodpractice as identified in exception issues and reports, together with actions taken or planned toaddress the issues / disseminate good practice.Where issues are generic, write “Generic” under the heading “Programme Specialty” and/or“Local Education Provider”, and put N/A under other column headings as appropriate.The Quality Department will be responsible for co-ordinating the drafts of the report and followingup any requests for further information or clarification from the DR Project Group following theReview Meetings.The Quality Department will update/amend the report as required by the DR Project Group,produce the final report for approval by the Quality Management Steering Group and sign-off bythe Dean Director, and submit the final report to the GMC.2

Producing the KSS Deanery ReportTimelineMidSeptemberTaskSet up a Deanery Report (DR) Project Group andarrange review meetingsResponsibilityQualityDepartmentLateSeptemberLateOctoberPopulate template with issues, confidential issuesand good practice as identified in LAB AARsPopulate template with issues, confidential issuesand good practice as identified in School ReportsQualityDepartmentAll Schools -Specialty, GP,FoundationLateOctoberPopulate template with issues, confidential issuesand good practice as identified in Contract ReviewsEducationDepartmentEarlyNovemberProduce first draft of Deanery Report including allException IssuesQualityDepartmentMidNovemberMeet to review first draft of Deanery ReportDR ProjectGroupMidNovemberProduce second draft of Deanery ReportQualityDepartmentLateNovemberMeet to review second draft of Deanery ReportDR ProjectGroupEarlyDecemberProduce final draft of Deanery ReportQualityDepartmentMidDecemberMeet to review final draft of Deanery Report(to go to December QMSG meeting)DR ProjectGroupLateDecemberSign off final Deanery ReportDeanDirectorEndJanuaryDeadline for submission to the GMCQualityDepartment

Guidance - Completion of the KSS Deanery Local Education Provider MetricsObjectives To give all LEPs ability to demonstrate improvement in objective measures of processesand outcomes for Postgraduate Medical Education. For LEPs to be able to compare themselves and their process with other LEPs. To put objective information about LEPs in the public domain. To act as one source of information for the Deanery in deciding on future investment ordisinvestment strategies. To assist on LEP reporting of their quality of Patient CareMechanism An annual self assessment by the LEP that is validated through the mechanism of externalquality control of Contract Review. Agreement and sign-off at the time of the educational contract with the Trust ChiefExecutive and other senior executives present. All measures subject to annual review, change, addition or removal. All measures generated from available LEP data.Completion1. The Deanery will populate the document for items 2, 3, 4, 5, 10 and 11 (GMC SurveyTrainers, GMC Survey Trainees, Foundation Quality, LTFT, Trainee Satisfaction andAppointing High Quality Trainees).2. The LEPs will then be responsible for self-assessment of the other indicators and forformal sign-off for accuracy.Indicator 1Indicator 6Indicator 7Indicator 8Indicator 9Indicator 12QESP to be signed off by the Medical Education ManagerPAs for education in the job plan to be signed off by the Director of MedicalEducation after discussion with the Medical DirectorLFG Meetings to be signed off by the Medical Education ManagerAdequate tracking of training data to be signed off by the MedicalEducation ManagerAbsence of postgraduate doctors to be signed off by the Medical StaffingManagerBoard-level engagement to be signed off by the Director of MedicalEducation3. The relevant people need to sign the confirmation form, which is included with the metricstemplate.5. The fully populated and signed metrics will then be discussed and signed off on theContract Review visit.PLEASE NOTE: Any standard not completed by the LEP will be rated as red and willcount as zero towards the overall metrics score.

KSS DEANERY LOCAL EDUCATION PROVIDER METRICS 2012Standard Milestone Red Amber Green1 QESP The proportion of LEP identified Educational Supervisors who havecompleted both parts of QESP or successfully completed the'Grandparent Clause'.2 GMC Survey for ConsultantEducators3 GMC Survey PostgraduateDoctorsPercentage of LEP identified Educational Supervisors who completedthe 2011 GMC National Training Survey.Percentage of postgraduate doctors who completed the 2011 GMCNational Training Survey.4 Foundation Programme Number of red flag indicators for Consent, Site Marking, andImmunosuppressants found by the most recent Foundation visitingprocess or by the annual STFS survey.5 Less Than Full Time Training(LTFT)6 PAs/SPA for Education in jobplanDH wants all postgraduate doctors to have access to LTFT, so theycan follow it if they wish. Thus the LEP should encourage and supportLTFT. The milestone is the number of LTFT postgraduate doctors thatthe LEP has been offered but unable to accommodate in the past year.All consultants should have clearly designated SPAs/PA time in theirjob plan for their educational activities to NHS SEC's publishedstandards. The milestone is the percentage of consultants withidentified educational PAs/SPA time in job plan.7 LFG Meetings LFGs that have not had their minimum 3 mandatory times a yearmeeting and produced minutes for each meeting and produced anAnnual Audit and Review.8 Adequate tracking of trainerdata9 Absence of postgraduatedoctors10 Postgraduate doctorsatisfaction11 Appointing high qualitypostgraduate doctors in SECLEPs12 Board-level Engagement inEducation and TrainingPercentage of LEP identified Educational Supervisors where the LEPhas in a database their up-to-date position on QESP, their equality anddiversity training status and their status in being fully trained forworkplace based assessment.Overall sickness absence for postgraduate doctors in the preceding 6months.Overall postgraduate doctor satisfaction taken from the most recentGMC Survey.Adequate data for specialty programmes in the KSS prospectus tomeet (a) the requirements of the national code of practice and (b) toattract postgraduate doctors to the programme.There must be full Board-level engagement in education and training,including a named individual and evidence that Board engagement isactive.Less than 60% 61– 90% More than90%Less than 50% 51 – 75% 90%Less than 80% 81 – 90% More than 90%3 indicators 1-2 indicators 0 indicators2 or more 1 00–50% 51-90% Over 90%2 or more 1 0Less than 75% or failure tocapture any of the 3 datasets76-90% More than 90%5% or over 2.1-4.9% 0-2%Less than 75% 75-79.9% 80% or greaterInadequate details of datato meet requirements of (a)and (b)There is no Board memberand education and traininghas not been discussed atBoard level in the precedingyear.Inadequate data for either(a) or (b) or generally poorinformationThere is a named Boardmember, education andtraining has been discussedat least once on the Boardduring that year; and thenamed Board member hasattended the LAB on at leastone occasion during theyear.Data contains allrequirements of (a) and(b) and in good detailThere is a namedmember on the Board;postgraduate educationand training is astanding item; and thenamed Board memberhas attended the LABfor the majority ofmeetings in thepreceding year.

KSS Deanery Local Education Provider Metrics for 2012 - signing off sheetTrust: _________________________________________IndicatorsAccuracy confirmed by:(Print name)SignatureDate6. PAs for education in job plan12. Board-level Engagement in Education and TrainingDirector of Medical Education1. Qualified Educational Supervisor Programme7. Local Faculty Group (LFG) Meetings8. Adequate tracking of trainer data Medical Education Manager9. Absence of postgraduate doctorsMedical Staffing Manager

Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT OF SPECIALTY TRAININGPROCESS FOR ADMINISTERING THE GMC SURVEYThis document provides and overview of the KSS procedure for administering the GMC National TrainingSurveys, and should be read in conjunction with the GMC Survey Briefing Notes. The trainee and trainersurveys will run concurrently. The timescales shown below are subject to change year on year, and will beupdated as required.GMC Timescale17 December 2010 to 31 January 2011Deaneries review their data (programmes,locations, post specialties and grades)and provide confirmation of data accuracy.KSS Deanery ActionsBy end January 2011The Quality Manager sends the blankspreadsheets for the trainee and trainer datato the nominated administrator in eachdepartment - GP, Foundation and Specialty.26 January 2011The GMC sends blank spreadsheetsfor the trainee and trainer datato the deaneries for completion.14 February 2011 to 28 February 2011The administrators send the completedspreadsheets to the Quality Manager, whosubmits the completed spreadsheets tothe GMC using Connect.14 February 2011 to 29 April 2011Deaneries send completed spreadsheets tothe GMC using Connect. GMC validates thespreadsheets and responds to the deanerywith any errors within two working days.14 February 2011 to 29 April 2011Quality Manager sends GMC error reportsto the relevant administrator, who returnsthe corrected data to the Quality Managerfor re-submission within two working days.02 May 2011 to July 2011(survey closes 22 July)Trainee and trainer survey invitationsemailed out to participants and thesurveys go live. Emails are sent out overa three week period.02 May 2011 to July 2011The three nominated administratorsvalidate data as required and respond toqueries from trainees and trainers, liaisingwith the GMC where necessary.August to September 2011Trainee and trainer surveyreports validated and madeavailable online.31 May 2011 to July 2011The administrators regularly monitor theGMC Survey website to check responserates, and liaise with MEMs and trainerswhere necessary to chase responses.October 2011National key findings report published.Following release of preliminary reportsThe Assistant Quality Manager analysesthe data and checks for errors, liaising withthe GMC where necessary, and producesreports as required.

1. At the beginning of the calendar year, the managers of GP, Foundation and Specialty eachnominate an individual who will administer the GMC Surveys on behalf of their department.The names of the nominated Survey Administrators are passed to the Quality Department,who will publish their contact details on the GMC Survey page of the KSS website.2. The Survey Administrators will receive the GMC spreadsheet templates from the QualityManager by the required deadline. They will enter the trainee and trainer data into thespreadsheets and return them to the Quality Manager for submission to the GMC via Connectby the required deadline. In exceptional circumstances, where it is necessary to obtainadditional data from another department, the Survey Administrator should inform the managerof that department, and arrange to liaise with relevant staff to obtain the required data.3. The GMC will upload any error reports to GMC Connect and inform the Quality Manager, whowill forward the error report to the relevant Survey Administrator. The Administrator will makethe necessary corrections and return the spreadsheet to the Quality Manager within threeworking days. The Quality Manager will then re-submit the corrected spreadsheet to theGMC.4. The Survey Administrators will manage any queries or issues from trainees or trainers fortheir department from initiation to completion. If they are unable to resolve an issue or answera query they refer the query to their line manager and concurrently inform the QualityManager that there is an outstanding query. The line manager sets a timescale for resolvingthe query and informs the Quality Manager when it has been resolved.5. The Survey Administrators monitor the GMC Survey website regularly to check completionrates and validate data where required. The aim is to achieve a response rate of 100%. TheAdministrators should be in regular contact with MEMs and trainers to encourage responses.If it becomes apparent that responses are not forthcoming from any particular area, theSurvey Administrators should inform their line managers, who should reinforce the request forresponses and inform the Quality Manager that they are doing so.6. Following the release of the preliminary reports, the Assistant Quality Manager analyses thedata and checks for errors, liaising with the GMC where necessary, and produces reports asrequired.2

Doc Ref: QMV-PRO-001Version 1.6Kent, Surrey & Sussex DeaneryVISITING PROCEDURE – SPECIALTY SCHOOL VISITS TO LOCAL EDUCATION PROVIDERSContentsPage Number1. Introduction 22. Objectives 23. LEP Visits 24. Routine Visits / Programme Reviews 25. Exception Visits 36. Organising the Visiting Team 37. The Visiting Team 48. Externality 59. Role and Requirements of Visitors 510. Visitor Training 511. Pre-visit Arrangements 512. Pre-visit Documentation - “The Bundle” 613. DME Self Assessment 614. Visiting Team Pro Forma 715. GMC Standards for Postgraduate Training 716. The Visit 717. Meetings with Trainees 818. Meetings with Educational / Clinical Supervisors 819. Feedback Preparation Meeting 820. Feedback Session 821. Feedback for Programme Reviews 922. Writing the Visit Report 923. Progressing the Visit Report 1024. Follow-up and Sign-off 1025. Document Control 1126. Change Log 12This document was printed on 03/10/2012 at 10:08:51. Before using this document, please ensureyou have the latest version by checking it against the Document Control Log located at: K:\QualityManagement\QM Documents\Master Documents.

1. IntroductionThis document describes the procedure for Kent, Surrey and Sussex Postgraduate Deanery(KSS) visits to all secondary care specialties in KSS Local Education Providers (LEPs).Visits are an important part of the KSS Quality Management (QM) process. They help to assurethe Deanery that LEPs providing Postgraduate Medical Education and Training meet therequirements of the General Medical Council (GMC) Standards for Postgraduate Training as setout in The Trainee Doctor: http://www.gmc-uk.org/Trainee_Doctor.pdf_39274940.pdf2. ObjectivesThe objectives of visits are to: improve the quality of education and training by identifying notable practice as well asrectifying issues; ensure that GMC standards for the delivery of postgraduate medical education are beingmet; investigate any matters of concern against the GMC standards; identify common issues and notable practice across the specialities; provide assurance to the GMC of the quality of training in the specialties.3. LEP VisitsVisits may be part of a planned visiting schedule (routine visits) or be triggered by specificconcerns (exception visits). KSS will also undertake follow-up visits where necessary.As well as assessing training at individual LEPs, KSS will also assess the delivery of trainingprogrammes or sub-regional rotational posts in programmes. Reviews of programmes willgenerally be combined with LEP visits, with a single LEP acting as host for the programmereview.The GMC defines a programme as a formal alignment or rotation of posts which togethercomprise a programme of training in a given specialty or subspecialty. A programme may eitherdeliver the totality of the curriculum though linked stages in an entirety to CCT, or the programmemay deliver different component elements of the approved curriculum.4. Routine Visits / Programme ReviewsThe specialties for routine visits and programme reviews in any one year are chosen by theHeads of Schools (HoS) on a risk-based approach. The HoS decide which Schools will visitwhich LEPs based on information from various sources including:Trainee / Trainer Survey data and analyses;the Contract Review process;minutes of Local Academic Board (LAB) meetings;minutes of Local Faculty Group (LFG) meetings;LAB and LFG Annual Audits and Reviews (AARs);records of academic development for individual teachers within LEPs;ARCP information;findings from previous visits;correspondence and other documentation relating to individual LEPs.2

When the HoS have decided which LEPs they wish to visit, the Quality Management Department(QMD) will liaise with the HoS and the LEPs’ Medical Education Managers (MEMs) and Directorsof Medical Education (DMEs) to agree all dates for visits. They will then prepare the final visitsschedule and ensure it is approved by the KSS Quality Management Steering Group (QMSG).Where a review of a programme is planned, the QMD will contact the MEMs in the host LEP tomake the necessary arrangements, and send the visit schedule to all MEMs who have traineeson the programme. The MEMs at the LEPs involved in the programme review will be requestedby the QMD to send representatives of their trainees and trainers to the host LEP.The QMD will prepare a draft timetable for each visit, which must be approved by the relevantHoS. The timetables and visiting teams will be reviewed by the KSS Quality ManagementOperational Group (QMOG) in advance of the visits to ensure any potential problems can beresolved prior to the visits taking place.The KSS Dean Director will write to the Chief Executive Officer (CEO) of each LEP, copied to therelevant Schools, to confirm formally the date of the visit and the specialties / programme / site tobe visited.5. Exception VisitsException visits may be made to LEPs, outside the routine LEP visiting process, as a result of: a serious untoward incident, which may or may not have involved a postgraduate traineedoctor but might have implications for training; a serious trainee complaint, either directly to KSS, or via a KSS School or a LondonSpecialty School, which raises a serious question about current training that cannot bemanaged through usual mechanisms; concerns raised by usual mechanisms such as GMC Surveys in small specialties orspecialties not routinely covered by the KSS visiting programme; evidence from any other source raising serious questions about potential serviceproblems that could affect trainees.The process for exception visits is: issues arising will be reviewed by the Dean Director, the Postgraduate Dean forSecondary Care, the Associate Dean for Quality, the KSS Head of School and the LondonDeanery Head of School if also relevant; If there is evidence of serious concern the Dean Director will make a decision for aDeanery visit and will inform the next meeting of the Quality Management SteeringGroup. if there is a chronic problem or there are other factors to be taken into account and it isless pressing, the matter will usually be discussed at the Quality Management SteeringGroup meeting before a decision is made; if it is decided that an exception visit is required, the Dean Director will inform the LEPCEO and will instruct the QMD and the relevant Specialty School(s) to prepare for a visit.6. Organising the Visiting TeamFor each School visit, the Medical Workforce Project Officer (MWPO) will liaise with the HoS todetermine the members of the visiting team, and will invite them accordingly, makingarrangements for travel and overnight accommodation where necessary. As each visitor confirmsattendance, the MWPO will enter the details on a shared master spreadsheet together with theemail addresses of those outside of KSS, and send the QMD the mobile telephone number ofeach visitor.3

If any visitor entered on the master spreadsheet subsequently cancels, the MWPO must removethe details from the spreadsheet and inform the QMD of the cancellation.The QMD will start sending pre-visit information and documentation (the bundle) to the confirmedvisitors six weeks before the visit, so it is essential that all visitors are added to the spreadsheetbefore this deadline. Any additional visitors entered onto the spreadsheet after this deadline willnot have been included on the distribution list for the bundle, so the MWPO must inform the QMDimmediately of the late additions to the spreadsheet and forward the bundle email to any suchvisitors, copied to the QMD.It is essential that the master spreadsheet is kept up to date to ensure that the correct peoplereceive all the relevant information and to enable the QMD to play an effective supporting role incoordinating the School visits.7. The Visiting TeamThe visiting team will comprise the following members:VisitorHead of School, KSS DeaneryTraining Programme Director (TPD), KSSDeaneryGP Patch Associate Dean (if GP is one ofthe specialties being visited)Trainee RepresentativeExternal or Lay Visitor (external reps aremandatory for exception visits)A member of the KSS Specialty WorkforceDepartmentResponsibilityLead Visitor. Broad clinical context.Reporting systems and processes.Lead for own specialty. Broad clinical context.Reporting systems and processes.Lead for own specialty. Broad clinical context.Reporting systems and processes.Trainee doctor context / voice.Provide externality.Visit Officer. Provision of administrativesupport including preparing the report inconsultation with the lead visitor.The following are optional members of the visiting team:Dean DirectorDeputy Dean for secondary CareGP DeanAssociate DeansAssistant Dean EducationObserver(s)Where GP is included in the visit to a hospital, the GP visitor(s) will see any GP trainees who arecurrently part of the other specialties being visited.When a visit includes consultations with trainees administratively managed by the LondonDeanery, the Quality Manager will send a letter from the Dean Director to the relevant Head ofSchool in London Deanery informing of the visit, inviting a representative from the LondonDeanery to attend the visit, and requesting any information that may be relevant to the visit.For exception visits, the visiting team will normally comprise the same members as above, butthe final members of the visiting team will be decided by the Lead Visitor based on the size of thevisit and the issues to be investigated. An external College visitor is mandatory for exceptionvisits.4

8. ExternalityIn line with GMC requirements (The Trainee Doctor, Standards for Deaneries, Standard 4), theremust be external input in some circumstances for specialty and GP training, involving‘independent and impartial advisers’. This is usually a requirement for all visits that are not‘routine’ in nature. External advisers may be medical or lay, depending on the area for adviceand/or scrutiny. They must be independent of the Deanery with no conflicts of interest. Medicaladvisers will have expertise appropriate for the specialty programme, course or school beingconsidered and will normally be drawn from the medical Royal Colleges, Faculties or specialtyassociations.The need for an external College representative and/or a lay visitor on a routine visit will dependon the issues with the LEP. It is the responsibility of the relevant HoS to decide whether or not anexternal College representative and/or a lay visitor is required on a particular routine visit.9. Role and Requirements of VisitorsThe role involves visitors seeking to gather evidence-based information that will be used toexpress an opinion on the LEP’s ability to ensure that the curriculum is being delivered byqualified trainers to all trainees within the LEP. This will involve verifying that robust qualitycontrol processes are in place and are followed, which allow for doctors to be trained in anenvironment that provides for their needs and consequently benefits patients.During the visit, the visitors will interview trainees and trainers in order to gather additionalinformation about the training environment and curriculum delivery, triangulate this with othersources of data such as the GMC Trainee and Trainer Survey, previous visits, etc. It is essentialthat the trainees and trainers feel confident that the information they communicate will be handledappropriately and confidentially.10. Visitor TrainingPotential future visitors without previous visiting experience will be expected to attend trainingsessions organised by KSS. Alternatively they may be invited to attend QM visits in anobservational capacity in order to gain experience of visits. In this case they will be provided withthe teaching material used in the formal training sessions. Visitors with previous experience ofvisiting elsewhere will be expected to familiarise themselves with the KSS visiting procedurebefore the visit.All visitors are required to sign the KSS Visitor Guidance and Declaration (QMV-FOR-001) beforetaking part in a visit. This will be sent to each visitor by the QMD, who will keep a record of thesigned declarations.11. Pre-visit ArrangementsAs each visit is usually conducted by more than one Specialty School, the MWPOs should decidebetween them who will be the lead MWPO for each visit.The MEM and/or DME will usually be the visit coordinator for the LEP, acting as the liaison pointbetween KSS and the LEP, disseminating details of the visit within the LEP, and distributing anypre-visit questionnaires provided by the Schools. This task will sometimes be delegated to anAssistant Manager or Administrator within the LEP.5

The MWPOs will inform the QMD of the trainees and trainers that the Schools wish to see on thevisit. The QMD will ask the LEP visit coordinator to invite these trainers and trainees and entertheir details on the attendee list sent to them with the visit timetable. This will be returned to theQMD, who will forward it to the visiting team.As the coordinator of the School QM visits, the KSS QMD needs to be aware of all mattersregarding visits. It is essential that the QMD is informed of any arrangements made by theSchools regarding the LEP visits.12. Pre-visit Documentation - “The Bundle”The bundle of documents, comprising information from various sources about the LEP and thespecialties being visited, is collated by the QMD nine weeks before the visit. A typical bundle willcontain the following documents:Contract Review - Education Management AuditContract Review Action PlanLAB Annual Audit and ReviewLFG Annual Audit and Reviews (for each specialty)Last 3 LAB minutes received from TrustLast 3 LFG minutes received from Trust (for each specialty)GMC Survey analysesLast LEP Visit Reports for the specialties being visitedLast Foundation Visit ReportARCP informationLFG HandbooksA list of contents of the bundle is sent to the Lead Visitor for each specialty eight weeks beforethe visit for approval. It is essential that the Lead Visitors check the contents to ensure they arehappy with the documentation. The Lead Visitors should ask the QMD to request any additionalinformation or documentation they require from the LEP before the visit, and/or a list ofdocuments they would like to be made available during the visit (e.g. diary cards).The QMD will send a list of contents of the bundle to the MEM eight weeks before the visit forapproval by the LEP, and will ask the MEM to forward any additional documents that the LEPwould like to be included in the bundle.Six weeks before the visit, each member of the visiting team is sent an email with a link to theKSS website, where they can download the bundle of documents.The MWPOs are copied into the emails when the bundles are sent to the visitors. The MWPOsshould check the email recipients to ensure all members of the visiting team have been included.If MWPOs add any visitors to the team after the bundles have been sent out, they must forwardthe bundle email to the additional visitors straight away, and copy this email to the QMD (seesection 6).13. DME Self AssessmentThe DME will be sent a pro forma set out under three sections; notable practice, areas of concernand details of actions planned/taken. The DME will be asked to use this pro forma to provide KSSwith a self assessment of training in the LEP. The self assessment should be sent to the QMD atquality@kssdeanery.ac.uk. It will then be forwarded to the visiting team in advance of the visit.6

14. Visiting Team Pro FormaEvidence for the delivery and support of appropriate education for specialty trainees will beobtained from a number of sources. The Visiting Team Pro Forma helps the visitors to review thebundle of documents and identify areas where further exploration is required. It is set out underthree sections; notable practice, areas of concern and areas for clarification/further investigation.It should be used in conjunction with the GMC guidance, ‘The Trainee Doctor’. Each visitor will beasked to complete a pro forma and send it to the QMD at quality@kssdeanery.ac.uk. The QMDwill then forward the pro formas to the rest of the visiting team.15. GMC Standards for Postgraduate TrainingThese are the set standards against which the visiting team needs to report, published in theGMC’s Standards document “The Trainee Doctor”. As the visitors review the bundle, they usethis document to help them focus on key areas and ensure adequate coverage of key issues. TheGMC Standards are set out under nine Domains:1. Patient safety2. Quality management, review and evaluation3. Equality, diversity and opportunity4. Recruitment, selection and appointment5. Delivery of approved curriculum including assessment6. Support and development of trainees, trainers and local faculty7. Management of education and training8. Educational resources and capacity9. Outcomes16. The VisitThe documentary evidence will be triangulated during the visit using interviews with trainees andthose delivering and facilitating the training. The visit will include structured focus groupdiscussions with:Trainees in hospital postsHospital Faculty LeadsSpecialty Programme DirectorsEducational SupervisorsClinical SupervisorsOn the day of the visit, the visiting team should have a private meeting to divide up tasks, gothrough the list of issues identified as being of interest, set rules for the day, refreshunderstanding of the GMC Domains, and ensure that all are clear about the division ofresponsibilities between members. For example, different team members can lead on askingquestions in different meetings. It is usual for the Lead Visitor to start the questioning and tosummarise where appropriate.At the opening meeting the Lead Visitor should ensure that the LEP understands the visitprocess, is fully aware of the timescales and activities to be undertaken and is clear about theinformation requested. The Lead Visitor should communicate to the LEPs that the visit is anopportunity for them to show how well they are doing as well as to explore matters of particularconcern. The DME or Faculty tutors may like to give a very brief presentation at this time. Thisshould last in total no more than 10 minutes.7

17. Meetings with TraineesThe visit timetable should be constructed to include meetings with separate groups of trainees,which may be conducted in parallel. The Team should aim to meet a wide range of trainees,including full-time, academic, flexible, supernumerary trainees, trainees on different placements,trainees in difficulty, etc. Trainees should be assured of confidentiality by the Visiting Team at thebeginning of each meeting. Trainees should be offered an opportunity to meet any member of theVisiting Team one-to-one should this be required.18. Meetings with Educational / Clinical SupervisorsThe trainers from the specialties being visited will usually be seen together as one group. Thepurpose of these meetings is to discuss the trainers’ experience of training-related issues. Whilstthe visitors may wish to explore areas raised during the meetings with the trainees, this sessionshould not include any direct feedback from those meetings.Where a programme is being reviewed alongside a routine LEP visit, the trainers from theprogramme will usually be seen as a separate group. This is because the trainers in the host LEPmay not wish to discuss issues in front of trainers from other LEPs.19. Feedback Preparation MeetingThe Visiting Team will meet in advance of the feedback session to discuss their headlinefindings, both in terms of notable practice and areas for improvement. These should benoted in brief bullet points on the feedback forms.The purpose of the feedback form is to provide the LEP with a record of the brief headlineverbal feedback given to senior LEP representatives, and provide KSS with evidence ofacknowledgement by the LEP of the main headlines arising from the visit.The Visiting Team should agree any issues that the LEP has to address immediately, whichwould primarily relate to service issues affecting patient and trainee safety, and note these on thefeedback forms, using one form for each specialty being visited. The Visiting Team should ensurethat all findings are based on clear evidence.Where a programme review has taken place alongside a routine LEP visit, immediate verbalfeedback to senior staff at the LEP will be provided for the specialties visited at that LEPonly, not for the programme review.20. Feedback SessionAt the end of the visit, brief headline verbal feedback, as encapsulated in the feedbackforms, will be given to the senior LEP representatives, usually the CEO accompanied by theDME and other relevant staff. (This feedback will be for the specialties visited at that LEPonly, not for any programme reviews undertaken on the same day.)Any areas requiring immediate action by the LEP, particularly where patient and/or trainee safetyis compromised, will be communicated to the senior LEP representatives. In addition to this, theCEO and DME will be contacted by the KSS Dean Director via e-mail by the following day.8

After receiving the verbal feedback, the senior LEP representative and the Lead Visitorshould sign the feedback forms. The Visit Officer should ask the MEM to photocopy thecompleted and signed feedback forms. One copy of each form should be left with the seniorLEP representative and the other should be passed to the KSS QMD, who will save theforms with the rest of the visit documentation.The senior LEP representatives should be informed that the visit report may contain otherareas of notable practice and improvement in addition to those listed on the feedback formsand communicated verbally.21. Feedback for Programme ReviewsProgramme reviews involve a number of different LEPs, and it is extremely unlikely thatsenior representatives will be present from all LEPs involved in the programme. Thereforethe lead visitor will not provide verbal feedback for the programme review.However, any patient and/or trainee safety issues identified in a programme review will bereported by telephone immediately to the relevant CEO (or senior representative), and the DeanDirector will also contact the CEO and DME via e-mail by the following day.22. Writing the Visit ReportThe first draft of the visit report should be written by the visiting team, coordinated by the LeadVisitor, immediately following the visit. All members of the visiting team, including lay and externalrepresentatives, are expected to contribute to the KSS visit report, to be agreed by all visitors. Itis essential that visitors do not produce supplementary reports or other documents that makereference to the visit, without the express permission of the Dean Director of KSS Deanery.Where a programme review has taken place alongside a routine LEP visit, separate visit reportswill be produced. A report will be produced for the LEP, and will cover the specialties visited inthat LEP only. A separate report will be produced for the programme review, and will cover allLEPs involved in that programme.The Visit Officer will type the details of the report into a Visit Report Template, which is set outunder the nine GMC Domains (see Section 15). The visit report should be written in conjunctionwith the GMC guidance, ‘The Trainee Doctor’, which sets out the standards against which thevisiting team needs to report.The full report must follow the KSS Deanery reporting template and include:the detail of the visit (the name of the LEP, details of the Visiting Team, etc.)the percentage of trainees from each specialty who attended the visitLEP performance under each Domainspecific examples of notable practicespecific concerns indicating the evidencemandatory requirements for action with details of evidence required and suggesteddeadlines for correctionrecommendations with suggested deadlinesThe content of the draft and final visit reports should include issues encapsulated on theFeedback Form and communicated in verbal feedback.9

Section 2 of the report (Findings against GMC Standards) should only contain matters of(reported) fact, and should not include the opinions or suggestions of the visitors. AllMandatory Requirements and Recommendations made in Section 4 of the report will bereferenced back to the findings in section 2, and in the case of Mandatory Requirements willalso be referenced to the relevant GMC Mandatory Requirement set out in the Standardspublished in The Trainee Doctor.The Visit Officer will circulate the draft report to all members of the visiting team for approval.The Visit Officer will amend the draft report as suggested by the visitors and forward it to theQuality Manager no later than 5 working days from the date of the visit.23. Progressing the Visit ReportThe Quality Manager will check and amend the report as necessary, and forward to theAssociate Dean for Quality (ADQ) for a consistency check. The ADQ will make anynecessary amendments and return the draft report to the Quality Manager for finalformatting. The draft report will then be sent to the DME for a factual accuracy check. TheDME should receive the draft report no later than two weeks from the date of the visit.The Quality Manager will submit the report (with any amendments suggested by the DME) to bereviewed and formally approved at the subsequent meeting of the KSS QMSG, which meetsmonthly. These meetings are chaired by the Dean Director and attended by the KSS Heads ofSchools. The QMSG will often suggest minor changes to reports. These changes are made bythe Quality Manager before the report is signed off by the Dean Director. If substantial changesare necessary or clarification is required (and the HoS is not present at the meeting), the QualityManager will confirm the changes with the relevant HoS (or lead visitor) before the report is sentout.The final report will be sent to the CEO (copied to the DME, MEM and other relevantstakeholders) together with a pre-populated Action Planning Template, drawn up from therequirements and recommendations in the report, to facilitate the response. The LEP will beasked to complete the action plan as part of their response to the report findings.Final reports will usually be sent out within six weeks of the visit.24. Follow-up and Sign-offAn audit trail of responses to the visit report, in the form of a “tracking chart” will be kept by theQuality Manager, who ensures that all actions are followed up and all requested evidence isprovided to the QMSG.Any change in practice suggested that relates to a mandatory requirement in the GMC Standardsis classified as a mandatory requirement, and will be followed up by the QMSG.Recommendations are suggestions that should be considered by the LEP, but do not relate toGMC mandatory requirements. These are not followed up by the QMSG; however, the LABshould discuss with the relevant LFGs what actions have been taken on any recommendations.This may then be reported to the QMSG by the LAB when responding to visit reports and will bediscussed and monitored by the relevant KSS Specialty School.10

All responses to mandatory requirements are reviewed and signed off by the QMSG. When allmandatory requirements are met, the Dean Director will confirm this formally in writing to theCEO.Once the report is signed off, the notable practice and mandatory requirements will be publishedon the KSS Deanery website together with the response(s) from the LEP and the formal sign-offdate. The report will be made available to the GMC when required for their Quality Assuranceprocesses.25. Document ControlTitle:Originator:Document Owner:Document Number:Local Education Provider Visiting Process - Secondary CareSpecialtiesKaren Gibson, Quality ManagerDavid Yates, Associate Dean for QualityQMV-PRO-001Version Number: V 1.6Approved / Authorised by:KSS Quality Management Steering GroupDate Issued: May 2011Next Review Date: January 2013Master Location:Publication Scheme:Purpose of document:K:\QUALITY MANAGEMENT\LEP Visits (LV)\Visit DocumentsKSS WebsiteTo set out the procedure for the KSS visiting process.11

26. Change LogVersion Date Revisions0.1 20-01-11 First draft written by Karen Gibson, Quality Manager.0.2 25-01-11 Minor revisions made to procedure at request of Zoe Playdon, Head ofEducation - paragraph numbering, positioning of acronyms.0.3 01-02-11 Additions to section 13, 14 and 15 by Karen Gibson, Quality Manager -information on feedback form added.0.4 14-03-11 Updated to reflect consolidated standards document from the GMC -The Trainee Doctor.0.5 03-05-11 Updated by David Yates, Associate Dean for Quality, to includeinformation on visitor training (section 5), presentations (section 11),meetings with trainers (section 13) and report writing (section 16).0.6 15-05-11 Paragraph added by Karen Gibson, Quality Manager, explainingmandatory requirements and recommendations (section 16). Contentslist added.0.7 16-05-11 Updated to clarify paragraph on mandatory requirements andrecommendations (section 18). Section 16 split into 3 sections.1.0 24-05-11 Sections 5 and 18 amended to provide further clarity. Document agreedas final at May QMSG meeting.1.1 25-07-11 Addition of Section 6, “Role and Requirements of Visitors”, and Section7, “Externality”. Following sections renumbered to incorporate sections 6and 7. Update to Section 8 to clarify the single point of control. Additionto Section 18 to clarify the requirement for one single visit report.1.2 27-07-11 Updated and approved by David Black, Dean Director - minor changesto wording in Section 6 and Section 7.1.3 21-09-11 Updated by Quality Manager to include information on programmereviews - additions to Sections 3, 18, 19 and 22. New section added -Section 21. Section 3 split into two sections. All numbering changed toincorporate new sections. Amendments made to clarify processes -additions to Sections 6, 7, 8 and 12.1.4 22-09-11 Minor changes made to paragraph positioning by David Yates,Associate Dean for Quality, to clarify information on programme reviews.1.5 24-10-11 Changes made to the order of paragraphs to improve the flow ofinformation. Minor changes made to wording.1.6 03-01-12 Document was reviewed by the QMSG on 16 December 2011. It wasagreed that a headline feedback form should be used for each specialtyvisited rather than one single form. The procedure has been updated toreflect this, and a few minor changes were made to improve clarity. Nextreview date January 2013.12

Kent, Surrey & Sussex DeaneryProcess for reporting Visits to Programmes* or sub-regional rotational posts in programmes.The KSS Deanery has a well established process for visiting Local Education providers (LEPs)to assess training posts and the educational environment.We are increasingly managing higher specialty training across Kent, Surrey and Sussex.Assessment of the quality of this training will require a wider view and we intend to look at thedelivery of training programmes or sub-regional rotational posts in programmes in future.After exploring different ways of assessing programme delivery last year, we have agreed thatvisits to programmes or parts thereof will generally be combined with LEP visits. The processwill be similar to LEP visits, but there are significant differences, summarised below: Trainees and trainers from other centres will be asked to travel to the LEP where the visit isbased. Immediate verbal feedback to senior staff at the end of the visit will only be provided inrelation to the specialties visited at that LEP only. Because programme visits will beconsidering experiences from a number of different LEPs it will not be possible to providefeedback in the same way, as senior representatives will not be present from all relevantsites. It should be noted that our current practice whereby areas requiring immediate action by theLEP (particularly those where patient and/or trainee safety is compromised) arecommunicated to the senior LEP representatives will apply to all sites considered inprogramme visits, even if no senior representatives are present. In this case telephonecontact will be made, and the CEO and DME will be contacted by the KSS Dean Director viae-mail by the following day in the normal way. Separate visit reports will be produced for the LEP and programme visits. The programmevisit report will be circulated to all LEPs that are involved in that programme visit.We consider the visiting process to be a vital part of quality management. We recognise thatsome disruption to clinical services is inevitable with any visiting process, but we hope that thisway of conducting our visits will give the best outcomes with the least disruption.David Yates, Associate Dean for Quality, 20 September 2011* GMC DefinitionA programme is a formal alignment or rotation of posts which together comprise a programmeof training in a given specialty or subspecialty. A programme may either deliver the totality of thecurriculum though linked stages in an entirety to CCT, or the programme may deliver differentcomponent elements of the approved curriculum.

Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT OF POSTGRADUATEMEDICAL EDUCATION AND TRAININGLocal Education Provider Specialty Visit ReportRoutine LEP Visit / Exception Visit / Follow-up Visit / Programme Review(delete as appropriate)Please note: this report is about the postgraduate medical education and training of doctors and not aboutthe level of service provided.Purpose of Visit• To ensure that national standards for the delivery of postgraduate medical education are being met• To improve the quality of education and training• To identify common issues and good practice across the specialitiesSection 1Visit DetailsLocal Education ProviderDate of VisitSpecialties / Grades VisitedPercentage of trainees from eachspecialty who attended the visitVisiting TeamPosition Name Email addressPeople to whom the visit report is to be sentPosition Name Email addressChief Executive of TrustDirector of Medical EducationMedical Education ManagerCollege TutorInformation and reports received prior to the visitContract Review - Education Management auditContract Review Action PlanLAB Annual Audit and ReviewLFG Annual Audit and Reviews (for each specialty)Last 3 LAB minutes received from TrustLast 3 LFG minutes received from Trust (for each specialty)GMC Survey analysesReceivedPage 1 of 6

Last LEP Visit ReportFaculty HandbooksSelf Assessment from Trust DMESection 2Findings against the GMC Standards for Postgraduate TrainingRefer: http://www.gmc-uk.org/Trainee_Doctor.pdf_39274940.pdfDomain 1 - Patient safetyStandard: The responsibilities, related duties, working hours and supervision of trainees must be consistent with thedelivery of high-quality safe patient care. There must be clear procedures to address immediately any concerns aboutpatient safety arising from the training of doctors.Ref: The Trainee Doctor - page 12Specialty 1 Name1.1.1.2.1.3.1.4.Specialty 2 Name1.5.1.6.1.7.1.8.Specialty 3 Name1.9.1.10.1.11.1.12.Domain 2 - Quality management, review and evaluationStandard: Training must be quality managed, monitored, reviewed, evaluated and improved.Ref: The Trainee Doctor - page 15Specialty 1 Name2.1.2.2.2.3.2.4.Specialty 2 Name2.5.2.6.2.7.Specialty 3 Name2.8.2.9.2.10.Page 2 of 6

Domain 3 - Equality, diversity and opportunityStandard: Training must be fair and based on principles of equality.Ref: The Trainee Doctor - page 16Specialty 1 Name3.1.3.2.3.3.3.4.Specialty 2 Name3.5.3.6.3.7.3.8.Specialty 3 Name3.9.3.10.3.11.3.12.Domain 4 - Recruitment, selection and appointmentStandard: Processes for recruitment, selection and appointment must be open, fair and effective.Ref: The Trainee Doctor - page 18Specialty 1 Name4.1.4.2.4.3.4.4.Specialty 2 Name4.5.4.6.4.7.4.8.Specialty 3 Name4.9.4.10.4.11.4.12.Domain 5 - Delivery of approved curriculum including assessmentStandard: The requirements set out in the approved curriculum and assessment system must be delivered andassessed.Ref: The Trainee Doctor - page 20Specialty 1 Name5.1.5.2.5.3.5.4.Page 3 of 6

Specialty 2 Name5.5.5.6.5.7.5.8.Specialty 3 Name5.9.5.10.5.11.5.12.Domain 6 - Support and development of trainees, trainers and local facultyStandards: Trainees must be supported to acquire the necessary skills and experience through induction, effectiveeducational and clinical supervision, an appropriate workload, relevant learning opportunities, personal support andtime to learn. Trainers must provide a level of supervision appropriate to the competence and experience of thetrainee. Trainers must be involved in, and contribute to, the learning culture in which patient care occurs. Trainers mustbe supported in their role by a postgraduate medical education team and have a suitable job plan with an appropriateworkload and sufficient time to train, supervise, assess and provide feedback to develop trainees. Trainers mustunderstand the structure and purpose of, and their role in, the training programme of their designated trainees.Ref: The Trainee Doctor - page 25Specialty 1 Name6.1.6.2.6.3.6.4.Specialty 2 Name6.5.6.6.6.7.6.8.Specialty 3 Name6.9.6.10.6.11.6.12.Domain 7 - Management of education and trainingStandard: Education and training must be planned and managed through transparent processes that show who isresponsible at each stage.Ref: The Trainee Doctor - page 32Specialty 1 Name7.1.7.2.7.3.7.4.Specialty 2 Name7.5.7.6.7.7.Page 4 of 6

7.8.Specialty 3 Name7.9.7.10.7.11.7.12.Domain 8 - Educational resources and capacityStandard: The educational facilities, infrastructure and leadership must be adequate to deliver the curriculum.Ref: The Trainee Doctor - page 34Specialty 1 Name8.1.8.2.8.3.8.4.Specialty 2 Name8.5.8.6.8.7.8.8.Specialty 3 Name8.9.8.10.8.11.8.12.Domain 9 - OutcomesStandard: The impact of the standards must be tracked against trainee outcomes and clear linkages should be madeto improving the quality of training and the outcomes of the training programmes.Ref: The Trainee Doctor - page 36Specialty 1 Name9.1.9.2.9.3.9.4.Specialty 2 Name9.5.9.6.9.7.9.8.Specialty 3 Name9.9.9.10.9.11.9.12.Page 5 of 6

Section 3123456Notable PracticeNote as * any exceptional examples that have the potential for wider use or development elsewhere in the NHS.Section 4123456Mandatory RequirementsActions / EvidenceRequiredReference(Domain andparagraph no.)GMCMandatoryReq. no.Due DateSection 5123456RecommendationsReference(Domain andparagraph no.)Approved by KSS Deanery Quality Management Steering GroupSigned by Professor David BlackDean of Postgraduate EducationKSS Postgraduate DeaneryDate:_____________________________________________Page 6 of 6

Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT OF SPECIALTY TRAININGLocal Education Provider Specialty Visits - Headline Feedback FormThe purpose of this form is to provide the LEP with a bullet-point record of the brief headline verbal feedbackgiven to senior LEP representatives at the end of the visit, and provide KSS with evidence ofacknowledgement by the LEP of the main headlines arising from the visit.A detailed report will follow in line with the KSS LEP Visiting Procedure. The report may contain other areasof notable practice and mandatory requirements / recommendations in addition to those listed below.All notes should be entered on this form, which should be signed by the senior LEP representative and theLead Visitor after the verbal feedback is given. Once completed and signed, a copy of the form should beleft with the LEP senior representative, and the original should be forwarded to the KSS QualityManagement Department.LEP VisitedDate of VisitSpecialtyAreas of Notable PracticeDomain

Areas for ImprovementDomainAreas Requiring Immediate Action (Dean Director to be notified immediately)DomainSigned by Lead Visitor for Specialty and Senior LEP RepresentativePosition Name Signature

Kent, Surrey & Sussex DeaneryAction Plan for Visit ReportsLEP Name:Director of Medical Education:Visit Date:Medical Education Manager:The following mandatory requirements relate to the GMC Standards, and must be addressed by the LEP. All actions to address mandatoryrequirements will be followed up by the KSS Quality Management Steering Group (QMSG).No. Mandatory Requirements Domain Actions/Evidence Required Deadline Progress Further ActionPlanned

The following recommendations are suggestions that should be considered by the LEP, but do not relate to GMC Standards. These are notfollowed up by the QMSG. However, the LAB should discuss with the relevant LFGs whether or not actions should be taken on anyrecommendations. This may then be reported to the QMSG by the LAB when responding to visit reports and will be discussed and monitored bythe relevant KSS School Committee.No. Recommendations Domain Comments

Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT OF SPECIALTY TRAININGDME Self Assessment Pro FormaName of Trust:Specialties being visited:Name of DME:Date of visit:As your Trust is due to be visited by a team from KSS Deanery, you are asked to complete a selfassessment of training in your Trust in conjunction with the relevant Clinical Tutors. Please use this form tomake a note of any areas of concern or notable practice. Please also describe any actions you have takenor are planning.A bundle of documents containing the most recent information from various sources about your Trust andthe specialties that will be visited has been sent to you in the form of a online webpage. This webpageincludes the GMC standards document, The Trainee Doctor, which should be used to help you focus on keyareas and ensure adequate coverage of issues.Your notes will be sent to the visiting team prior to the visit. All members of the visiting team will also beprovided with the bundle of documents. They will use these documents together with your self assessmentto identify areas requiring further investigation, which will be followed up on the visit.Please return your completed form to quality@kssdeanery.ac.ukPlease Note: This form must be typed and sent by email as a Word document. Handwritten andscanned forms cannot be accepted.Areas of Notable Practice

Areas / Issues of ConcernActions Planned / Taken

Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT OF SPECIALTY TRAININGVisiting Team Pro FormaName of Trust:Specialties being visited:Name of Visitor:Date of visit:Thank you for agreeing to participate in this visit to a Local Education Provider on behalf of KSS Deanery.You have been provided with a bundle of documents containing the most recent information from varioussources about the Trust and the specialties you will be visiting.As you review the bundle, please use this form to make a note of any areas/issues of concern, notablepractice or issues requiring clarification/further investigation. The accompanying GMC standards document,The Trainee Doctor, should be used to help you focus on key areas and ensure adequate coverage of issues.Your notes will be sent to the other members of the Visiting Team for information. The Lead Visitor will usethese notes to identify areas requiring further investigation, which will be followed up on the visit.Please return your completed form to quality@kssdeanery.ac.ukPlease Note: This form must be typed and sent by email as a Word document. Handwritten andscanned forms cannot be accepted.Areas of Notable Practice

Areas / issues of concernIssues requiring clarification / further investigation

Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT OF SPECIALTY TRAININGQuestion PromptThank you for agreeing to participate in a visit to a Local Education Provider on behalf of KSS Deanery.For some areas, sufficient evidence may have been provided from the documentation sent to you prior to thevisit, however, if the documentation indicates areas for further exploration, the areas below provide a promptfor questions to ensure adequate coverage of key issues.Domain 1 - Patient safetyAreas for exploration with specialty trainees in Hospital posts Any concerns about patient safety related to the working environment/s Educational / Clinical supervision appropriate for level of responsibility Any examples of good educational / clinical supervision arrangements When help is required, is it easily available? Do the working hours/shift patterns allow adequate rest? Is the appropriate information about individual patients easily available? Do the patient records allow effective and safe management of every patient? Are shift/patient handovers adequate? Is there a hospital at night process? If so, how does it work? Any concerns about patient safety in the out of hour’s placements Taking consent appropriate to level of experience.Areas for exploration with the Local Specialty Training Programme Director, Local Faculty Group Good things about specialty training in this locality Difficulties with specialty training in this locality Any trainees including GP exposed to situations that may compromise patient safety? Concerns about the provision of supervision for Specialty/ GP trainees in any location? Working rotas for trainees Any variations in the specialty placements? Organisation of patient handover in the specialty OOH arrangements, especially supervision and teachingDomain 2 - Quality Management, Review and EvaluationAreas for exploration with Local Education Provider Process to manage EWTD, Data Protection Act, and Freedom of Information Local Faculty Group management of quality control of the training posts? LFG relationship with the Local Academic Board? LFG relationship with other LFGs, where there are overlapping concerns such as GP How necessary changes are action planned, progressed and audited Compliance with EWTD Level of support from Medical Staffing Level of support from Education CentreAreas for exploration with Specialty Trainers and Programme Directors Familiarity with GMC Generic Standards for Training Familiarity with postgraduate medical educational organisational structure in KSS Familiarity with GEAR Representation of GP Trainers on the LFG What constitutes good practice in the LFG? What needs development?

Domain 3 - Equality, Diversity and OpportunityAreas for exploration with LEP Any examples of problems relating to these areas with any trainees? Process and practice for resolution of problems How HR/Medical Staffing department deals with issues of disability or special needs in traineesAreas for exploration with Trainees (NB individuals may not wish to disclose personal details) Seen/ experienced discrimination in the workplace? Have full information about posts, the job description, and the content and purpose of the posts? Know about, or how to get information about:o Planned absenceo Unplanned absenceo Training at less than full-timeo Level of support offered for any disability or special needs?Areas for exploration with Specialty Educational and or Clinical Supervisors. Local TrainingProgramme Directors / Local Faculty Group LFG monitoring processes for discrimination, either direct, or indirect Any examples of how a trainee with disability or special needs has been appropriatelyaccommodated in training?Areas for exploration with Specialty Local Training Programme Directors / DMEs Process for monitoring that those involved in training have been trained in Equality and Diversity inthe last three yearsDomain 4 - Recruitment, selection and appointmentAreas for exploration How Trainers keep up to date with the documentation and processes that they are required toprovide for the employment of trainees How the Local Faculty supports the Specialty Recruitment and Selection process carried out by theKSS Deanery on behalf of the national processDomain 5 - Delivery of curriculum including assessmentAreas for exploration with Trust/DEM/ Educational and Clinical Supervisors Who carries out WPB assessments for trainee doctors How they have been trained How assessment is monitored Local curriculum audited against national curriculum framework? Curriculum individualised to meet needs of learners? Process of Educational Supervision Monitoring of Educational Supervision Process of LFG reporting to/ discussing with Educational Supervisors How Educational and Clinical Supervisors communicate with each other over trainee progression Arrangements for appropriate protected teaching for Specialty trainees Arrangements for carrying out NHS appraisal for traineesAreas for exploration with trainees How Educational or Clinical Supervisors carry out assessments How Educational or Clinical Supervisors input to Trainee Portfolio / ePortfolio How their progress is discussed with Trainees Best part of the educational process How NHS appraisal is carried out

Areas for exploration with Local Faculty Group / Educational and or Clinical Supervisors Any problems with the hospital posts in supporting the learning outcomes of the Specialty curriculumfor specialty trainees or GP trainees Any problems with the hospital posts in providing effective assessments in a timely and appropriatefashion How the LFG ensures that all are trained and moderated in the WPB assessments How the LFG supports individual Educational / Clinical Supervisor development, in the light ofinformation from ARCP panels How the LFG ensures that it is on track to meet GMC Standards for Training and target that allEducational Supervisors will be trained by 2010 What is going well in carrying out assessmentsDomain 6 - Support and development of trainees, trainers and local facultyAreas for exploration with trainees The process for induction:o To the Trusto To the clinical teamo In the context of on-call Nominated Clinical Supervisor/s? Nominated Educational Supervisor?o Planned or achieved Educational Supervision meetings?o Use of portfolio / ePortfolio? Content and location/s of Specialty training programme Access and provision of career advice Relevance of posts for GP training [if appropriate] Any concerns about quantity or kind of work Weekly protected teaching time:o Trainee voice in choice of subjectso Consistency of attendance of teacherso Consistency of attendance of learners Learning experience in Outpatients – quantity/ quality Awareness of study leave support for trainees Experienced of undue pressure or bullying Opportunities to learn from, or with, professionals other than doctorsAreas for exploration with Training Programme Directors Induction of new entrants to Specialty training in the locality Allocation of Educational Supervisors to trainees How trainees are supported in their learning needs in each year How teaching time is managed and organised Study leave arrangements for trainees CPD arrangements for trainers Trainee voice in LFG and LAB Process for implementation of trainee recommendations and examples of it Support for LFG Accreditation and reaccreditation of Educational Supervisors Provision of OOH experienceAreas for exploration with GP Trainers on the Local Specialty Faculty Group [if appropriate] Processes for induction for GP trainees when they come to the Practice in their ST1 year Process for induction for GP trainees when they come to the Practice for their ST3 year Study leave process for trainees in the hospital posts (the days in GP) How GP trainees are involved in audit in their GP placements How other professionals are involved in the teaching of GP trainees in the Practice and how they aremonitored Deanery support processes for trainer support and continuing professional development as GPeducators Provision of OOH experience

Domain 7 - Management of Education and TrainingAreas for exploration with Trust How well embedded the LFG and LAB processes are How issues from the LAB are communicated to Specialty LFG and Specialty trainees Effectiveness of communication between consultant Educational / Clinical Supervisors and SpecialtyProgramme Directors How GP is represented on other specialty LFGs Responses to the outcomes of the GMC survey Processes for identifying and supporting trainees whose conduct, health, progress or performancegive cause for concern, with examplesDomain 8 - Educational resources and capacityAreas for exploration with trainees Appropriateness of learning opportunities and experience required for your specialty training Training or educational support from non-doctors Enough Supervisors (consultants, middle grades, and other professionals) to provide appropriatelevels of educational support Information resources: library internet access to portfolio / ePortfolio Perception of the learning environment in the Specialty/ LEPDomain 9 - OutcomesAreas for exploration with Faculty and LEP How identify a relationship between the GMC standards and the outcomes achieved by Specialtytrainees? How do these outcomes feed back into changes for development of education and training forSpecialty trainees and how are these shared?Areas for exploration with trainees Any information about the educational outcomes for doctors in the specialty training programme here(e.g. numbers of doctors achieving satisfactory outcomes at ARCP)?

Overview of the role of the Lead Visitor on KSS VisitsThis document is intended to provide you with a brief overview of your responsibilities as a leadvisitor on a KSS visit to a Local Education Provider (LEP). It should be read in conjunction with theLEP Visiting Procedure (document no. QMV-PRO-001).Pre-VisitIt is the lead visitor’s responsibility to check that each member of the visiting team is prepared forthe visit. You should contact all members of the team a few days before the visit to ensure theyhave read the bundle of documents and made notes on the Visiting Team Pro Forma. You shouldread these notes (sent to all visitors by the Quality Department) in advance of the visit in order toidentify areas requiring further investigation, which can be followed up on the visit.Visiting Team BriefingThe first session of the day is the visiting team briefing, a half-hour meeting. You need to check allthe team have arrived and ask them to introduce themselves. Then go through the key issues thatpeople have picked up from the bundle and discuss the particular concerns they wish toinvestigate. It is helpful to allocate specific areas of questioning to visiting team members.You should run through the timetable to ensure everyone is aware of what happens in eachsession. There is one mistake that has been made a few times in the past; following the sessionwith the trainees, there is a session with the faculty groups. This has sometimes turned into afeedback session, with the visitors feeding back to the consultants the issues raised by thetrainees. Whilst the purpose of this session is to discuss the key issues arising from discussionswith trainees together with issues identified from the bundle, the aim is to obtain the trainers’ viewsand experiences of training-related issues. This session should not involve any direct feedbackfrom the trainee session, which has the potential to breach confidentiality. You will need to makesure the other visitors are aware of this before the start of the visit.Meeting the Trainers and TraineesAt the opening meeting with the faculty leads, you should ask everyone to introduce themselves,and give a brief overview of the visit. Make sure the faculty leads understand the process, andcheck if they have any initial concerns. You need to make it clear that it is not an ‘inspection’ but asupportive process to help them identify any areas of concern that need improving in order to meetthe GMC standards. Let them know that it is also an opportunity for them to highlight areas ofnotable practice. At this first session, ask the DME if he will be giving a presentation (this isoptional, but most LEPs choose to do so). You should ask him to keep the presentation brief, nomore than 10 minutes.It is usual for the lead visitor to start the questioning for each session and to bring in the othervisitors where appropriate, ensuring everyone has the opportunity to explore any issues. It isimportant in the trainee session to make sure the trainees understand why they are there, and toreassure them that the discussions are in confidence and no-one will be identified by theircomments. You should ensure they are all encouraged to speak openly, and also give them theopportunity to speak with any of the visitors privately if they wish.

Visiting Team ReviewAfter the session with the faculty group, the visiting team members will meet to discuss theirfindings. You should note these (as brief bullet points) on the headline feedback form, or you canask the visit secretary (usually a member of the KSS Workforce Team) to do it. The reason wehave started to use this form is that there have been times in the past where LEPs havecomplained that a particular issue was not mentioned at the feedback session, but later appearedin the visit report. This provides us with a record of the points that were covered.Feedback SessionAt the feedback session, you should thank the LEP representatives for their time, and make sureyou highlight all the positives as well as the areas where improvement is necessary. Tell the LEPrepresentatives when to expect the draft report, which will be sent to the DME for a factualaccuracy check. The DME should receive this within a week of the visit. The final report needs tobe signed off by the KSS Quality Management Steering Group, which meets monthly. The finalreport will be sent to the LEP within 2 or 3 days of the Steering Group meeting.If there are any patient or trainee safety issues, which require immediate action, these must becommunicated to the LEP, entered in the relevant section of the feedback form and reportedstraight away to the Dean Director, who will contact the Trust’s CEO.The headline feedback form should be signed by you and the LEP CEO (or senior representative)at the end of the feedback session and then photocopied. One copy should be left with the LEPand the other returned to the Quality Team at the Deanery.Writing the ReportAfter the feedback session, the visiting team will write the first draft of the report on the visit reporttemplate. The visit secretary will have populated some of the report throughout the day, but thelead visitor is responsible for ensuring each issue is captured and entered under the correctdomain. Make sure all members of the visiting team contribute to the report. One thing toremember is that section 2 of the report (the main body of the report) should describe all thefindings, but the visitors’ recommendations, requirements and comments on notable practiceshould not appear in this section. These should be listed in sections 3, 4 and 5. Don’t worry toomuch about the deadlines, as these are likely to be changed or added at the Steering Groupmeeting, but if you decide something must be done immediately, this must be stated. Therecommendations and mandatory requirements should be referenced back to section 2 of thereport, and in the case of the mandatory requirements, should also be referenced to the relevantGMC standards (set out in The Trainee Doctor).Post-VisitAfter the visit, the visit secretary will type the report with the correct formatting and send it to youand the rest of the visitors for comments/approval, then send the final approved draft to the QualityTeam. The Quality Manager will check through the report and make any minor amendments asnecessary to correct errors and ensure consistency of numbering and formatting, then forward it tothe DME for a factual accuracy check. The Associate Dean for Quality will check the report toensure consistency with other reports in terms of domains, mandatory requirements andrecommendations, and will make any necessary amendments. Any significant amendments will bereferred back to you for approval.

The report will then go to the next meeting of the Quality Management Steering Group. You shouldattend this meeting in order to discuss the report. If you are unable to attend, it is likely thatchanges will be made to the report in your absence; however, if any significant queries are raisedthat require your input, the Quality Manager will need to contact you to request clarification. Thiscauses unnecessary delays in processing the report, so it is important that you attend this meetingif possible.Once approved, the final report will be signed by the Dean Director and sent to the LEP. You willreceive a copy of the final report.The LEP response to the mandatory requirements will be reviewed by the Steering Group. If theresponse is not straightforward, you will be asked to give your approval or otherwise in advance ofthe meeting if you are unable to attend. In this case, the Quality Manager will contact you with thedetails, etc. You will receive a copy of the final sign-off letter once all the requirements have beenmet.Karen Gibson, Quality Manager, KSS Deanery, November 2011.

Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT OF SPECIALTY TRAININGVISIT FEEDBACK FORMThank you for hosting a KSS Deanery Quality Management Visit. This form will be used byKSS Deanery to assist in evaluating our quality practices. We are dedicated to ensuring thatour processes are robust and effective, as well as to making the visit experience a positiveand productive one for everyone involved. Your comments will help us examine what workedand what didn’t, and give us ideas for any future changes or improvements to the visitingprocess. We will keep these forms confidential and anonymise any excerpts we may use inthe future. We appreciate your feedback.Local Education Provider:Date of Visit:Name of person providing feedback:Position within LEP:Once you have received the final report, please complete this form and return it to:quality@kssdeanery.ac.uk

Please put a X in the appropriate box after each of the following statements:Section 1: Pre-visitStrongly agreeAgreeNeither agreenor disagreeDisagreeStronglydisagreeNot applicable1. The pre-visit information was informative anduseful.2. The timing of the visit was appropriate.3. Any questions I had regarding the visit wereanswered promptly and satisfactorily.4. I knew who to contact at the Deanery forparticular issues or queries.5. We were informed of the visit date and thespecialties to be visited well in advance of thevisit.6. It was clear which evidence would be used bythe visit team to inform the visit.7. I had positive interactions with Deanery staffwhile organising the visit.Additional comments regarding the pre-visit process:

Section 2: The VisitStrongly agreeAgreeNeither agreenor disagreeDisagreeStronglydisagreeNot applicable1. There were no difficulties hosting the visitingteam.2. I had confidence in the visiting team’sunderstanding of the LEP and its qualitymanagement systems.3. The visiting team seemed to listen to ourcontributions.4. The visiting team members conductedthemselves in a professional and appropriatemanner throughout the visit.5. The visiting team was an appropriate size.6. I was confident in the Lead Visitor’s ability tofacilitate the visit.7. At the conclusion of the visit, I felt that it hadbeen a positive experience.Additional comments regarding the visit itself:

Section 3: Post-visitStrongly agreeAgreeNeither agreenor disagreeDisagreeStronglydisagreeNot applicable1. The visit report form is fit-for-purpose.2. The visit report adequately reflected thediscussion that took place during the visit.3. There were no surprises present in the draftreport.4. We were given the opportunity to check thedraft report for factual accuracy.5. The report was sent at the time promised.6. The mandatory requirements andrecommendations were clear and concise.7. The mandatory requirements andrecommendations had appropriate deadlines.Additional comments on the visit report or on post-visit activities:

Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT OF SPECIALTY TRAININGVISITOR FEEDBACK FORMThank you for taking part in a Quality Management Visit to a Local Education Provider onbehalf of KSS Deanery. This form will be used by KSS Deanery to assist in evaluating ourquality practices. We are dedicated to ensuring that our processes are robust and effective,as well as to making the visit experience a positive and productive one for everyoneinvolved. Your comments will help us examine what worked and what didn’t, and give usideas for any future changes or improvements to the visiting process. We will keep theseforms confidential and anonymise any excerpts we may use in the future. We appreciateyour feedback.Local Education Provider Visited:Date of Visit:Name of person providing feedback:Job Title:Please return to:quality@kssdeanery.ac.ukPlease put a X in the appropriate box after each of the following statements:

Section 1: Pre-visitStrongly agreeAgreeNeither agreenor disagreeDisagreeStronglydisagreeNot applicable1. The timing of the visit was appropriate.2. Any questions I had regarding the visit wereanswered promptly and satisfactorily.3. I knew who to contact at the Deanery forparticular issues or queries.4. I was informed of the visit date and thespecialties to be visited well in advance of thevisit.5. The email with the website link to the bundlewas received in good time for the visit.6. The content of the website was clear andinformative.7. The visit pro formas were clear and easy touse.8. The timetable was appropriate for the visit.9. The address/directions/maps were clear andaccurate.10. The website was easy to use, and theinstructions were clear and easy to understand.Additional comments regarding the pre-visit process:

Section 2: The VisitStrongly agreeAgreeNeither agreenor disagreeDisagreeStronglydisagreeNot applicable1. I had no problems parking at the Trust.2. I had confidence in my fellow visitors’understanding of the LEP and its qualitymanagement systems.3. I was confident in the Lead Visitor’s ability tofacilitate the visit.4. The visit team was an appropriate size.5. The meeting rooms were an appropriate size.6. The MEM and other staff at the Trust ensuredall ran smoothly.7. All stakeholders conducted themselves in aprofessional and appropriate manner throughoutthe visit.8. At the conclusion of the visit, I felt that it hadbeen a positive experience.Additional comments regarding the visit itself:

Section 3: Post-visitStrongly agreeAgreeNeither agreenor disagreeDisagreeStronglydisagreeNot applicable1. The visit report form was fit-for-purpose andeasy to complete.2. I was given the opportunity to contribute to thefinal report.3. The visit report reflected accurately thediscussion that took place during the visit.4. The visit report reflected the views of allmembers of the visiting team.Additional comments on the visit report or on post-visit activities:

Doc Ref: QMV-FOR-001Version 1.2Human Resources DepartmentLEP Visitor Guidance & Declaration1. IntroductionThis guidance is intended to clarify the confidentiality requirements of visitors involved in qualityvisits to Local Education Providers (LEP) within Kent, Surrey and Sussex.2. ScopeThe guidance relates to the full visiting panel, who will be expected to read this guidance andthe KSS LEP Visiting Procedure before confirming their agreement to the requirements outlinedwithin this guidance document and the KSS LEP Visiting Procedure.3. TrainingPotential future visitors without previous visiting experience will be expected to attend trainingsessions organised by KSS before they can participate in a visit. Alternatively they may be invited toattend QM visits in an observational capacity in order to gain experience of visits. In this case theywill be provided with the teaching material used in the formal training sessions. Visitors with previousexperience of visiting elsewhere will be expected to familiarise themselves with the KSS visitingprocess before the visit. Visitors will be expected to confirm that they have read the KSS LEP VisitingProcedure before signing the below declaration.4. Information GovernanceVisitors will also receive information in a variety of formats. Visitors will be expected to maintainthe confidentiality of all information related to visits and only use the information received for thispurpose. Visitors will be expected to arrange for the appropriate destruction of visit materials viaconfidential waste disposal or by returning information to the relevant visit secretary.5. Role and Requirements of VisitorsThe role involves visitors seeking to gather evidence-based information that will be used toexpress an opinion on the LEP’s ability to ensure that the curriculum is being delivered byqualified trainers to all trainees within the LEP. This will involve verifying that robust qualitycontrol processes are in place and are followed, which allow for doctors to be trained in anenvironment that provides for their needs and consequently benefits patients.

During the visit, the visitors will interview trainees and trainers in order to gather additionalinformation about the training environment and curriculum delivery, triangulate this with othersources of data such as the GMC Surveys, previous visit reports, etc. It is essential that thetrainees and trainers feel confident that the information they communicate will be handledappropriately and confidentially.A single report will be produced as a consequence of the visit, which will be agreed by allvisitors. The report is subsequently signed off by the KSS Quality Management Steering Group,after which it can be shared with other professional organisations as appropriate. Since thisprocess has been publicised and agreed with LEPs, it is essential that visitors do not producesupplementary reports or other documents that make reference to the visit, without the expresspermission of the Dean Director of KSS Deanery. Any concerns should be raised as part of thevisiting process.Visitors are required to sign the below page to confirm acceptance of the requirements outlinedabove.2

QUALITY MANAGEMENT VISITOR DECLARATIONPlease complete this reply slip and return it to the KSS Deanery Quality ManagementDepartment, either by post: 7 Bermondsey Street, London SE1 2DD, or by email:quality@kssdeanery.ac.ukI have signed below to confirm my acceptance of the requirements stated in the LEP VisitorGuidance & Declaration (QMV-FOR-001) and the requirements covered in the KSS LEPVisiting Procedure (QMV-PRO-001).I understand that I am required to comply with the confidentiality requirement, which preventsme from producing a separate report or other related documentation that relates to the LEP visitin which I have participated on behalf of KSS Deanery, without the express permission of theDean Director of KSS Deanery.Signed forms will be held on file by the KSS Quality Management Department and may bereviewed by nominated Deanery representatives involved in the Quality Management visitingprocess.Signature:Full Name:Role/Post Title:Date:…………………………………………………………………………….…………………………………………………………………………….…………………………………………………………………………….…………………………………………………………………………….3

South Thames Foundation SchoolQUALITY MANAGEMENT OF FOUNDATION TRAINING IN KSSFOUNDATION FACULTY VISITING PROCESS 2010-20131. INTRODUCTIONThe GMC has defined a framework for the quality assurance of the FoundationProgramme (QAFP). The South Thames Foundation School, on behalf of KSS Deanery,will need to ensure within this framework that there is a clear set of standards for trainersand training environments and that evidence of educational delivery is shared.Local foundation faculty groups will be expected to review and maintain the qualitystandards of foundation training within the LEP and STFS will undertake to verify andvalidate the process of local quality control.Any queries regarding this process or foundation quality issues should be directed toquality@stfs.org.uk2. FOUNDATION DOCTOR ANNUAL QUESTIONNAIREFoundation doctors will be required to complete a short questionnaire (appendix A)during November. The questionnaire is located within the foundation e-portfolio.LEPs will be responsible for ensuring completion of the questionnaire by all F1 andF2 doctors by the beginning of December. It is estimated that the form should onlytake approximately 10-15 minutes to complete. A questionnaire response rate of lessthan 70% may prompt the visiting team to raise this as an item for discussion duringthe visit.LEPs will be able to download a summary of local responses via the e-portfolio. LEPs willbe responsible for circulating the results of the questionnaire to local F1/F2 doctors.The responses will be reviewed by the STFS Director/Associate Directors for any issuesof major concern which may require an earlier than scheduled visit (see 3). A summary ofthe responses from the relevant LEP will also be included in the visiting team pre-visitdocumentation (see 5).3. VISITING CYCLESTFS visiting teams will usually visit all KSS LEPs providing foundation trainingprogrammes on a three-year cycle (see appendix B). If, however, the results of theannual trainee questionnaire indicate that there are any issues of major concern thenSTFS reserves the right to schedule an earlier visit. If an earlier visit is required, the LEPwill be notified of this by early February and the visit will usually take place in May.

4. STFS VISITING TEAMSMinimum RequirementVisitorSTFS Director/Associate DirectorA member of the KSS EducationDepartmentSTFS Manager/AdministratorDesirable If availableFoundation doctor representativeService representative (e.g. DME/MEM from another LEP)External visitorKSS Associate DeanDeanery Quality ManagerResponsibilityLead visitorBroader clinical context.Reporting systems and processes.Signing-off the visit report.Curriculum, teacher education,supervision, learning resources,foundation doctor education experience.Administrative context. Provision of adminsupport including preparing the report inconsultation with the lead visitorFoundation doctor context/voiceBroader management and administrativeaspects, including resource.ExternalityLocal patch issuesCo-ordination of visits and documentation5. PRE-VISIT DOCUMENTATION – “The Bundle”The following written information will be collated by the STFS quality administrator fromthe information already held centrally by KSS/STFS. It will be sent to the LEP (DME &MEM) 10 weeks in advance of the visit together with an LEP self-assessment whichshould be completed and returned within 3-weeks. The bundle, including the completedself-assessment, will be sent to the visiting team no later than 6 weeks before the visit.DocSource1 Quality Management of Foundation Training in KSS Foundation STFSFaculty Visiting Process 2010-20132 Contract Review – background, management audit & action plan Education Dept3 Local foundation faculty handbook STFS4 Most recent LFG annual audit and review STFS5 Minutes of 3 most recent local academic board meetings. STFS6 Minutes of 3 most recent local foundation faculty group meetings. STFS7 National trainee survey data STFS8 Previous foundation faculty visit report STFS9 Summary of responses to the annual trainee questionnaire STFS10 LEP self-assessment STFSThe visiting team will review this documentation and note any areas of concern on a proforma. Each visitor will return their pro forma to the STFS quality administrator within 2weeks of dispatch and responses will then be forwarded to the lead visitor within 2 weeksof the visit. The faculty may be required to provide further information prior to the visit onany areas or issues that emerge from the pre-visit documentation.

6. VISITING TEAM TRAININGTeam members will be expected to be familiar with the following documentation referenceto which will be included in the training:1. GMC The Trainee Doctorhttp://kssdeanery.org/search/apachesolr_search/the%20trainee%20doctor2. GMC Outcomes for Full Registrationhttp://www.gmcuk.org/Outcomes_to_be_demonstrated_by_provisionally_registered_doctors_F1.pdf_26990221.pdf3. Foundation Programme Curriculumhttp://www.foundationprogramme.nhs.uk/download.asp?file=Foundation_Curriculum_2011_WEB.pdfhttp://www.foundationprogramme.nhs.uk/download.asp?file=Key_changes_to_the_FP_Curriculum_and_FP_Reference_Guide_FINAL.pdf4. Foundation Programme Reference Guidehttp://www.foundationprogramme.nhs.uk/download.asp?file=Reference_Guide_WEB.PDFhttp://www.foundationprogramme.nhs.uk/download.asp?file=Key_changes_to_the_FP_Curriculum_and_FP_Reference_Guide_FINAL.pdf5. Foundation Programme e-Portfoliohttps://www.nhseportfolios.org/Anon/AboutUs.aspx6. KSS Graduate Education & Assessment Regulations (GEAR)A hard copy is available from the KSS Education Department.7. STFS Policies/Procedures –See STFS Website – http://www.stfs.org.uk/key-documents-localIn particular:a. Foundation Doctor Role and Minimum Requirements for ClinicalSupervisionb. Delivery of the Foundation Programme Curriculum through Formal TeachingProgrammeVisitors will have attended a previous visit in an observer capacity before activelyparticipating as a visitor.On the morning of the visit, the lead visitor will provide a 30-minute briefing/trainingsession to the visiting team which will include:• the aims of the dayo Identify & explore patient/trainee safety issueso Qualitative assessment of the trainee experienceo Exploration with trainers of any concerns raised by themo Identification of areas of faculty development and training environmentneeds• brief review of the documentation• identify the main issues to discuss/clarify• agree on the distribution of questioning with appropriate regard for theexperience of different members of the team7. VISIT TIMETABLEThe visit will include structured focus group discussions with:• Foundation doctors• Hospital faculty leads (DME, Clinical Tutor, MEM)

• Foundation training programme directors• Educational supervisorsDuring the visit the visiting team will triangulate the documentary evidence usinginterviews with foundation doctors and those delivering and facilitating the training.Time Session Required9:30 Visiting team meet and final briefing Visiting team10:00 – 10:30 Meet faculty to discuss facultyDME/CT/FTPD/MEMdevelopment10:30 – 11:45 Meet F1 doctors 1 As many F1s as possible(ideally including a rep fromeach specialty) 211:55 – 13:10 Meet F2 doctors 1 As many F2s as possible(ideally including a rep fromeach specialty) 213:10 – 13:40 LUNCH -13:40 – 14:40 Meet focus group ofFTPDs/educationalhospital faculty leads/foundation supervisors (rep fromprogramme directors/educational each dept if possible)supervisors14:45 – 16:00 Collate information and prepare feedback Visiting team16:00 Feedback session LEP Chief Executive/DME/MEM/Medical Director/ FTPD# Tea/coffee to be available at all sessions12If a foundation doctor wishes to speak to someone confidentially about anyissues/concerns they will be offered an appointment to see the STFSDirector/Associate Director.Minimum 50% of all foundation doctors to attend.Local LEP administrative staff will be responsible for arranging appropriateaccommodation and refreshments for the visit. They will also arrange for staff/foundation doctors to attend the relevant sessions.Brief verbal feedback will be given to the LEP CEO and DME and other relevant staff atthe end of the day. Any areas requiring an immediate response will be communicated tothe LEP CEO, DME and KSS Dean Director by the lead visitor via e-mail by the end ofthe following day.8. VISIT REPORTA draft written report will be produced by the lead visitor working with the relevant STFSmanager/administrator within two weeks of the visit for the DME to check for factualaccuracy. Once agreed, the final draft will be considered by the next scheduled monthlymeeting of the KSS Quality Management Steering Group and, once signed off, the reportwill be formally sent to the LEP within one week.The outcome of the process will be to deliver a report highlighting examples of notablepractice and the sharing of that, and mandatory and desirable developmental areas withtime-limited action points.

The subsequent response to this report will be delivered by the local faculty group andlocal academic board for consideration by the KSS Deanery Quality Management Group.The report will also be available to the GMC when required for their quality assuranceprocess.9. SUMMARY OF THE PROCESS10 weeks in advance of the VisitBundle, questionnaire results and LEP self-assessment issued to LEP7 weeks in advance of the VisitLEP self-assessment to be returned. Confirmation of visit day arrangements to beprovided to STFS quality administrator.6 weeks in advance of the VisitBundle sent to visiting team4 weeks in advance of the VisitVisitors return visitor pro-formas to STFS quality administrator2 weeks in advance of the VisitSTFS quality administrator forwards visiting team pro formas to lead visitorVisitBy the end of the day following the VisitLead visitor advises LEP CEO and DME of any areas requiring immediate responseWithin 2 weeks of the VisitDraft report provided to the LEPNext scheduled monthly meeting of QMSGConsiders draft reportWithin 1 week of QMSG approving draft reportFinal report provided to the LEP with deadline for response to recommendations

Next Scheduled meeting of QMSGConsiders LEP response to recommendationsWithin 1 week of QMSG considering response to recommendationsLetter to trust confirming satisfactory response or additional action required10. EXCEPTION VISITSException visits are visits to local education providers that are outside of the normalfoundation faculty visit cycle.They may be initiated because of:• A serious clinical incident which may or may not have involved a trainee butmight have implications for training.• A serious trainee complaint either directly to the Deanery/STFS, or via aKSS/London Specialty School which raises a serious question about currenttraining that cannot be managed through usual mechanisms.• Evidence from any other source which raises serious questions aboutpotential service problems which could affect trainees.• Concerns arising from the STFS foundation doctor annual questionnaire.Process• Issues arising will be discussed by the Dean Director and the STFS Director.• If there is evidence of serious concern the Dean Director will make a decisionfor a Deanery visit and will inform the next meeting of the QualityManagement Steering Group.• It there is a more complex or chronic problem or there are other factors to betaken into account and it is less pressing, the matter will usually be discussedat the Quality Management Steering Group before a decision is made.• Exception visits will usually follow a similar process to that described above,however, an external/lay representative will be required to join the visitingteam.• The report will come to the Quality Management Steering Group fordiscussion and approval of action, following which the Dean Director will writeto the Chief Executive of the LEP.• The response of the LEP will be followed up and discussed at the QualityManagement Steering Group until adequate evidence of resolution isprovided.• Where serious problems cannot be resolved it will be normal to approach theGMC for a trigger visit.

• If at any stage serious problems are uncovered which put trainees or patientsat risk, the Dean Director will take immediate executive action.

Appendix ASouth Thames Foundation SchoolFOUNDATION DOCTOR ANNUAL QUESTIONNAIRE (KSS)1. Grade (F1/F2)F1F22. Which rotation are you in?1234Induction3. Did you receive a contract, terms and conditions, banding notification and job descriptionwithin the first 6 weeks (or earlier) of starting in the trust?YesNo4. Did you receive an induction into your local foundation training programme?YesNo5. Did you receive an up to date job description for your current post?YesNo6a. Did you receive a local foundation faculty handbook?YesNo6b. If yes, how would you rate the usefulness of the handbook? (If no, please mark "N/A")ExcellentGoodAveragePoorN/A7. Please rate your induction to the hospital/trust.ExcellentGoodAveragePoorDid not happen8. Did you have the opportunity to shadow staff before starting your post in August?YesNo9. On the first day with your current firm, please rate your induction to your patients, otherstaff, duties and health and safety procedures.ExcellentGoodwww.stfs.org.ukPage 1 of 7Updated: Jan 2011

AveragePoorDid not happen10. Did you meet your clinical supervisor to discuss your duties in the post, expectations ofyour progress etc. within the first 2 weeks of starting?YesNoSupervision & Support11. How would you rate the day-to-day level of supervision you receive from your consultant(clinical supervision)?ExcellentGoodAdequatePoor12. Do you receive frequent constructive feedback on your clinical performance?YesNo13. Do you know who your educational supervisor is?YesNo14. Did you meet with your educational supervisor to agree educational objectives within thefirst 2 weeks of starting your post?YesNo15. How many formal meetings have you had with your educational supervisor?01-34-78-1112+16. Do you know who to approach if you are experiencing problems with your work ortraining?YesNo17. Have you had problems identifying/encouraging sufficient numbers of staff to allow youto complete your foundation ePortfolio?YesNo18. Have you received, or been offered, support with your career decision making?YesNoFeedback19. Do you know who your foundation trainee representative is on the trust faculty group?YesNowww.stfs.org.ukPage 2 of 7Updated: Jan 2011

20. How would you rate the level of communication you receive from South ThamesFoundation School?ExcellentGoodAveragePoorHours21. How often do you estimate you work over your contracted hours?NeverRarelyMost monthsMost weeksDailySafety22. Is there a formal hand-over period in the evening supervised by a registrar or consultant?YesNo23a. Have you ever been asked to do anything which you felt was above your competence?YesNo23b. If yes, did you question this? (If no to 23a, please mark "N/A")YesNoN/A23c. If yes to 23a, did you complete the task? (If no to 23a, please mark "N/A")YesNoN/A24. Have you ever been expected to cope alone beyond your knowledge and experience?YesNo25. Have you ever obtained consent for a procedure with which you were unfamiliar?YesNo26a. F1 ONLY - Have you ever prescribed, transcribed or administered cytotoxic drugs orimmunosuppresants (excluding corticosteroids)?(If F2, please mark "N/A")YesNoN/A26b. F2 ONLY - Have you ever initiated or administered cytotoxic drugs orimmunosuppresants (excluding corticosteriods)?(If F1, please mark "N/A")YesNoN/A26c. F2 ONLY - If yes to 26b, had you been trained in the relevant procedure?www.stfs.org.ukPage 3 of 7Updated: Jan 2011

(If F1 or no to 26b, please mark "N/A")YesNoN/A27. Have you been asked to site mark a patient without appropriate prior training (surgicalposts only)?YesNoN/A28. When help is required, is it easily available?YesNo29. On the whole, how would you rate the level of work intensity with your current rotation?Too highHigh but manageableAverageLow but adequateToo lowTeaching & Learning30. Are there foundation specific (weekly) formal education sessions for you as a foundationdoctor?YesNo31. If yes, are they bleep free? (If no to 30, please mark "N/A")YesNoN/A32. Are you able to easily attend foundation specific teaching other than when you are oncall,on nights or on leave?YesNo33. Do you usually receive 3 hours of protected teaching time for educational activity eachweek? (Protected time refers to the release of foundation doctors from their clinicalresponsibilities)YesNo34. On the whole, how would you rate the quality and usefulness of formal educationsessions?ExcellentGoodAveragePoorFor the following staff, how would you rate the informal teaching you receive e.g.discussions/teaching at bedside, in theatre, in clinics etc. either by instruction, feedback ordiscussion around cases?35. ConsultantsExcellentGoodwww.stfs.org.ukPage 4 of 7Updated: Jan 2011

AveragePoorNone36. GPs (if applicable)ExcellentGoodAveragePoorNone37. RegistrarsExcellentGoodAveragePoorNone38. ST/Trust-grade/Staff-grade/Associate Specialist levelExcellentGoodAveragePoorNone39. Other medical professionals e.g. nurses, pharmacists etc.ExcellentGoodAveragePoorNone40. Have you received teaching/training in equality & diversity?YesNoEducational Environment41a. Have you ever been subjected to any forms of discrimination, bullying or harassment?YesNo41b. If yes, please indicate by whom.ConsultantGPSpRNurseManagerOther41c.If yes, how did you follow this through? (If no, please mark "N/A")Formal complaintInformal complaintDiscussion with individualDid not take actionN/A42. Are you regularly seeing and assessing acute ill patients admitted via A&E?Yeswww.stfs.org.ukPage 5 of 7Updated: Jan 2011

No43. How many outpatient clinics have you attended?01-34-78-1112+N/A44. How many theatre sessions have you attended? (surgical posts only)01-34-78-1112+N/A45. How many pre-assessment/pre-clerking clinics have you attended? (surgical posts only)01-34-78-1112+N/A46. How would you rate the clinical experience you are gaining in this post?ExcellentGoodAveragePoorFacilities47. How would you rate the phlebotomy service?ExcellentGoodAveragePoor48. Is there a weekend phlebotomy service?YesNo49. How would you rate the radiology service?ExcellentGoodAveragePoor50. How would you rate the laboratory services?ExcellentGoodAveragePoor51. Do you know where your postgraduate centre is?YesNowww.stfs.org.ukPage 6 of 7Updated: Jan 2011

52. Do you have easy access to a networked computer which you can use for onlinelearning, research and access to relevant websites?YesNo53. How would you rate the service provided by the postgraduate education centre?ExcellentGoodAveragePoor54. How would you rate the library resources and services for your learning requirements?ExcellentGoodAveragePoorOverall55. STFS/KSS Deanery welcomes any feedback and comments from all trainees. If you feelthere is anything we have not covered in this questionnaire or you would like to raise anyspecific issues, please complete the comments box below.www.stfs.org.ukPage 7 of 7Updated: Jan 2011

Appendix BFoundation Faculty Visit Schedule 2010-13TrustMaidstone and Tunbridge Wells NHS TrustRoyal Surrey County Hospital NHS Trust, TheDartford & Gravesham NHS TrustEast Sussex Hospitals NHS TrustDate of Visit08-Mar-1124-Mar-1101-Apr-1114-Feb-12Ashford & St Peter's Hospitals NHS Foundation Trust 07-Feb-12Surrey and Sussex Healthcare NHS TrustBrighton and Sussex University Hospitals NHS TrustMedway NHS Foundation TrustWestern Sussex Hospitals NHS TrustDeferred201324-Apr-1204-Feb-1311-Mar-13East Kent Hospitals University NHS Foundation Trust 16-Apr-13Frimley Park Hospital NHS Foundation Trust30-Apr-13

DOCUMENT CONTROLTitle:Originator:Manager Responsible:Quality management of foundation training in KSSFoundation faculty visiting process 2010-2013Marc Terry, Head of Foundation WorkforceJan Welch, Director, STFSPolicy Number:Version Number:Approving Body:v.1.1KSS Quality Management Steering GroupDate Issued: December 2011Review Date: September 2012Date Equality ImpactAssessed:Legal AdviceRequired/Obtained:Master Location:Publication Scheme:Purpose of document:N/AK:\South Thames Foundation School\QualityManagement\Foundation Visits\KSS\Master DocumentsSTFS e-Update, STFS WebsiteSummarise KSS/STFS process for administering foundationfaculty visiting process.Document HistoryVersion Name Date Revisions/ Outcome1.1 QMSG December 2011 • Section 2update toreflectQuestionnaireincluded in e-portfolio• Section 5updated toinclude LABminutes addedto bundlerequirements• Section 6updated toreflectpublication ofTraineeDoctor0.1 QMSG

South Thames Foundation SchoolCHECKLIST FOR USE DURING DISCUSSIONS WITHF1 DOCTORSName of TrustDate of VisitTo be completed by lead administrator and forwarded to lead visitor in advance of the visitIssueSummary fromTrainee QuestionnaireVisitors supplementary questions1 Hospital Induction –a) Did you have an induction to the hospital when you started work here?inc STFS slidesb) What could be done to improve it?2 Firm Induction a) Did you have an induction to your department (ward, GP surgery etc) when you started?b) Did it give you all the information you needed to start your work? What could be done toimprove it?3 ShadowingDid you have adequate time to spend shadowing the outgoing F1?(F1 only)4 Feedback a) Do you receive regular constructive feedback?5 Educationalsupervision/Assessment/Portfoliosb) Do you receive it if you ask for it?a) Do you know who your Educational Supervisor is?b) Have you had regular meetings with your Educational Supervisor to discuss yourprogress?c) Does he/she look at your portfolio?d) Are you able to get your assessments carried out (e.g. DOPS, mini-cex etc?) If not, whynot? If so who does them for you?6 IT Issues Do you have convenient access to computers with Internet access to be able to access e-portfolio?7 Clinical Supervision a) Do you feel adequately supervised and supported according to your level of experience?b) Who do you ask for clinical advice in the daytime?c) Who do you ask after hours?d) How often do you have consultant ward rounds?e) Do you work nights? If so, is this part of a Hospital at Night team? How does it work?8 Hours Have you been asked to complete diary cards?9 Handover/Competencea) How often have you been asked to undertake tasks beyond your level of competence andwithout supervision?b) What were the tasks?Visitor Noteswww.stfs.org.ukUpdated: 23 February 2012

c) Do you have appropriate middle grade cover?d) How do you hand over the care of your patients to your colleagues?e) Is there a process for handing over the care of patients at the end of the shift?f) Is there time set aside in your timetable for handover?g) How often have you been asked to carry out inappropriate duties? What are theseduties?h) Have you ever lost patients? (e.g. Over the weekend?)10 Consent Have you been asked to take consent for a procedure that you are not able to perform?If yes, how often and who has asked you to do it? What did you do?11 Cytotoxics Do you prescribe or administer cytotoxics?Have you been asked to?12 Site Marking Have you been asked to site mark?13 Teaching a) How much teaching time do you have during the week, other than the generic teachingprogramme?b) What form does it take?c) Is it bleep free?d) Is it useful to you as a Foundation Doctor?e) How often do you attend the generic teaching programme?f) Are you able to get to the sessions without difficulty?g) Do you feel that there is sufficient practical experience available so that you can obtainthe competences in your curriculum?h) How could the education and training content of the programme be improved?i) Is there anything about your training programme which we have not covered that youwould like to tell us about?14 Bullying a) Have you ever been subjected to personal behaviour by others which has eroded yourconfidence?b) Who by?15 Whistleblowing a) How would you feed back your concerns about a colleague who behaved unethically?b) Are you aware of any formal procedure for this?16 Theatre/Opavailability/attendance17 Facilities/ SupportServices18 PostgraduateCentrea) Do you have timetabled sessions when you attend theatre/OP?b) Who covers your ward duties when you attend?a) Where do you access up to date clinical guidelines to which you can refer?b) Can you describe the relationship between Foundation doctors and the Radiologyservices?19 Careers support a) Have you had any careers advice?b) Do you know who your careers advisors are?20 How rate as a placeto work?Would you recommend this particular post you are currently doing to a friend?www.stfs.org.ukUpdated: 23 February 2012

www.stfs.org.ukUpdated: 23 February 2012

South Thames Foundation SchoolCHECKLIST FOR USE DURING DISCUSSIONS WITHF2 DOCTORSName of TrustDate of VisitTo be completed by lead administrator and forwarded to lead visitor in advance of the visitIssueSummary from TraineeQuestionnaireVisitors supplementary questions1 Hospital Induction –a) Did you have an induction to the hospital when you started work here?inc STFS slidesb) What could be done to improve it?2 Firm Induction a) Did you have an induction to your department (ward, GP surgery etc) when youstarted?b) Did it give you all the information you needed to start your work? What could be doneto improve it?3 Feedback a) Do you receive regular constructive feedback?b) Do you receive it if you ask for it?4 Educationalsupervision/Assessment/Portfoliosa) Do you know who your Educational Supervisor is?b) Have you had regular meetings with your Educational Supervisor to discuss yourprogress?c) Does he/she look at your portfolio?d) Are you able to get your assessments carried out (e.g. DOPS, mini-cex etc?) If not,why not? If so who does them for you?5 IT Issues Do you have convenient access to computers with Internet access to be able to access e-portfolio?6 Clinical Supervision a) Do you feel adequately supervised and supported according to your level of experience?b) Who do you ask for clinical advice in the daytime?c) Who do you ask after hours?d) How often do you have consultant ward rounds?e) Do you work nights? If so, is this part of a Hospital at Night team? How does it work?7 Hours Have you been asked to complete diary cards?8 Handover/Competencea) How often have you been asked to undertake tasks beyond your level of competenceand without supervision?b) What were the tasks?c) Do you have appropriate middle grade cover?d) How do you hand over the care of your patients to your colleagues?e) Is there a process for handing over the care of patients at the end of the shift?Visitor Noteswww.stfs.org.ukUpdated: 23 February 2012

f) Is there time set aside in your timetable for handover?g) How often have you been asked to carry out inappropriate duties? What are theseduties?h) Have you ever lost patients? (e.g. Over the weekend?)9 Consent Have you been asked to take consent for a procedure that you are not able to perform?If yes, how often and who has asked you to do it? What did you do?10 Cytotoxics Do you prescribe or administer cytotoxics?Have you been asked to?11 Site Marking Have you been asked to site mark?12 Teaching a) How much teaching time do you have during the week, other than the genericteaching programme?b) What form does it take?c) Is it bleep free?d) Is it useful to you as a Foundation Doctor?e) How often do you attend the generic teaching programme?f) Are you able to get to the sessions without difficulty?g) Do you feel that there is sufficient practical experience available so that you can obtainthe competences in your curriculum?h) How could the education and training content of the programme be improved?i) Is there anything about your training programme which we have not covered that youwould like to tell us about?13 Bullying a) Have you ever been subjected to personal behaviour by others which has erodedyour confidence?b) Who by?14 Whistleblowing a) How would you feed back your concerns about a colleague who behaved unethically?b) Are you aware of any formal procedure for this?15 Theatre/Opavailability/attendance16 Facilities/ SupportServices17 PostgraduateCentrec) Do you have timetabled sessions when you attend theatre/OP?d) Who covers your ward duties when you attend?a) Where do you access up to date clinical guidelines to which you can refer?b) Can you describe the relationship between Foundation doctors and the Radiologyservices?18 Careers support a) Have you had any careers advice?b) Do you know who your careers advisors are?19 How rate as a placeto work?Would you recommend this particular post you are currently doing to a friend?www.stfs.org.ukUpdated: 23 February 2012

South Thames Foundation SchoolCHECKLIST FOR USE DURING DISCUSSIONS WITHFOUNDATION FACULTY (DME, FTPD, MEM)Name of TrustDate of VisitIssue1 How are things in general?Notes2 Any issues that the Faculty would like to bring to the attention ofthe Visiting Team3 Any particular developments that the Faculty would like to bring tothe attention of the Visiting Teamwww.stfs.org.ukUpdated: 23 February 2012

4 Key Issues from the trainee pre-visit questionnaire TO BE COMPLETED BY LEAD ADMINISTRATOR5 General Noteswww.stfs.org.ukUpdated: 23 February 2012

South Thames Foundation SchoolCHECKLIST FOR USE DURING DISCUSSIONS WITHEDUCATIONAL SUPERVISORSName of TrustDate of VisitIssue1 How are things in general?Notes2 Any issues that the ES would like to bring to the attention of theVisiting Team3 Any particular developments that the ES would like to bring to theattention of the Visiting Teamwww.stfs.org.ukUpdated: 23 February 2012

4 Key Issues from the trainee pre-visit questionnaire TO BE COMPLETED BY LEAD ADMINISTRATOR5 General Noteswww.stfs.org.ukUpdated: 23 February 2012

South Thames Foundation SchoolFOUNDATION FACULTY VISITING PROCESSGUIDANCE NOTES FOR LEAD VISITORSIn advance of the visit1. Review the bundle including the summary of trainee feedback2. Review the lead visitor checklists (produced by lead administrator for the visit)3. Review the summary of visiting team pro-formas with the lead administratorOn the day of the visit4. Brief the visiting team regarding the aims of the day which are:• Identify & explore patient/trainee safety issues• Qualitative assessment of the trainee experience• Exploration with trainers of any concerns raised by them• Identification of areas of faculty development and training environmentneedsOutline the timetable for the day5. Circulate the lead visitor checklists and the summary of the visiting team proformas6. As a team, identify the main issues to discuss/clarify7. Agree on the distribution of questioning with appropriate regard for theexperience of different members of the team. It is recommended that the leadvisitor lead the discussions in the meetings with the faculty group, educationalsupervisors and feedback session bringing in the different members of theteam as appropriate.8. Remind all about the confidential nature of the visit (all have signed aconfidentiality agreement).During interviews with Foundation Doctors9. Remind Foundation Doctors that they may arrange a confidential 1:1 with thelead visitor if there are any issues that they would prefer to discuss privately.They should contact the lead administrator via e-mail to arrange either a faceto-faceor telephone interview.Collate Information & prepare feedback10. Visiting Team to agree on which items they are going to feedback on.11. Visiting team to agree items to be included in the report, which domains theyapply to and the requirements/recommendations.12. The Headline Feedback Form (Appendix 1) needs to be completed. Thepurpose of this form is to provide the LEP with a record of the brief headlineverbal feedback given to senior LEP representatives at the end of the visit,and provide KSS with evidence of acknowledgement by the LEP of the mainheadlines arising from the visit. Any areas requiring immediate action by theLEP will be noted on this form and communicated to the senior LEPwww.stfs.org.ukPage 1 of 2Updated: 30 th January 2012

epresentatives. In addition to this, the CEO and DME will be contacted by theKSS Dean Director via e-mail the following day.During Feedback session13. Thank staff for their preparations for the visit as appropriate14. Feedback positives first15. Highlight any patient safety issues that have been identified16. Discuss other areas for improvement/of concern17. Confirm that a draft report will be sent to the DME within 2-wks of the visit toconfirm factual content, will then be approved by KSS Quality ManagementSteering Group and subsequently circulated formally to Chief Executive,Medical Director, DME, FTPDs and MEM.After the Feedback Session18. A copy of the completed and signed Headline feedback form (signed bysenior LEP representative and the Lead Visitor) should be left with the TrustSenior Representative and the original should be forwarded toquality@stfs.org.uk the next day.After the Visit19. Liaise with the lead administrator to draft/agree the report within 2-wks of thevisit.www.stfs.org.ukPage 2 of 2Updated: 30 th January 2012

South Thames Foundation SchoolFOUNDATION FACULTY VISITING PROCESSGUIDANCE NOTES FOR LEAD ADMINISTRATORSIn advance of the visit1. Review the bundle including the summary of trainee feedback2. Populate lead visitor checklists with data from trainee pre-visit questionnaireresults3. Review the summary of visiting team pro-formas with the lead visitor.4. Bring copies of lead visitor checklists and collated visiting team pro-formas formembers of the visiting teamOn the day of the visit5. Make detailed notes of all sessions6. Liaise with local admin staff regarding arrangements for the day7. Contact London Bridge office (020 7188 9590) if any queries8. After the feedback session to the Foundation Faculty, visiting team to agreeitems to be included in the report, which domains they apply to and therequirements/recommendations.9. After the verbal feedback is given The Headline Feedback Form (Appendix 1)needs to be completed. The purpose of this form is to provide the LEP with arecord of the brief headline verbal feedback given to senior LEPrepresentatives at the end of the visit, and provide KSS with evidence ofacknowledgement by the LEP of the main headlines arising from the visit. Anyareas requiring immediate action by the LEP will be noted on this form andcommunicated to the senior LEP representatives. In addition to this, the CEOand DME will be contacted by the KSS Dean Director via e-mail the followingday. A detailed report will follow in line with the KSS LEP Visiting procedure.The report may contain other areas of notable practice and improvement inaddition to those listed.After the Visit10. A copy of the completed and signed Headline feedback form (signed bysenior LEP representative and the Lead Visitor) should be left with the TrustSenior Representative and the original should be forwarded toquality@stfs.org.uk11. Liaise with the Lead Visitor to draft/agree the report using the standard reporttemplate (R:\South Thames Foundation School\QualityManagement\Foundation Visits\KSS\Master Documents\ STFS-KSS DeaneryFoundation Visit Report Template) within 2-wks of the Visit12. Forward draft report to London Bridge Office to send to the DME to confirmfactual contentwww.stfs.org.ukPage 1 of 1Updated: 30 th January 2012

South Thames Foundation SchoolBRIEFING NOTE FOR FOUNDATION FACULTY VISITING TEAMVisit to:Venue:Date of visit:Trust contact:STFS LB Contact:NAME POSITION ORGANISATION CONTACTDETAILSVISITING TEAMOBSERVERSTIMETABLETime Session Required9:30 Visiting team meet and final briefing Visiting team10:00 – 10:30 Meet faculty to discuss faculty development DME/CT/FTPD/MEM10:30 – 11:45 Meet F1 doctors1 As many F1s as possible11:55 – 13:10 Meet F2 doctors1 As many F2s as possible13:10 – 13:40 LUNCH -13:40 – 14:40 Meet focus group ofhospital faculty leads/foundationprogramme directors/educationalsupervisorsFTPDs/educationalsupervisors (rep fromeach dept if possible)14:45 – 16:00 Collate information and prepare feedback Visiting team16:00 Feedback session LEP Chief Executive/DME/MEM/Medical Director/ FTPDNotesAdditional Issueswww.stfs.org.ukPage 1 of 1Updated 18 TH April 2012

Appendix 1Kent, Surrey & Sussex DeaneryQUALITY MANAGEMENT OF SPECIALTY TRAININGLocal Education Provider Specialty Visits - Headline Feedback FormThe purpose of this form is to provide the LEP with a record of the brief headline verbal feedback given tosenior LEP representatives at the end of the visit, and provide KSS with evidence of acknowledgement bythe LEP of the main headlines arising from the visit.Any areas requiring immediate action by the LEP will be noted on this form and communicated to the seniorLEP representatives. In addition to this, the CEO and DME will be contacted by the KSS Dean Director viae-mail by the following day.A detailed report will follow in line with the KSS LEP Visiting Procedure. The report may contain other areasof notable practice and improvement in addition to those listed below.All notes should be entered on this form, which should be signed by the senior LEP representative and theLead Visitor after the verbal feedback is given. Once completed and signed, a copy of the form should beleft with the LEP senior representative, and the original should be forwarded to: quality@stfs.org.ukLEP VisitedDate of VisitAreas of Notable PracticeDomainwww.stfs.org.ukPage 1 of 2Updated: 30 th January 2012

Areas for ImprovementDomainAreas Requiring Immediate Action (Dean Director to be notified immediately)DomainSigned by Lead Visitor and Senior LEP RepresentativePosition Name Signature12www.stfs.org.ukPage 2 of 2Updated: 30 th January 2012

www.stfs.org.ukPage 3 of 2Updated: 30 th January 2012

Version 1.3LOCAL EDUCATION PROVIDER PHARMACY VISITING PROCEDURESThis document describes the procedure for Kent, Surrey and Sussex Postgraduate Deanery(KSS) visits to pharmacy departments in KSS Local Education Providers (LEPs).1. Types of VisitThere are 3 types of visits which may be made to LEPs dependent on the issues and risks:-1. Annual verification and contract review visit2. Developmental visit3. Exception visit1.1. Annual verification and contract reviewThis is an annual process by which the Deanery reviews that the infrastructure to deliver qualitypharmacy education and training is in place. The Deanery outlines a list of quality standardsbased on and mapped to the General Pharmaceutical Council’s Standards for the InitialEducation and Training of Pharmacists. Local Education Providers compile a Quality Manualwhich outlines procedures to ensure these standards are met and evidence to support this.In addition to this LEPs undertake an annual audit and review of their own practice against theGPhC education and training standards.Both the Quality Manual and Annual Audit and Review are submitted to the Deanery at the end ofMarch each year.The Quality Manual content is subsequently checked during a verification visit scheduledbetween April and June. The findings from verification are reported and discussed at thesubsequent Contract Review meeting held in May/ June each year.1.2 A developmental visit will take place when:-:Concerns are raised through trainee surveys either by a majority of trainees orcontinued trends over 2 years or more have not been addressedLEP annual audit and review indicates issues that are not being addressed locallyactions from contract review or annual audit and review remain unactioned over morethan one yearLEP reporting to the Deanery has consistently not occurred eg workforce numbers,identification of trainees in difficulty, trainee attritionThis document was printed on 08/10/2012 at 15:38:23. Before using this document, please ensureyou have the latest version by checking it against the Document Control Log located at: K:\QualityManagement\QM Documents\Master Documents.

consistently low trainee progression or high attritionnon compliance with Deanery: Trust Placement Agreementsthe LEP has requested advice or analysis of local pharmacy education and training(subject to available resources)The process for developmental visits is that the issue arising will be documented by the Head ofPharmacy and a request for a developmental visit sent to the Dean Director. If the need for a visitis agreed the KSSD Associate Dean for Quality and Quality Manager will be informedimmediately and the QMSG at the next meeting.1.3 An exception visit will take place when there is/ are:-a serious trainee complaint which raises a question about current training that cannotbe managed through usual mechanismsConcern over potential patient safety / risk issues that require further investigation egidentified throughooooWhistle blowing / concern raisedLEP annual audit and reviewA serious untoward incident, which may or may not have involved a pharmacytrainee but might have implications for trainingRisks raised through other reporting mechanisms eg compliance with HCAI,aseptic audits that could impact upon the quality of trainingissues identified in a developmental exception visit that have not been resolved inreasonable timescales and need escalation.issues identified as high risk and require a level of clinical externality outside of theDeanery.The process for exception visits is:issues arising will be reviewed by the Dean Director and the Head of PharmacyIf there is evidence of serious concern the Dean Director will make a decision for aDeanery visit and will inform the next meeting of the Quality Management SteeringGroup.if there is a chronic problem or there are other factors to be taken into account and it isless pressing, the matter will usually be discussed at the Quality Management SteeringGroup meeting before a decision is made;if it is decided that an exception visit is required, the Dean Director will inform the LEPCEO and will instruct the QMD and Head of Pharmacy to prepare for a visit.2. Organising the VisitThe KSSD Pharmacy Department will liaise with the Trust Chief Pharmacist to inform them of thelevel of visit and agree a date. The KSSD Pharmacy Dept will ascertain who should take part inthe visit, and will invite them accordingly, making arrangements for travel where necessary. Aseach visitor confirms attendance, the Pharmacy Dept will record and store confirmation andcontact details.2

3. The Visiting TeamThe visiting team will depend on the level of visit.3.1 Verification Visits and Contract ReviewVerification will always be carried out by 2 verifiers. The lead verifier will be a member of theKSSD Pharmacy Department. The second verifier will be either a member of KSSD staff or aPharmacy Educational Programme Director from another LEP. Occasionally an observer will alsobe present – observers will generally be either KSSD staff or EPDs training to be verifiers.Contract Review visits will discuss all aspects of Deanery education i.e. medicine, dentistry,libraries and pharmacy. The Pharmacy representative will be either the Head of Pharmacy or asenior member of the KSSD Pharmacy team registered with the General Pharmaceutical Council.3.2 Developmental visitsA developmental visit team will comprise the following members:VisitorHead of Pharmacy, KSS Deanery1-2 senior KSSD Pharmacy staff.Occasionally other LEP EPDs will act asvisitors dependent on the nature of the visite.g. if they can bring additional specialistexpertise in an area.ResponsibilityLead Visitor. Broad pharmacy context.Reporting systems and processes.Lead for own specialty. Broad practice context.Reporting systems and processes.Occasionally there will be observers who will normally be future visitors in training.3.3. Exception visitsAn exception visit will comprise:-VisitorHead of Pharmacy, KSS Deanery1-2 senior KSSD Pharmacy staff.Occasionally other LEP EPDs will act asvisitors dependent on the nature of the visite.g. if they can bring additional specialistexpertise in an area.Trainee Representative (to be dictated byQMSG)External or Lay Visitor (to be dictated byQMSG)ResponsibilityLead Visitor. Broad pharmacy context.Reporting systems and processes.Lead for own specialty. Broad practice context.Reporting systems and processes.Trainee context / voice.Provide externality.3

4. Visitor TrainingPotential future visitors without previous visiting experience will be expected to attend trainingsessions organised by KSS. In addition they must attend at least one QM visit in an observationalcapacity in order to gain experience of visits. Visitors with previous experience of visitingelsewhere will be expected to familiarise themselves with the KSS visiting procedure before thevisit.All visitors are required to sign the KSS Visitor Guidance and Declaration (QMV-FOR-001) beforetaking part in a visit. This will be sent to each visitor by the KSSD Pharmacy Department who willkeep a record of the signed declarations.5. Role and Requirements of VisitorsThe role involves visitors seeking to gather evidence-based information that will be used toexpress an opinion on the LEP’s ability to ensure that the curriculum is being delivered byqualified trainers to all trainees within the LEP. This will involve verifying that robust qualitycontrol processes are in place and are followed, which allow for pharmacy trainees to be trainedin an environment that provides for their needs and consequently benefits patients.During the visit, the visitors will interview trainees and trainers in order to gather additionalinformation about the training environment and curriculum delivery, triangulate this with othersources of data such as trainee exit data, contract review reports, previous visits, etc. It isessential that the trainees and trainers feel confident that the information they communicate willbe handled appropriately and confidentially.6. ExternalityIn any full exception visit, there must be external input involving ‘independent and impartialadvisers’. External advisers may be registered pharmacy professionals or lay, depending on thearea for advice and/or scrutiny. They must be independent of the Deanery with no conflicts ofinterest. Pharmacy advisers will have expertise appropriate for the programme and will normallybe either experienced Education Programme Directors or Academic Programme Directors.7. Pre-visit ArrangementsThe LEP Pharmacy Education Programme Director will usually be the visit coordinator, acting asthe liaison point between the KSSD Pharmacy and the LEP, disseminating details of the visitwithin the Pharmacy Department. This task will sometimes be delegated to an Assistant Manageror Administrator within the LEP.The KSSD Pharmacy Department will be the single point of control at KSS for any mattersregarding visits. It is essential that all communications regarding visit arrangements between KSSand the LEP go through the Pharmacy Team and the LEP Pharmacy EPD (or nominated visitcoordinator for the LEP).8. Pre-visit Documentation - “The Bundle”Each member of the visiting team is sent an email with a link or attached bundle of documentscomprising information from various sources about the LEP and the specialties being visited.The bundle of documents is collated by the Pharmacy Department at least 3 weeks before a visit.For a verification visit, visitors will be sent :-4

LEP Quality ManualLEP Annual Audit and ReviewContract Review action plan from the previous yearTrainee feedback from the previous yearGuidance on “deep dive” focus for verification where applicableFor developmental and exception visits, a typical bundle will contain the following documents:Contract Review Action PlanLFG Annual Audit and ReviewLast 3 LAB minutes received from TrustLast 3 LFG minutes received from TrustMost recent trainee survey dataBackground to the purpose and reason for the visit9. Visiting Team Pro FormaEvidence for the delivery and support of appropriate education for trainees will be obtained from anumber of sources. The Visiting Team Pro Forma helps the visitors to review the bundle ofdocuments and identify areas where further exploration is required. It is set out under threesections; notable practice, areas of concern and areas for clarification/further investigation. Eachvisitor will be asked to complete a pro forma in advance of the visit and bring it with them on theday.10. GPhC Standards for the initial education and training of pharmacistsThese are the set standards against which the visiting team needs to report, published on theGPhC website. As the visitors review the bundle, they use this document to help them focus onkey areas and ensure adequate coverage of key issues. The GPhC Standards are set out underten Domains:1. Patient and public safety2. Monitoring, review and evaluation of initial education and training3. Equality, diversity and fairness4. Selection of trainees5. Curriculum delivery and the student experience6. Support and development of trainees7. Support and development of academic staff and preregistration tutors8. Management of education and training9. Resources and capacity10. OutcomesIn developmental visits there may be a focus on specific standards and therefore not everystandard might be looked at. In exception visits, all standards will be covered.12. The VisitAt verification visits, the visiting team will focus on verifying that procedures are in place to ensurecompliance with GPhC education standards and that there is evidence to support this. The LEPPharmacy Education & Training Lead must be available throughout the verification visit andshould expect to be part of it. It will also be helpful but not essential for the relevant EducationProgramme Directors eg Preregistration Pharmacist Training Manager, Preregistration PharmacyTechnician Training Lead, NVQ Internal Verifier or PG Diploma EPD to be available if required.5

In developmental and exception visits, the documentary evidence will be triangulated usinginterviews with trainees and those delivering and facilitating the training. The visit will includestructured focus group discussions with:Trainees in hospital postsEducation Programme DirectorsEducational SupervisorsPractice SupervisorsOn the day of the visit, the visiting team should have a private meeting to divide up tasks, gothrough the list of issues identified as being of interest, set rules for the day, refreshunderstanding of the GPhC Domains, and ensure that all are clear about the division ofresponsibilities between members. For example, different team members can lead on askingquestions in different meetings. It is usual for the Lead Visitor to start the questioning and tosummarise where appropriate.At the opening meeting the Lead Visitor should ensure that the LEP understands the visitprocess, is fully aware of the timescales and activities to be undertaken and is clear about theinformation requested. The Lead Visitor should communicate to the LEPs that the visit is anopportunity for them to show how well they are doing as well as to explore matters of particularconcern.13. Meetings with Trainees (Developmental and Exception visits only)The visit timetable should be constructed to include meetings with trainees. The Team should aimto meet a wide range of trainees, including trainees on different placements, trainees in difficulty,etc. Trainees should be assured of confidentiality by the Visiting Team at the beginning of eachmeeting. Trainees should be offered an opportunity to meet any member of the Visiting Teamone-to-one should this be required.14. Meetings with Educational / Practice Supervisors (Developmental and Exception visitsonly)The ESs will usually be seen together as one group. The purpose of these meetings is to discussthe ESs’ experience of training-related issues. Whilst the visitors may wish to explore areasraised during the meetings with the trainees, this session should not include any direct feedbackfrom those meetings.PSs may be seen as a group or occasionally individually if a specific placement is beingreviewed.15. Feedback Preparation MeetingThe Visiting Team will meet in advance of the feedback session to discuss their headlinefindings, both in terms of notable practice and areas for improvement. These should benoted in brief bullet points on the feedback form.The purpose of the feedback form is to provide the LEP with a record of the brief headlineverbal feedback given to senior LEP representatives, and provide KSS with evidence ofacknowledgement by the LEP of the main headlines arising from the visit.The Visiting Team should agree any issues that the LEP has to address immediately, whichwould primarily relate to service issues affecting patient and trainee safety, and note these on thefeedback form. The Visiting Team should ensure that all findings are based on clear evidence.6

16. Feedback SessionAt the end of the visit, brief headline verbal feedback, as encapsulated in the feedback form,will be given to the senior LEP representatives, usually the Chief Pharmacist or PharmacyEPD.Any areas requiring immediate action by the LEP, particularly where patient and/or trainee safetyis compromised, will be communicated to the senior LEP representatives. In addition to this, theCEO will be contacted by the KSS Dean Director via e-mail by the following day.The senior LEP representatives should be informed that the visit report may contain otherareas of notable practice and improvement in addition to those listed on the feedback formand communicated verbally.17. Writing the Visit ReportThe first draft of the visit report should be written by the visiting team, coordinated by the LeadVisitor, immediately following the visit. All members of the visiting team, including lay and externalrepresentatives, are expected to contribute to the KSS visit report, to be agreed by all visitors. Itis essential that visitors do not produce supplementary reports or other documents that makereference to the visit, without the express permission of the Dean Director of KSS Deanery.17.1 Verification reports consist of a checklist of Quality Manual standards as well as notes ofgood practice and issues ro be taken forward and discussed at the forthcoming Contract Reviewmeeting. The report will be sent to the KSSD Education Department for inclusion in the widerbundle of Contract Review documents covering medicine, dentistry, libraries and pharmacy.Contract Review bundles are administered and circulated by the Education Department.Responsibility for the production of the Contract Review report and action plan rests with theKSSD Education Department. The Pharmacy Lead Visitor will be responsible for producing asummary of points agreed in relation to pharmacy which will be included in the report and forchecking its accuracy within the final report. The Education Department will circulate the actionplan to the LEP.17.2 Developmental and Exception visits are recorded on a Visit Report Template, which is setout under the 10 GPhC Domains.The full report must follow the KSS Deanery reporting template and include:the detail of the visit (the name of the LEP, details of the Visiting Team, etc.)the percentage of trainees who attended the visitLEP performance under each Domainspecific examples of notable practicespecific concerns indicating the evidencemandatory requirements for action with details of evidence required and suggesteddeadlines for correctionrecommendations with suggested deadlinesThe content of the draft and final visit reports should include issues encapsulated on theFeedback Form and communicated in verbal feedback.Section 2 of the report (Findings against GPhC Standards) should only contain matters of(reported) fact, and should not include the opinions or suggestions of the visitors. AllMandatory Requirements and Recommendations made in Section 4 of the report will bereferenced back to the findings in section 2.7

The Visit Secretary will circulate the draft report to all members of the visiting team forapproval. The Visit Secretary will amend the draft report as suggested by the visitors andforward it to the Quality Manager no later than 5 working days from the date of the visit.18. Progressing Developmental and Exception Visit ReportsThe Quality Manager will check and amend the report as necessary, and forward to theAssociate Dean for Quality (ADQ) for a consistency check. The ADQ will make anynecessary amendments and return the draft report to the Quality Manager for finalformatting. The draft report will also be sent by KSSD Pharmacy to the Chief Pharmacist andPharmacy EPD for a factual accuracy check. The Chief Pharmacist should receive the draftreport no later than two weeks from the date of the visit.The Quality Manager will submit the report (with any amendments suggested by the ChiefPharmacist) to be reviewed and formally approved at the subsequent meeting of the KSS QMSG,which meets monthly. These meetings are chaired by the Dean Director and attended by the KSSHeads of Schools and Head of Pharmacy.Following approval by the QMSG, the final report will be sent to the CEO (copied to the ChiefPharmacist, Pharmacy EPD and other relevant stakeholders) together with a pre-populatedAction Planning Template, drawn up from the requirements and recommendations in the report,to facilitate the response. The LEP will be asked to complete the action plan as part of theirresponse to the report findings.Final reports will usually be sent out within six weeks of the visit.19. Follow-up and Sign-off19.1 An audit trail of responses to a Contract Review action plan in the form of a tracking chartwill be kept within the KSSD Pharmacy Department and reviewed at 3 monthly intervals. If anaction is not completed, a reminder will be sent. If an action continually remains outstanding, thismay trigger a developmental visit.19.2 An audit trail of responses to the developmental and exception visits, in the form of a“tracking chart” will be kept by the Quality Manager, who ensures that all actions are followed upand all requested evidence is provided to the QMSG.Any change in practice suggested that relates to a mandatory requirement will be followed up bythe QMSG. Recommendations are suggestions that should be considered by the LEP. These arenot followed up by the QMSG; however, the LAB should discuss with the Pharmacy LFG whatactions have been taken on any recommendations. This may then be reported to the QMSG bythe LAB when responding to visit reports and will be discussed and monitored by the relevantKSS School.All responses to mandatory requirements are reviewed and signed off by the QMSG. When allmandatory requirements are met, the Dean Director will confirm this formally in writing to theCEO.Once the report is signed off, the notable practice and mandatory requirements will be publishedon the KSS Deanery website together with the response(s) from the LEP and the formal sign-offdate.8

20. Document ControlTitle: LOC PHARMACY EXCEPTION VISITING PROCEDUREOriginator:Gail Fleming, Head of PharmacyDate Issued: March 2012Review Date: March 20139

Kent, Surrey & Sussex DeaneryAction Plan for Visit Reports - PharmacyLEP Name:Visit Date:The following mandatory requirements relate to the GPhC Standards for Pharmacy Education and Training, and must be addressed by the LEP.All actions to address mandatory requirements will be followed up by the KSS Quality Management Steering Group (QMSG).No. Mandatory Requirements Standard Actions/Evidence Required Deadline Progress Further ActionPlanned123456The following recommendations are suggestions that should be considered by the LEP, but do not relate to mandatory standards. These are notfollowed up by the QMSG. However, the LAB should discuss with the LFG whether or not actions should be taken on any recommendations. Thismay then be reported to the QMSG when responding to visit reports and will be discussed and monitored by the KSS Pharmacy Department.No. Recommendations Standard Comments12345

Doc 1KSS GP SchoolGuidance on the Quality Management of GP Specialty Training in the KSS DeaneryThis guidance is intended for GP Specialty Programme Directors, GP Trainers, Medical Education Managers , GPFaculty Administrators and GP Training Practice Managers, but will be also helpful for GPStRs, to inform themabout the context and procedures of the GP Faculty visiting process and will inform those acting as visitors andthose being visited.The rationale for quality managementThe GMC is the statutory organisation responsible for the delivery of good quality medical training and educationfor all doctors in postgraduate specialty training. It sets criteria for the delivery of training, and for trainers, andapproves specialty curricula. It is the body that approves GP training programmes and posts and GP Trainers, andhas approved the GP curriculum.GP training is carried out in environments such as hospital and GP Training Practices, which are referred to asLocal Education Providers (LEP). It is the responsibility of LEPs, and their GP Faculties (local units of the GP School)to ensure a process of quality control is in place.The Deanery is charged by GMC with the task of quality managing the quality control in all locations, and the GMCwill undertake a series of processes, including visits to Deaneries, to quality assure medical education in the UK.The KSS Deanery provides guidance to all Trusts and Educators and sets out the structure of Quality Managementin the Deanery in the form of the Graduate Educational and Academic Regulations (GEAR)As part of its quality management, the KSS Department of General Practice Education will seek to gaininformation about the delivery of GP Education and training from a number of sources including a rolling series ofvisits to each Trust and GP Local Faculty Group. The purpose of the visit is to review the provision of education fordoctors in training against the standards set by GMC. This process is looking not just at the educationalexperience of GPStR doctors in hospital posts but how the local faculties support the process and in turn aresupported. The visiting process is collaborative involving both Secondary, Education and General PracticeDepartments and all specialty schools.The visit will aim to celebrate notable practice, investigate areas of uncertainty and be formative in exploring howeducational provision can be improved in any locality. In doing so, it will allow the Deanery to confirm that theGMC criteria for training and trainers are being met. Where areas of concern are identified these will be fed backto the Trust and the Local Faculty Group for action.The GMC criteria (domains) will be the common context of all parts of the visiting process and should be familiarto educators and the visitors. These form the backbone of the GP Trainer Selection evidence and also the KSSDeanery Graduate Educational and Academic Regulations (GEAR) for local Faculties and the Local AcademicBoard. They are available from the GMC website:http://www.gmc-uk.org/Generic_standards_for_specialty_including_GP_training_Oct_2010.pdf_35788108.pdf_39279982.pdfand in brief are:-Domain 1: Patient safetyDomain 2: Quality Assurance, Review and EvaluationDomain 3: Equality Diversity and OpportunityDomain 4: Recruitment, selection and appointmentDomain 5: Delivery of curriculum including assessmentsDomain 6: Support and development of trainees, trainers and local facultyDomain 7: Management of Education and trainingDomain 8: Educational resources and capacityDomain 9: OutcomesKSS GP School QM process v.5 Page 1 of 12 Revision Date: August 2012

IMPORTANT NOTE FOR GPSTRSThis process is about the educational support GPStRs are being given, and is NOT about their performance orprogress in GP training. Appendix 4 is a letter that you may provide to your Trainees advising them about thevisit.The ProcessThis involves two parts.1) Annual documentation checkAn annual information pack to be submitted by each GP LFG to consist of the following:• LFG minutes and annual report to the LAB (AAR) will should incorporate: Reflection on GMC survey results Reflection on on-line Trainee Survey Feedback MRCGP examination results report (CSA, AKT and WPBA) ARCP results of all GPStRs in LFG Record of attendance of PDs at PD conferences / workshops Record of GP Trainer attendance at GP Trainer Days / Workshops Attendance registers of GP ST1/2/3 at teaching sessions Number of GPStRs defined as being in difficulty Details of Half-Day Release Course (GPStR learning sets) – including dates and topics Any comments by locality PAD after reviewing LAB annual report to the DeaneryFinal report approved and submitted to Head of School (HoS) for sign-off.Any concerns raised will need to be explored by the HoS with the locality GP Patch Associate Dean (PAD) and GPProgramme Directors (PD) if needed in order to determine what further action may be necessary.This further action may include a Deanery Exception Visit to confirm and validate any concerns. For furtherinformation please see Appendix 5.2) 3-Yearly Routine Visit to each LEPEach GP Training Programme will be visited on a scheduled rolling programme. Large Training Programmes withmore than one centre (East Kent, Brighton and Mid-Sussex, East Sussex, Maidstone and Tunbridge Wells) willrotate the visit location every three years.These visits will be timed to link with the regular Deanery Quality Management visits to LEPs for the appropriatearea.This means that not all KSS Deanery Specialty School quality management visits to Trusts will include GP. Wherethe GP Faculty is being visited, the Visit process will take place on two days: in some cases these are consecutivedays in others they are separate. If there are no GPStRs in the hospital specialty posts being visited on the secondday, then there will be no need for the GP visitor to interview the specialty GPStRs. The GP visitors will obtaininformation from a number of sources, which include Faculty documentation, ARCP outcomes, GMC surveyresults, GPStR feedback from departmental on-line surveys and from direct discussion with GP educators(including hospital consultants) and GPStRs. Thus the visitors meeting with individuals are only one part of thewhole process. The arrangements and organisation for the first day (GP) will be organised through the GPDepartment and queries concerning these arrangements will be answered by the relevant GP Patch Manager. AllGP visits will run over two days, but not all Deanery Quality Management visits to Acute Hospital Trusts (LEPs) willinclude GP.KSS GP School QM process v.5 Page 2 of 12 Revision Date: August 2012

Day 1Visit to the local GP Faculty which will involve visiting a local practice selected to represent the Faculty. This willbe followed by meetings with the ST3 GPStRs and any ST1 and ST2 GPStRs currently in General Practice. Thevisiting team will also meet with local Trainers, Practice Managers and GP Programme Directors. Where possiblethis meeting will be held in a suitable GP Practice (which does not have to be the same practice as that visited).Before the visit:The local GP Programme Directors, working with the MEM or GP Faculty Administrator, will need to inform thelocal GP Trainer Group, and the group of GPStRs in GP placements (this will be mainly ST3 GPStRs, but will alsoinclude ST1 and ST2 doctors in GP placements, including Integrated Training Posts) of the dates and times of themeetings for the discussion groups.No preparation for these meetings will need to be done by GP Trainers or GPStRs.One GP Training Practice will, via local negotiation, need to be identified for visiting by the team of visitors.Prior to the visit, Programme Directors may be contacted by administrative lead in the GP Department (normallythe Patch Manager) to provide some documentation relating to the visit if they do not already have theinformation. The relevant data includes:The Local Faculty Handbook that has been developedMinutes of Local Faculty Group meetingsGP LFG Annual Audit and Review (AAR)Any other data which GP Faculty members locally represents good practice (for example initiatives fromthe GP Trainer group, the half-day release programme for GPStRs)Programme Directors do not need to specifically prepare anything for the visit, but copies of relevantdocumentation would be very useful to have to hand.The suggested timings of the day are given below outlining the visit programme.The timetable will be finalised in discussion with the GP Patch Manager for each locality and the GP LeadVisitor and Medical Education Manager (MEM) for the Hospital or Psychiatric Trust as this may be changed tomeet local needs. The GP Patch Manager will confirm the final arrangements.DurationSession30 minutes GP Visiting team meet for briefing1.5 hours Practice Visit including discussion with practice members in groups, visiting team de-brief and verbalfeedback to Trainer and practice teamUp to 1 hour Travel/Lunch if required (depending if staying in first location or need to travel)45 minutes Meet group of GPStRs (ST3’s and include ST1 and ST2 doctors in GPplacements, including Integrated Training Posts)15 minutes Tea break45 minutes Meet group local GP Trainers and Practice Managers45 minutes Meet GP Programme Directors for discussion and feedback30 minutes Visiting Team Review visit and to start to write report6 hours Total Visit timeKSS GP School QM process v.5 Page 3 of 12 Revision Date: August 2012

A full visiting team will consist of:• Patch Associate GP Dean from a different patch (Lead Visitor)• GP Training Practice Manager from a different patch• A GP Programme Director from a different patch (to provide an external input)• A GPStR (preferably one who is in, or who has experienced training in a Practice placement)These visits form an excellent opportunity for GP Programme Directors to have the ability to observe and learnfrom their colleagues in different areas, and will provide evidence and learning opportunities for their personaldevelopment plans as Programme Directors.Evidence for each of the GMC domains will be sought from a variety of sources, as previously described, anddiscussion and questions will also relate to these domains. Specimen examples can be found in Appendix 1attached to this document.You may find it helpful to visit the GMC website www.GMC.org.uk and refer to the section on generic standardsfor training and the section on standards for trainers.Guidance to the GP Training Practice visit is described in Appendix 2.GPStRs will need to ensure that they are familiar with the guidance to visits.Day 2 is a visit to the Acute Trust. Unless the Trust (LEP) is included in the GP Training Programme area that isbeing visited, GP will not be involved in this. If GP is involved, only the Lead GP Visitor (PAD) will be involved.This is the day in which the other Specialty Schools have the opportunity to meet with their trainees and theirSupervisors in hospital posts. In each case a number of specialties will be reviewed in detail (including higher leveltraining specialties) and if these specialties include GPStRs (in ST1 and ST2 at the time of the visit) at that location,they will be interviewed by the GP visitor/s if that LEP is also being visited for GP.Note: If there are no substantive posts used for GP training in those specialties, but the LEP is being visited as part of a GPvisit, the GP visitor will support the process of the Quality Management visit, which may mean if appropriate, acting as theLead Visitor.The roles and responsibilities of GP visitors are described in Appendix 3.Psychiatric Trusts will have separate visits as a result of their different geographical locations and they mayinclude a GP visitor, as this specialty hosts a significant number of GPStRs who may not always manage to makethe first day of a GP LFG visit.The organisation of the 2 nd day will be carried out by the KSS Deanery Quality Manager, who will liaise with theTrust via the Medical Education Manager, and ensure that the necessary documentation is shared with the GPvisitor (normally accessible via a weblink).KSS GP School QM process v.5 Page 4 of 12 Revision Date: August 2012

An example timetable of the day is given below (the actual timetable will be theresponsibility of the KSS Quality Manager and will vary according to the number of specialties being visited):-TimeSession09:00 – 09.30 Visiting Team BriefingThe team meets with the Trust for final briefing session09.30 – 10:30 Faculty LeadsMeet the DME, MEM and Faculty Group Chairs (from each of the specialties being visited) asone group to discuss key issues10.30 + Trainee Interviews by Specialty11.30 – 11.45 Coffee break11.45 – 12.45 Trainee Interviews by Specialty12.45 – 13.30 Lunch13.30 – 14.30 Visiting Team ReviewThe Visiting Team meets as a group to collate information and prepare for verbalfeedback.14.30 – 15.00 Feedback sessionThe Visitors provide brief verbal feedback to the CEO (or delegated deputy), DME and MD.Any patient safety issues must be reported and documented.15.00 – 17.00 Report WritingThe Visiting Team writes the first draft of the visit report as a group and agrees mandatoryrequirements and recommendations.The visiting Patch Associate GP Dean will be present only if the GP LFG is being visited at that Trust LEP, and mostof the GP information will have been gained on the first day of the visit. For this day at the Trust the GP visitor willnot need to meet any of the GP Educators again but at least one of the local team of Programme Directors willneed be available to hear the feedback from the visitors at the end of the visit, and ideally, if possible, the PatchAssociate GP Dean responsible for that area.Feedback will be given by the whole team of visitors to the Faculties and LAB in the PGMC, and will relate to theoverall provision of educational support at the LEP, highlighting good practice, as well as areas for improvementin the mandatory and developmental criteria in the GMC domains. Any issues that may arise during a visitconcerning GP training posts in hospital specialties that are not being formally assessed (i.e. are not any of thespecialties being visited) will not be raised in the formal feedback session, but will be fed back directly to thePatch Associate GP Dean for that GP Training Programme in order to validate and resolve locally if necessary, andwill not form part of the final report.The GP report will be written using the KSS quality visit report template and will relate only to the GP placements,outcomes for GP training, and the management of the GP LFG, and the learning sets, using information gatheredfrom both days of the visit, (or from just one if there are no hospital posts to visit) and the other evidence. Issuesrelating specifically to specialty posts used for GP Training will be reported on only if those specialties form part ofthose visited on the second day. The report will be sent to the Head of the GP School and also to the specialtyworkforce team member who is writing the report for Secondary Care. The specialty workforce manager willcombine the reports for all into the unified and integrated report which will be returned to the Deanery QualityManager in order to then be sent to be checked for accuracy with the Trust being visited, before going to the KSSDeanery Quality Management Steering Group (QMSG). Once this is signed off by the KSS QMSG, a copy will besent to the visited Trust with the action points. The action points will have a timescale for the LEP to address andreport back on. Community issues related to general practice will be addressed by the local GP education networkwith reporting mechanism through the local LABKSS GP School QM process v.5 Page 5 of 12 Revision Date: August 2012

APPENDIX 1Specimen Questions Visitors may ask Programme Directors at a Faculty Visit(NB, as described above, answers to these questions will also be sought and may be provided from the othersources of evidence. These are suggested questions to help visitors that would address the GMC domains and arenot considered comprehensive, exclusive, or mandatory As a result of other information visitors may consider isnecessary to prioritise particular areas.)oooooooooooooooooooooooooooGive an overview of the local faculty (hospital posts, VTS, GPStRs, trainers, the Trust LFG)– good practice,developments your concernsDo you have any concerns about the working environments of GPStRs enrolled in the programme in eitherhospital or GP placements?Do you have any concerns about supervision in OOH training and in hospital placements?How informed are you about the wider guidance and criteria fro GP training posts?How aware are you of the GEAR guidance?How does the LFG monitor the quality of training?How does the VTS deal with issues of equality and diversity?How has the VTS dealt with any examples of direct or indirect discrimination?How do you advise GPStRs about the posts they will work in and what information do you give them?Do you know about or how to get information on sickness, maternity leave, training less than full time?How have you kept up to date with the recruitment process?How is local allocation arranged – how much are GPStRs involved?How do you use feedback from the recruitment process?How have you inducted GPStRs in to all aspects of GP specialty training?How do you work with the Trust to ensure experiences relevant to the GP curriculum are delivered?How have you supported clinical supervisors in understand the WPBA assessments?How do you support doctors seeking career guidance for entry to general practice and for their futurecareers?How study leave is arranged locally – any concerns?Are you aware of any GPStRs being bullied?How has the LFG been established?How do you ensure ST1 2 3 participation in the LFG?How does the LFG support local trainers?How have you dealt with any GPStRs in difficulty?How are you supported by the PGMC?How have your current cohorts performed in MRCGP?How do you gain feedback from GPStRs and how has this influenced your VTS?How do you manage the educational needs of the group?Similar questions will be asked of the GP Trainer group and GPStR group met by the visitorsKSS GP School QM process v.5 Page 6 of 12 Revision Date: August 2012

Specimen questions visitors may ask the GP Trainer group at a GP Faculty Visit(NB, as described above, answers to these questions will also be sought and may be provided from the othersources of evidence. These are suggested questions to help visitors that would address the GMC domains and arenot considered comprehensive, exclusive, or mandatory)o Give an overview from your perspective of how the local faculty (hospital posts, VTS, GPStRs, trainers, theTrust LFG) supports GP Specialty training. Do you have examples of good practice in your own Practice (oracross the area) or concerns.o What is the experience of organizing clinical supervision of GPStRs in your Practices?o How does the Trainer group share issues or concerns about patient safety relating to any GPStRs?o Do you have any concerns about OOH training for GPStRs?o How informed are you about the wider guidance and criteria fro GP training posts?o How aware are you of the GEAR guidance?o How much do you know about the activity of the Local GP Faculty group (LFG)?o Do you attend GP LFG meetings?o Has the Trainer group dealt with any issues of equality and diversity in GP training?o Have you all had E&D training. How useful has this been?o Do you know about, or how to get information on, sickness, maternity leave, training less than full time forGPStRs?o How have you kept up to date with the recruitment process?o How do you use feedback from the recruitment process?o How much has the local Faculty / Programme Directors / Associate Dean supported you?o How have you shared good Practice for GPStR induction for GPStRs?o How do you work with GPStRs to ensure experiences relevant to the GP curriculum are delivered?o How have you supported GPStRs in understanding the WPBA assessments?o What is going well / or is difficult with MRCGP? How could it be improved?o How have local study leave arrangements worked?o How have you found the Educational supervisor role?o Have you had examples of where handover of a GPStR from each department to you has worked well /been problematic?o How do you use the Trainer group to involve and support others in your Practice involved in teachingGPStRs?o How has the Trainer group / Deanery supported your professional development?o How has the Faculty supported approval and re-approval for GP Trainers?o Are you aware of any GPStRs being bullied?o Have you had any GPStRs in difficulty? How have you and the GPStR been supported?o How do you ensure ST1 2 3 participation in the LFG?o How does the LFG support local trainers?o How have you dealt with any GPStRs in difficulty?o How do you access and use other educational resources locally?KSS GP School QM process v.5 Page 7 of 12 Revision Date: August 2012

APPENDIX 2Guidance for a GP Training Practice being visited on the GP Faculty VisitGP Trainers and Training Practices are approved and re-approved in the KSS Deanery via a separate formal, evidencedprocess. This visit, which forms part of the Local GP Faculty quality inspection, is not meant to replicate that process, but isintended to gain further information to support and triangulate that obtained in other areas of the visit.GP Trainers and their Practices are not required to make any special preparations for the visit, apart from the practicalities ofhaving appropriate members of the team available for the time.It is important that the information obtained from this part of the overall visit, is related to that obtained from the othersources of information.The visit provides an opportunity for visitors to informally feedback on aspects of good practice, and illuminate areas wherethe Trainer/s and the Practice team could consider development.Individual members of the visiting team will interview individuals in the Practice Organisation to gain this information, and asuggested scheme is described below.The visit, and the visiting team, will be coordinated by the Lead Visitor who will normally be a Patch Associate GP Dean fromanother area and who will have responsibility for the conduct and timetabling of the visit.Visiting team member and team members to be seeno Patch Associate GP Dean from another patch (Lead visitor)o GP Training Programme Director from another GP Training Programmeo GP Training Practice Managero GPStR from another GP Training Programme.The lead visitor should ensure that they and the other visitors are familiar with any documentation relating to the Practice(particularly the previous visit report, if any, GMC trainee surveys, and previous GPStR feedback on placement).The lead visitor should take a few minutes with the other visitors at the start of the visit to raise any particular issues thatmay have been indicated from the documentation or from the discussions with other groups earlier in the day, and todetermine the timetable for the visit (this could be done just before leaving the Medical Education Centre, or on the journeyif possible). The visit will just involve the visitors talking to the different individuals in the Practice and will not normallyinvolve the assessment of other evidence, unless the visited Trainer and Practice wish this to be considered.Suggested timetable Visitors arrive at Practice Introductions and explanation of process 10 minutes Visitors split into groups to speak to different individuals 60 minutes Visitors meet to share and collate information 15 minutes Lead visitor gives brief verbal feedback to visited Trainer and their team 10 minutes Practice Visit concludesTotal time approximately 90 minutesThere will be no specific report created for the Training Practice visit, as the information gained will form part of the finalFaculty report.KSS GP School QM process v.5 Page 8 of 12 Revision Date: August 2012

Specimen Questions Visitors may ask Trainers at a Faculty Visito Give an overview from your perspective of how the local faculty (hospital posts, VTS, GPStRs, trainers, theTrust LFG) supports GP Specialty training. Do you have examples of good practice in your own Practice (oracross the area) or concerns?o How do you arrange clinical supervision of GPStRs in your Practice?o Do you have any concerns that GPStRs in your Practice are exposed to situations that compromise patientsafety?o Do you have any concerns about OOH training?o How informed are you about the wider guidance and criteria for GP training posts?o How aware are you of the GEAR guidance?o How much do you know about the activity of the Local Faculty group (LFG)?o Do you attend LFG meetings?o How does the Practice dealt with issues of equality and diversity?o How has the Practice dealt with any examples of direct or indirect discrimination?o How have you used your Equality and Diversity training?o Do you know about or how to get information on sickness, maternity leave, training less than full time?o How have you kept up to date with the recruitment process?o How is local allocation arranged – how much are GPStRs/ trainers involved?o How do you use feedback from the recruitment process?o How much has the local faculty / Programme Directors / Associate Dean supported you?o How have you inducted GPStRs?o How do you work with GPStRs to ensure experiences relevant to the GP curriculum are delivered?o How have you supported GPStRs in understand the WPBA assessments?o What is going well / difficult with MRCGP? How could it be improved?o How have others in the Practice been made aware of the GP curriculum?o How have you prepared the team for undertaking multisource feedback?o How has local study leave arrangements worked?o How have you found the Educational supervisor role?o Have you had examples of where handover of a GPStR from each department to you has worked well /been problematic?o How do you involve and support others in your Practice involved in teaching GPStRs?o How has the Trainer group / Deanery supported your professional development?o Are you aware of any GPStRs being bullied?o Have you had any GPStRs in difficulty? How have you and the GPStR been supported?o How do you ensure ST1 2 3 participation in the LFG?o How does the LFG support local trainers?o How have you dealt with any GPStRs in difficulty?o How do you access and use other educational resources locally?KSS GP School QM process v.5 Page 9 of 12 Revision Date: August 2012

APPENDIX 3Roles and responsibilities of visitorsAll visitors must understand their process of the visit and be familiar with their role.All visitors must be familiar with the GMC criteria for training and trainers.The lead visitor should speak to all visitors before the visit to ensure that this is the case, and must clarifyany information needs.All visitors must adhere to principles of Equality and Diversity, and should be up to date with their trainingin this (with the last 3 years).All visitors must ensure that they are familiar with the documentary or electronic evidence provided priorto the visit.All other visitors will be guided by the lead visitor in terms of timing, process and areas to investigate.Lead visitor (Patch Associate GP Dean).ooooooooooooTo work with the GP Patch Manager to ensure that the date and timings are agreed and notified to theFaculty being visited.To ensure that the other visitors are contacted and have been informed about the date and time andhave confirmed thisTo have read the provided documentation prior to the visit, and relevant feedback, such as GMC andDeanery GPStR surveysTo share any appropriate and relevant information with the other members of the visiting team for thefirst day.To share any appropriate and relevant information with other specialty visitors pertaining the LEPTo coordinate the timetable for the first day of the visitTo negotiate and agree responsibilities, such as areas of questions, or individuals to interview, with theother members of the visiting team.To support the other specialty visitors in questioning GPStRs on the second day of the visit to the LEP ifappropriate and indicated.To interview the group of GPStRs on the second day of the visit.To feedback to the GP Trainer and members of the Training Practice any notable outcomes from the visitto the Practice on the first dayTo take part in the overall feedback on the second day with a particular emphasis on the GP trainingTo write the report with the support of the GP Patch Manager.KSS GP School QM process v.5 Page 10 of 12 Revision Date: August 2012

APPENDIX 4Information and briefing letter for GPStRs being visited on GP Quality VisitsTo all GP Trainees in a GP Training Faculty who will be visited.Dear DoctorA team from the KSS GP School will be visiting your GP Training Programme in a few weeks. The visit is not toassess you, but is to assess the quality and appropriateness of the training environment for us to get a good ideaof the educational experience provided by your department. We have a number of ways of looking at this, but inour view the best way of finding out what it is like to work in a department is to talk with the trainees.The KSS deanery has responsibility for approving all training posts in KSS on behalf of the GMC (which is theregulator for the quality of medical education), and for making sure that each post delivers a good trainingexperience for you. Most trainees in KSS are satisfied with their posts, but there is almost always room forimprovement. There are some posts which provide a truly excellent experience, and in the same way that weneed to identify the weak posts we want to know about these excellent posts which can provide lessons forothers.The GP visiting team will usually have up to 4 members on the first day, normally made up a a Lead Visitor, who isthe Patch Associate GP Dean, a GP Training Programme Director, a GP Training Practice Manager and a GPStR.Some visits cover a number of specialties. The GP School visits GP training programmes over 2 days, with themain focus of the visit on the first day, which is located in general practice and in the community. The second dayof the visit will be to the hospital, and will allow the GP visitor (only the Lead GP visitor goes to the second day) tointerview those GP trainees who are undertaking hospital posts in the Specialties being visited by the secondarycare visitors, who form the majority of the second day visiting team.If you wish to find out more about the areas covered in these visits and the kind of questions you can expect, youcan read the guide to GP Faculty Quality Management at:http://kssdeanery.org/general-practice/gp-programme-directors/forms-guidance-handbooks-policiesOn rare occasions we will identify problems which give a real concern for patient safety, and in these cases wewill may ask Practices, or Trust Chief Executives (where the problem is in the hospital) to make immediatechanges. More commonly there are normal developmental changes resulting from the visit, which may take a fewmonths to be implemented.We hope you will make every effort to meet with the visitors. We recognise that not everybody can alwaysattend, and if you are unable to attend we would ask you to share your views on your training experience withcolleagues who can then speak on your behalf.Yours faithfullyIan McLeanHead of KSS GP SchoolKSS GP School QM process v.5 Page 11 of 12 Revision Date: August 2012

APPENDIX 5Exception VisitsException visits are visits to Local Education Providers that are outside of the normal year-on-year qualitymanagement processes of the Deanery.They may be initiated because of:A serious clinical incident which may or may not have involved a trainee but might have implications fortraining.A serious trainee complaint either directly to the Deanery, or via a KSS School or via a London SpecialtySchool which raises a serious question about current training that cannot be managed through usualmechanisms.Concerns raised by usual mechanisms such as GMC Surveys in small specialties or specialties not routinelycovered by the Deanery visiting process. An example might be Occupational Health with just 3 posts inKSS, all of which are in the private sector.Evidence from any other source which raise serious questions about potential service problems whichcould affect trainees.ProcessIssues arising will be discussed between the Dean Director and the Postgraduate Dean for Secondary careand the KSS Head of School and the London Head of School if also relevant.If there is evidence of serious concern the Dean Director will make a decision for a Deanery visit and willinform the next meeting of the Quality Management Steering Group.It there is a more complex or chronic problem or there are other factors to be taken into account and it isless pressing, the matter will usually be discussed at the Quality Management Steering Group before adecision is made.The standard KSS methodology for the visit is set out in Appendix 1. However, all visits to any LEP in KSSwill be led by KSS.The report will come to the Quality Management Steering Group for discussion and approval of action,following which the Dean Director will write to the Chief Executive of the LEP.The response of the LEP will be followed up and discussed at the Quality Management Steering Groupuntil adequate evidence of resolution is provided.Where serious problems cannot be resolved it will be normal to approach GMC for a trigger visit.If at any stage serious problems are uncovered which put trainees or patients at risk, the Dean Directorwill take immediate executive action.KSS GP School QM process v.5 Page 12 of 12 Revision Date: August 2012

7 Bermondsey StreetLondonSE1 2DDMain Tel: 0207 415 3400Main Fax: 0207 415 3686Educational Governance:Contract Review and DevelopmentContract Review Process 2012/131 Quality Manual Verification1.1 During October the first meeting to discuss the process will take place.1.2 KSS Education Department [Education] will be offering dates for the Contract Reviewmeetings to the Medical Education Managers (MEM) during December. As dates areset they will be distributed by Education to the KSS Heads of Library & KnowledgeServices [LKS] and Pharmacy [KSS Heads].1.3 As dates are confirmed, Education will ask MEMs for dates for the verification visit totake place. As dates are agreed, Education will inform KSS Heads.1.4 If the LEP has gained Earned Autonomy for PGMDE, Internal Verification and ExternalReview will be coordinated by Education.1.5 If the LEP has not gained Earned Autonomy for PGMDE external verification will beorganised by Education.1.6 All verification visits for LKS and Pharmacy will be organised by KSS Heads. As datesare finalised KSS Heads will send them to Education. The LEP’s MEM will be informedof these dates as a matter of continuity.1.7 The KSS Heads will be drafting all documentation from November to early March.Once all documents are completed, they will be sent to the Head of Education at KSS.1.8 Final versions of the documentation will be sent to the MEM, LKS Manager andPharmacy by March for completion.1.9 Where LEPs are to undergo the full verification visit for all departments, all QMs will be sentto Education at least two weeks before the verification visit takes place. It will be theresponsibility of each of the leads to send their own documentation to Education. LKS andpharmacy leads must send a copy of their QM to either their respective KSS Heads. A copyof all documentation should also be sent to the MEM. Education will then send a printed copyto the designated verifiers two weeks before the visit. A copy of last year’s Action Plan fromthe Contract Review meeting will also be sent to verifiers.Where Earned Autonomy has been gained for PGMDE the KSS Heads will send theirQM to Education should this be appropriate.1.10 MEMs will follow the Earned Autonomy process laid out in the relevant documentationprovided by Education.1.11 From 2011, only one verification visit per LEP will take place. Thus, only one QM perdepartment should be produced by every Trust. These QMs must contain informationfrom all sites and departments. Documents from sites and departments where no visitwill take place should be made available electronically to Verifiers.With our partnersChair, Deanery Board - Professor Sir David Melville CBEDean Director - Professor David Black

1.12 If the LEP has gained Earned Autonomy, only the LKS and Pharmacy departments willundergo the verification process. No Library and Knowledge Service verification visitswill be made to Sussex Partnership Foundation LEP or Surrey and BordersPartnership LEPs as no funding flows from KSS to these LEPs for Library andKnowledge Services.1.13 The purpose of the verification visit is to audit the QM. The Verifiers will: ensure that procedures are in place to meet KSS Deanery requirements; check whether the processes and procedures set out in the QM are supported byevidence provided by the department; produce a verification report (appropriate to the QM being verified) for Education.The report will provide comments on areas of good practice and areas whichrequire development and potential changes in practice there these are consideredto be required.1.14 The verification visit will normally last from 09.30 to 17.00 for PGMDE and from 10.00– 14.00 for LKS and for Pharmacy.1.15 An appropriate space should be made available for Verifiers to work in. Provision willbe made for the verification report to be sent to the Deanery via email on the day of thevisit.1.16 Access to all filing systems referred to in the QM must be provided. All colleagueswhose files are to be viewed are to be made aware that the verifiers are working onbehalf of KSS, which files should be made available, and why they need to see them.This is particularly important where there is limited access to files (for example,because they are kept by part-time staff).1.17 It would be helpful if a light lunch could be provided for the verifiers. Education shouldbe informed if there are hospitality restrictions imposed by the LEP and therefore nolunch available.1.18 The relevant lead, designated representative or manager must be available throughoutthe verification visit and should expect to be part of it.1.19 If processes are considered to be inadequate and changes are required, thedepartment will be requested to provide an action plan for future compliance with arealistic time line before the Contract Review visit, and verification of the QM will bedelayed until then. If it is not possible for this to be done, a second verification visit willbe agreed at the Contract Review visit and the contract will be signed subject to therelevant changes being made.1.20 When the QM has been verified, Education will issue a formal Certificate ofVerification. No QM is formally verified until the Certificate has been issued.1.21 The Verification Report will be made available to the team completing the ContractReview visit and will feed into the discussion which will take place at that meeting.1.22 Verifiers will provide the department leads with a copy of the Verification Report on theday of the verification visit.1.23 Should a MEM, LKS or Pharmacy lead require assistance in writing the QM, theyshould contact Education in the first instance who will identify someone to assist withthe process.

2 Verifiers2.1 Verifiers will operate in pairs wherever possible.The verification teams will comprise of:a) PGMDE- a member of Education staff together with a MEMb) LKS – a member of the LKS team and a senior member of LKS from another countyc) Pharmacy – normally a member of SEMMED and a senior pharmacy staff memberfrom another LEP who will verify the QM for the appropriate department.2.2 A computer will be available for verifiers to use so that the report template can bedownloaded and the final Report can be emailed to Education on the day (see 2.12above).2.3 Verification Development Meetings will be held annually in January for verifiers todevelop processes and to share standards.2.4 New verifiers will:a) Attend an Education Verifier Development meeting;b) Receive a sample QM;c) Have the opportunity to shadow experienced verifiers;d) Complete their first visit with an experienced verifier.2.5 The verifiers provide a link between the Educational Contract signed by the DeanDirector, LEP Chief Executive and Director of Medical Education/Clinical Tutor, and theoperation of that Contract at daily level.2.6 Verifiers are using their experience and knowledge to make a professional judgementin order to decide whether they can verify the procedure or not.‘Hold points’ occur when:othe Procedure does not meet the Deanery Requirement in the QualityManual Specification;o Evidence is not available or recognised to show that the procedure iseffective.If a verifier thinks there may be a hold point they should:o Discuss with their fellow verifier to agree the hold point;o discuss and explore the issue with the MEM, LKS or pharmacy lead, or averifying colleague where there is just one verifier for the departmentalverification;o agree with the MEM, LKS or pharmacy lead what corrective action will betaken; If there are more than five hold points, or one or more critical hold points, verifiersshould use their judgement as to whether a second visit is required. Issues that are recognised as being addressed by the LEP are not hold points andshould be noted in the Verification Report as such in the appropriate section.2.7 Education is looking for processes that are good enough; they have to be reasonableand workable within the daily context of the LEP. The aim is to work with the LEPjointly to produce a system which works well for both the LEP and Education: this isemphatically not an inspection but is a developmental and motivational processdesigned to support the MEM, LKS and Pharmacy leads in the quality control ofeducation within the LEP.

3 Contract Review Visits3.1 The collated LAB Strategy must be sent to Education at least three weeks in advance of theContract Review visit by the MEM. Where possible it should be sent together with the QMdocumentation. LKS and pharmacy leads must send a copy of the LEP LAB Strategy to KSSHeads.3.2 Education will gather all documents and produce the relevant documentation for the ContractReview meetings and send them to KSS Visitors, and the LEP’s MEM, at least two weeksbefore the visit.3.3 The Contract Review visit must be attended by the LEP’s Chief Executive, DME/ClinicalTutor, MEM, LKS and Pharmacy leads. The Medical Director of the LEP or Chair of ClinicalGovernance, or equivalent, will also be welcome to attend the meeting.3.4 An Associate Dean, an Assistant Dean Education and KSS Heads will form the Visitors.Other KSS staff may be invited to attend and verifiers may attend as observers. LEPs arewelcome to nominate any additional members of KSS staff whose attendance they would findhelpful and such requests will be honoured whenever possible. MEMs should invite the LKSand Pharmacy leads to the meeting.3.5 The Contract Review visit will normally take place between 10.00 and 13.00. The usualprogramme will be:10.00-12.00 DME/CT, MEM, LKS and Pharmacy meet Deanery visitors. A programme forthis section of the meeting may be devised by the education leads within the LEP.12.00-13.00 The Chief Executive and other staff at her/his discretion join the meeting.Where possible and/or appropriate, LEPs are asked to provide a light lunch for Visitors.3.6 Discussion at the Contract Review visit will usually cover: issues arising from the QM Verification Reports (both verification visit and earnedautonomy); a review of the Contract Review Action Plan from the previous year; discussion of the LAB Strategy.The aim is to support LEPs in taking forward their local education agendas, within regionaland national guidelines.3.7 At the end of the Contract Review visit, a draft Action Plan will be produced and forwarded tothe LEP on the next working day. Each KSS visitor will write their section using the templateand this will be collated by Education. Education will circulate the draft Action Plan to Visitorsfor signing-off and will then send it to the LEP’s MEM on the next working day. The LEP’sMEM will collate responses from the LEP and return an amended Action Plan, or confirmationof acceptance of the Action Plan, to Education within one week of receipt. Once agreed theAction Plan will be attached to the KSS Single Contract as a binding agreement between theLEP and KSS. All relevant parties within the LEP can expect to receive the final Action Planone week after any comments or changes are received by Education.3.8 The Chief Executive and DME will sign the KSS Single Contract at the Contract Review visitagreeing to comply with any required actions set out in the Action Plan.

4 Deadlines4.1 Each LEP will be given two weeks in which to arrange dates for the Contract Reviewvisit. If a LEP has not confirmed dates in that two week period, then dates will beallocated by the Deanery with which the NHS LEP will be expected to comply.4.2 Documentation for the Contract Review visit must be received by the Deanery threeweeks in advance of that visit.4.3 Cancellation of visits by the LEP is unacceptable except for reasons beyond thecontrol of the NHS LEP.5 Earned Autonomy5.1 LEPs that have been awarded Earned Autonomy will be provided with relevantdocumentation by Education

7 Bermondsey StreetLondonSE1 2DDMain Tel: 0207 415 3400Main Fax: 0207 415 3686NHS Postgraduate DeaneryforKent, Surrey and SussexKSS Single Contract1 April 2012 - 31 March 2013With our partnersChair, Deanery Advisory Board - Professor Sir David Melville CBEDean Director - Professor Deanery David Chair Black – Name

Contents1. Purposes and Scope2. Terms and Conditions3. Required process for implementation4. Specifications5. Funding Arrangements6. Management of funds issued by KSS7. Exclusions8. Appendices

Education ContractPurposes and Scope1. Since 2010 the NHS Postgraduate Deanery for Kent, Surrey and Sussex [KSS] has issued anannual Single Contract to its Local Education Providers [LEPs] to cover all KSS ContractedServices provided by a single LEP and the LEP has managed that Contract through its LocalAcademic Board [LAB].2. This Single Contract sets out KSS’s provision for quality managing and quality controllingpostgraduate medical and dental education, pharmacy education and library and knowledgeservices and provides detail of the allocation of NHS funding related to those activities. Itspurpose is to support, develop, quality manage and quality control KSS Contracted Services inLEPs in Kent, Surrey and Sussex, with the wider purpose of improving patient care.3. This Contract is made under the conditions of Section 4 of the National Health Services andCommunity Care Act 1960.4. This Contract is subject to all national statutes, regulations and requirements that affect NHSfunding and to any requirements of the NHS and the appropriate national regulatoryauthorities.Terms and conditions5. In exchange for the provision of services to the specifications described below, KSS willprovide funding to your LEP as detailed in the appended Schedules of Funding for 2011/12.6. This Contract covers the period 1 April 2012 to 31 March 2013.7. The Dean Director of KSS, the Chief Executive of the LEP and the Chair of the LAB at the LEPwill sign this Contract on completion of KSS’s annual Contract Review process. Its terms andconditions will take effect automatically from 1 April 2012 unless any formal written variation tothe Contract has been signed by the Dean Director of KSS, the Chief Executive of the LEPand the Chair of the LAB at the LEP.8. The failure of the LEP to provide the services specified in this Contract will constitute noncompliance.In the event of non-compliance KSS may:8.1. withhold 2% of the total funding in respect of postgraduate doctors’ salaries (as detailed onSchedule A), where mandatory GMC requirements are not met [for example, whereRevalidation data for a postgraduate doctor is not submitted appropriately, or where apostgraduate doctor is not being supervised by a KSS accredited Educational Supervisor];8.2. withhold 2% of the total funding where the LEP is not supporting its staff to enable them tocarry out duties associated with the KSS Contract [for example, where EducationalSupervisors are not provided with appropriate time in their Job Plans; or where time,payments or reimbursement of expenses is not provided for duties associated withrecruitment, selection, or School duties];8.3. require corrective action to be taken in a specified time-scale;8.4. inform other stakeholders, in particular the General Medical Council [GMC], of themeasures it is taking;8.5. review the appropriateness of training posts in the LEP and any corresponding paymentsin respect of them.8.6. identify and withhold specific costs to KSS of remediating non-compliance with theContract’s Specifications.

9. If the LEP decides to sub-contract any part of this Contract to a third party (for example, anISTC), then the LEP must ensure that the quality of services are at least equivalent to andcompatible with those specified in this Contract.10. KSS reserves the right to inspect KSS and LEP funded posts within approved trainingprogrammes and visit postgraduate doctors and dentists and Pre-registration Pharmacists atany time.Required process for implementation11. On receipt of this Contract, the Chief Executive must consult with the LEP’s LAB Chair,Academic Registrar and Library and Knowledge Services Manager.12. Any queries about the Single Contract should be emailed immediately to the KSS ContractReview Administrator, on contractreview@kssdeanery.ac.uk who will forward it to theappropriate KSS Business Manager for a response.13. Any agreed variations will be incorporated in the Single Contract signed at the end of theContract Review process.14. All queries, variations and communications concerning the Single Contract must be in writtenform so that they can be recorded by KSS. A copy of the record for each LEP will be providedto the Chief Executive or LAB Chair on request.15. If circumstances change in-year, for example, due to national instruction by the DH, the SHA,GMC, GDC, or any other relevant national agency, KSS will issue Executive Letters specifyingnew requirements to be met.16. In the case of dispute the Chief Executive should make direct contact with the Dean Director.Both parties will use all reasonable endeavours for resolution and, if necessary, the matter willbe decided by the Chief Executive of the SHA.Specifications17. Compliance is required in three areas:17.1. Education Programmes and Resources;17.2. Human Resources and Medical Staffing;17.3. Finance and IT.18. Detail of the requirements for compliance is provided annually in the Quality ManualSpecification and the Education Strategy Specification issued as part of Contract Review.When appropriate these requirements will be updated by KSS Executive Letters extending ormodifying the requirements for compliance.19. Compliance to specifications will be monitored by:19.1. LAB Agendas, Minutes and Reports;19.2. Local Faculty Group [LFG] Agendas, Minutes and Reports;19.3. Contract Review;19.4. KSS Visits on behalf of GMC;19.5. Other such visits and processes as KSS shall deem necessary.Funding arrangements20. Generic funding arrangements are set out below. Schedules of Funding specific to your NHSTrust are appended to this document.

21. Schedule A – Pay and Non-PaySchedule A comprises funds in respect of KSS approved postgraduate doctors’ and dentists’salary costs and a contribution to the cost of their employment. Salary costs will be as follows:21.1. F1 -100% of the agreed salary point (plus London weighting where appropriate) plusan amount in respect of employers on-costs.21.2. F2 – 50% of the agreed salary point (plus London weighting where appropriate) plusan amount in respect of employers on-costs.21.3. Academic F2, Hard to fill F2 and GP F2 – 100% of the agreed salary point (plusLondon weighting where appropriate) plus an amount in respect of employers on-costs.21.4. Former SpR – 100% of the agreed salary point (plus London weighting whereappropriate) plus an amount in respect of employers on-costs.21.5. ST1/2/3/4 where created from ex-KSS funded SHO posts, these posts will be fundedin this financial year at the SHO rate (i.e. 50%).21.6. It should be noted that if a funded post within Schedule A is unfilled for a period ofup to three months KSS will not normally take any action. However if a post remainsunfilled after three months, then KSS reserves the right to withhold funds for that post untilsuch time as it is occupied.21.7. Relocation and associated expenses for all postgraduate doctors in training posts,employed by the Trust, will be centrally managed through the London Deanery.22. Schedule B – Education CentresFunds in respect of Education Centres within the NHS Trust are calculated on a historic basis(except study leave). Study leave funding will be provided for all KSS funded postgraduatedoctors except:22.1 F1 doctors22.2 Anaesthetics Higher Speciality postgraduate doctors, where study leave will continueto be centrally managed, by Guys and St Thomas’ NHSFT, although this is subject to anongoing review.22.3 Those core training posts where an amount is withheld by the Head of School tofacilitate centrally run training [see KSS Study Leave Guidelines for Doctors and Dentistsin Training on the KSS website www.kssdeanery.ac.uk ]. No funds are provided in respectof capital charges.23. Schedule C – Library and Knowledge ServicesFrom April 2011 a new funding model has been implemented for the provision of Library andKnowledge Services within the LEP. This comprises a fixed cost associated with having alibrary presence and a variable cost based on activity, quality and collaboration. A transitionalarrangement is being applied to the model, to limit the impact of the changed arrangements onLibrary and Knowledge Services budgetary allocations.23.1 The LEP will provide equitable Library and Knowledge Services to all categories ofNHS staff working in the hospital, community and primary care settings in the local healtheconomy. Specific details of the organisations and users served as well as the servicesprovided can be found in Schedule C.23.2 It should be noted that KSS Deanery funded library and knowledge services postscannot be frozen without the agreement of the Library and Knowledge Services Manager andthe KSS Deanery.23.3 KSS requires that the total sum allocated must be spent as detailed in Schedule Con Library and Knowledge Services. Any virement and or other special arrangements (forexample library and knowledge services reconfigurations or staff re-gradings) must be agreedwith the KSS Library and Knowledge Services Team.

23.4 In collaboration with the NHS Trust Finance Department the Library and KnowledgeServices Manager will provide the KSS Library and Knowledge Services Team with a quarterlyreport on expenditure.Management of funds issued by KSS24. All funds issued by KSS must be used for educational purposes. KSS issues these funds tothe LEP expressly to support KSS Contracted Services.25. If funds cannot be utilised for the purpose of supporting KSS Contracted Services, within thefinancial year that they are issued, then they must be made available to support KSSContracted Services within the LEP in the following year, or returned to KSS.26. It is not acceptable for the LEP to generate savings from any funds issued by KSS, or to usethem for any purpose other than to support KSS Contracted Services.27. The LAB must have formal arrangements with the LEP whereby all monies provided to theLEP by KSS are ring-fenced and can be used for purposes deemed appropriate by the LAB’sChair or Academic Registrar or Library and Knowledge Services Manager without delay.28. Funds relating to Schedule A are used to reimburse the LEP for pay costs, which arise throughthe employment of postgraduate doctors and are therefore to be managed by a LEPrepresentative.29. Funds relating to Schedule B are to be managed by the Chair of the LAB.Funds relating to Schedule C are to be managed by the LEP’s Library and Knowledge ServicesManager.30. The LEP will be expected to account for its annual expenditure against KSS funding at eachContract Review as part of the Education Audit.Annual review of funding31. The level of funding which KSS provides to the LEP is entirely dependant upon:31.1. the rate at which the DH funds postgraduate medical education in future years and31.2. funding constraints within the NHS, which may impact upon KSS resources.KSS will, therefore, annually review its rate of funding to the LEP in light of any changes to theabove. This may occur in year if DH and NHS funding arrangements are only agreed after thestart of the financial year.Exclusions32. KSS will not pay for salary supplements, such as out of hours banding, or for any element ofsalary protection relating to any postgraduate doctor.

AppendicesSchedules of Funding: Schedule A – Pay. Schedule B – Education Centres Schedule C – Library and Knowledge Services which includes a specification of users andservicesQuality Manual SpecificationLocal Academic Board Education Strategy Specification

Signature by parties to the Education ContractThe undersigned agree to comply with the terms and conditions outlinedabove:Local Education Provider:Signed:Name:Date:Position:NHS Trust Chief Executive or nominated officerSigned:Name:Date:Position:Chair of Local Academic BoardSigned:KSS:Name:Professor David BlackPosition:Dean Director

7 Bermondsey StreetLondonSE1 2DDMain Tel: 0207 415 3400Main Fax: 0207 415 3686Educational Governance:Contract Review and Development2012/13Quality Manual SpecificationWith our partnersChair, Deanery Board - Professor Sir David Melville CBEDean Director - Professor David Black

CONTENTSGlossaryKSS specifications detailed by General Medical Council [GMC] DomainsDomain 1: Patient safetyDomain 2: Quality management, review and evaluationDomain 3: Equality, diversity and opportunityDomain 4: Recruitment, selection and appointmentDomain 5: Delivery of approved curriculum including assessmentDomain 6: Support and development of trainees, trainers and local facultyDomain 7: Management of education and trainingDomain 8: Educational resources and capacityDomain 9: Outcomes

Glossary of TermsARCP Annual Review of Competence ProgressionAV Audio-VisualCEO Chief Executive OfficerCPD Continuing Professional DevelopmentCS Clinical SupervisorDME Director of Medical EducationES Educational SupervisorEWTR European Working Time RegulationsGEAR Graduate Education and Assessment RegulationsGMC General Medical CouncilGP General PracticeGPSTP General Practice Specialist Training ProgrammeHR Human ResourcesHST Higher Specialty TrainingIT Information TechnologyKSS Kent, Surrey and SussexLAB Local Academic BoardLCP Local Curriculum in PracticeLEP Local Education ProviderLFG Local Faculty GroupLKS Library and Knowledge ServicesLTFTT Less Than Full Time TrainingMEM Medical Education ManagerNCF National Curriculum FrameworkPGMDE Postgraduate Medical and Dental EducationQESP Qualified Educational Supervisor ProgrammeQM Quality ManualSAS Staff and Associate SpecialistSIG Special Interest GroupSPA Supporting Professional ActivitiesTPD Training Programme Director

When completing the Quality Manual, it should be noted that it is insufficient to write that aLocal Education Provider (LEP) is compliant with the individual domains and their sub-criteria,it is also necessary to state how it is compliant and how this compliance is quality assured bythe Local Academic Board (LAB) and Local Faculty Group (LFG) structure.Domain 1: Patient safetyThe duties, working hours and supervision of trainees must be consistent with the delivery ofhigh quality, safe patient care. There must be a clear procedure to address immediately anyconcerns about patient safety arising from the training of doctors.1 Induction to the Local Education Provider [LEP]Domain 1.1 [see KSS specification 27 for Induction to Programmes; KSS specification 32 for Induction to theDepartment]The Local Academic Board [LAB] and Local Faculty Groups [LFGs] ensure that induction to the LEP:a) Emphasises that postgraduate doctors must make the needs of patients their first concern throughappropriate LEP mandatory training and as set out in the LEPs values and behaviours.b) Ensures that formal Induction into the LEP for all grades and specialties is structured, effective andinclusive (late starters, locums, etc).c) Ensures that induction includes NHS mandatory training requirements, and is recorded on NHSsecure management systems.d) Ensures that incoming Foundation year 1 [F1] doctors are able to shadow their opposite numberprior to taking up their first post, in order to support induction to the hospital and the post.e) Ensures that doctors from overseas receive appropriate induction to the UK and the NHS.2 Work patterns and intensityDomain 1.2, 1.3, 1.5, 1.6, 6.9, 6.10The LAB, linking with LFGs where appropriate must ensure that:a) Postgraduate doctors' working patterns and intensity of work, by day and by night, including on-callrotas:i) Are appropriate for learning new skills.ii) Enable access to theatre sessions, ward rounds and outpatient clinics as appropriate.iii) Provide shift and on-call rota patterns that minimise the effects of sleep deprivation in linewith European Working Time Regulations [EWTR].iv) Provide adequate time for well-organised handover arrangements, which ensure continuityof care at the start and end of periods of day or night duties.b) Working patterns are developed to ensure that:i) All postgraduate doctors and dentists are appropriately supervised according to theirexperience and competence.ii) Those supervising the clinical care provided by postgraduate doctors are clearly identified;competent to do so; accessible and approachable by day and by night; with sufficient timefor these responsibilities clearly identified within their job plan.c) Through its Human Resources [HR] Department:i) diary card exercises are completed appropriately.ii) compliance with EWTR is monitored appropriately.

3 Clinical responsibilityDomain 1.2, 1.4The LAB, with LFGs where appropriate, must ensure that those supervising postgraduate doctors inthe clinical setting (e.g. Educational Supervisors, Clinical Supervisors and other health careprofessionals):a) Carry out a realistic assessment of the competence of postgraduate doctors or dentists they aresupervising and on the basis of that assessment, judge the appropriate level of exposure to clinicalresponsibility commensurate with delivering safe patient care.b) Ensure that before seeking consent both postgraduate doctor and supervisor are satisfied that thepostgraduate doctor:i) Understands the proposed intervention and its risks.ii) Is prepared to answer associated questions the patient may ask.iii) Have access to a supervisor with the required knowledge if they are unable to answerquestions asked by the patient.iv) Is able to act in accordance with GMC guidance Consent: Patients and Doctors MakingDecisions Together (2008), The Michael Report: Healthcare for All (2008) and the GettingIt Right Charter (2010).4 Clinical supportDomain 1.1, 6.12, 8.1The LAB must ensure that Laboratory and Radiology services within the LEP are available on a 24-hour basis, in order to provide high quality patient care and to ensure that activities of no educationalvalue, such as inappropriate duties, do not obstruct PGMDE.

Domain 2: Quality Management, review and evaluationPostgraduate education must be quality managed locally by deaneries, working with others asappropriate e.g. medical Royal Colleges/Faculties, specialty associations, education providers.5 Graduate Education and Assessment Regulations [GEAR]Domains 2.1, 2.2, 2.3, 6.7, 6.29, 6.34, 7.1, 7.2, 7.4, 7.5GEAR sets out the academic quality management specification for progression, review and evaluationof PGMDE in KSS. The LAB must ensure that:a) Its operation is compliant with GEAR.b) Pharmacy is incorporated into its work and represented appropriately in its management,monitoring and review of the Contract.c) Library and Knowledge Services [LKS] is incorporated into its work and represented appropriatelyin its management, monitoring and review of the Contract.d) LFGs are established and constituted according to the requirements of GEAR in order to manage,monitor and review all KSS programmes within the LEP including Foundation, Core and HigherSpecialty Training [HST]. In accordance with GEAR LFGs are required to:i) manage, monitor, support and be held accountable for the progress of their postgraduate doctors,dentists and pharmacists, by holding formal LFG meetings at least three times each year.ii) progress any issues concerning recruitment, retention, progression, remediation or completion inorder to resolve them in a timely fashion.iii) receive a summary of feedback from their postgraduates, outlining what they value in theirprogramme and their main issues and concerns, at each meeting, and respond appropriately to it.e) All red flag issues identified within the yearly GMC surveys are progressed, resolved and reportedappropriately to KSS.f) All KSS Contract Review and GMC visits, are managed appropriately and take responsibility forresulting action plans, progressing reports within the time-scale laid out following each visit.g) A record of all Quality Management visits is maintained.h) Appropriate lines of communication are maintained between KSS, relevant national authorities andthe LEP by acting as a conduit for all matters concerning PGMDE.6 Security of InformationDomain 2.1The LAB must ensure that all information concerning postgraduate education is:a) maintained securely, and in accordance with NHS Information Governance requirements, DataProtection Act and Freedom of Information Act, with appropriate policies and procedures in place foraccess by postgraduates if necessary.b) transferred confidentially between the LEP and KSS; and between the LEP and other LEPs.

7 Intrepid: postgraduate doctor and dentist dataDomain 2.1, 6.20, 6.21, 9.1The LAB, with its LEP’s Information Technology [IT] Director and HR Director, must ensure that:a) The current data sets required by KSS are entered onto the Intrepid database within 4 weeks ofeach postgraduate taking up a new placement [‘new starters’] within the LEP as required by KSS.b) The LEP has a system for ensuring that all data are current which includes details of all study leavetaken by postgraduates as required by KSS.c) The LEP adheres to all KSS specifications for providing equipment and support for Intrepid.8 Intrepid: monitoring educational supervisionDomains 2.3, 9.1The LAB, through its LFGs and with its LEP’s IT Director, must record data for specialties without ane-portfolio, to show that all Education Supervisors meet their postgraduates at the start, middle andend of their post, using the appropriate section of Intrepid.9 Short term cover for medical staffing functionsDomain 2.3, 9.1The LAB, through its LEP’s HR Department, must ensure that trained short-term cover is provided forall medical staffing functions including usage of Intrepid.

Domain 3: Equality, diversity and opportunityPostgraduate training must be fair and based on principles of equality10 Equality, diversity and opportunity in appointmentsDomain 3.1, 3.5The LAB, through the LEP’s HR Department, must ensure that:a) The LEP’s local appointment processes for postgraduates adheres to the NHS equality anddiversity mandatory standards and relevant legislative regulations.b) Postgraduates have access to evidence on postgraduates' recruitment, appointment, andsatisfaction with the results analysed by appropriate characteristics of the Equality Act 2010, such asethnicity, place of qualification, disability, gender and part-time training/working.11 Equality, diversity and opportunity in educationDomain 3.1, 3.2The LAB, through its LFGs and the LEP’s Human Resources Department, must ensure that:a) All educational programmes and information about them is compliant with UK Employment Law,The Human Rights Act and with the characteristics of the Equality Act 2010 and other equalopportunity legislation that may be enacted and amended in the future and is working towards bestpractice.b) Information about all educational and training programmes, their content and purpose, is publiclyaccessible either on, or via links to postgraduate deaneries and GMC websites.12 Less than full time training [LTFTT]Domain 3.3The LAB, through its LFGs, and the LEP’s HR Department, must ensure that:a) Arrangements are in accordance with the KSS Less than Full Time Training Policyb) Programmes can be adjusted for postgraduate doctors and dentists with well-founded individualreasons for being unable to work full time to follow LTFTT.c) Its LEP accepts a fair share of LTFTT.d) Statistical data on LTFTT is provided to KSS in LAB and LFG Annual Audit and Reviews.13 Reasonable adjustmentsDomain 3.4The LAB, through its LFGs and the LEP’s HR Department, must ensure that reasonable steps aretaken to ensure that programmes can be adjusted for postgraduates who have disabilities, specialeducational or other relevant needs.

Domain 4: Recruitment, selection and appointmentProcesses for recruitment, selection and appointment must be open, fair, aid effective andthose appointed must be inducted appropriately into training14 Registration of postgraduate doctors and dentistsDomain 4.1The LAB, through its LFGs and the LEP’s HR Department, must ensure that all new postgraduates:a) Have an appropriate licence to practice.b) Are fit to practice.c) Have provided appropriate references.d) Have completed appropriate CRB checks.15 Immigration requirementsDomain 4.1The LAB, through its LEP’s HR Department, must ensure compliance with requests for informationfrom KSS to meet UK Border Agency monitoring requirements.16 Specialty training postsDomain 4.1The LAB, in partnership with the LFG, must ensure that:a) Posts are approved by KSS in order to allow these posts to be accredited by the GMC.b) Appropriate lines of communication must exist between Medical Education Managers [MEMs], KSSSchools, Training Programme Directors [TPDs], and medical staffing so that the correct information onnumbers and nature of posts is available.17 Selection into specialty and higher specialty programmesDomain 4.2The LAB, through its LFGs, must ensure that postgraduate doctors are provided with appropriateopportunities to gain competencies and progress towards sign off in order to be able to demonstratethe competencies required to complete Foundation and Core and thereby be considered for entry intospecialty or higher specialty programmes. (This covers candidates who have completed Foundationtraining, candidates who apply before completion and those who have not undertaken Foundationtraining, but can demonstrate the competencies in another way.)18 Managing HST transition into KSS Specialty SchoolsDomain 7.2The LAB, through its LFGs, must ensure that appropriate lines of communication are maintained withother deaneries regarding the recruitment, appointment and progress of Higher Specialtypostgraduate doctors participating in programmes with the LEP.

19 Recruitment and selectionDomain 4.3The LAB, through its LFGs and the LEP’s HR Department, must ensure that:a) Information about places on programmes, eligibility and selection criteria and the applicationprocess is made widely available in sufficient time to doctors who may be eligible to apply.b) The selection process uses criteria and processes that treat eligible candidates fairly.c) Candidates are selected on the basis of open competition.d) There is an appeals system against non-selection on the grounds that the criteria were not appliedcorrectly, or were discriminatory.e) Only such information (apart from information sought for equalities monitoring purposes) is soughtfrom candidates as is relevant to the published criteria and which potential candidates have been toldwill be required.f) Timely reports and information about recruitment, selection and appointment processes arereceived by KSS and its Schools.20 Local selection panelsDomain 4.4, 4.5The LAB, through its LFGs and the LEP’s HR Department, must ensure that local selection panels:a) Consist of persons who have been trained in selection principles and processes.b) Include a KSS representative where appropriate, such as the Director of Medical Education [DME],the Clinical Tutor, or a TPD.c) Include a lay representative.21 Advertising placements locallyDomain 4.3The LAB and the LEP’s HR Department, must ensure that permission is sought from the KSS DeanDirector whenever it is proposed to advertise an education and training placement locally includingthose associated with a planned programme or rotation.22 Contract of employmentDomain 8.1The LAB and the LEP’s HR Department, must ensure that each postgraduate receives a written legalcontract of employment before commencing their post, and that even under exceptionalcircumstances it is received no later than six weeks after commencing their post.23 Job descriptionDomain 8.1The LAB and the LEP’s Human Resources Department, must ensure that every placement has an upto date and accurate job description, which is given to each postgraduate when entering the LEP.

Domain 5: Provision of approved curriculum including assessment.The requirements set out in the approved national curriculum framework [NCF] must beprovided by the local curriculum in practice [LCP]. The approved assessment system must befit for purpose.24 LFG HandbooksDomain 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, 6.8The LAB must ensure that each of its LFGs produces an annually updated handbook that sets out indetail its LCP, in compliance with GEAR, including:a) How competencies within the approved curriculum will be achieved.b) How the posts within the programme, taken together, will meet the requirements of the approvedcurriculum and what must be taught within each post.c) The need for postgraduate doctors to have due regard to, and to keep up to date with, theprinciples of Good Medical Practice.d) How postgraduates will be able to access and be free to attend training days, courses, resourcesand other learning opportunities that form an intrinsic part of their programme and constitute part oftheir learning entitlement.e) How postgraduates requiring additional support are provided with this.f) Where postgraduates should go for career support.g) Where postgraduates should go to personal counselling.h) The approved assessment system implemented by the LFG.i) The purposes of each and all components of the approved assessment system.j) The sequence of approved assessments, matched to the learner’s progression through their careerpathway.k) The points at which regular feedback will be given to the postgraduate on their performance withintheir post i.e. supervision meetings and appraisal meetings as distinct from assessments.25 Induction to educational programmeDomain 5.1, 5.2, 5.3, 5.4, 5.6The LAB must ensure that all its LFGs provide an induction into their educational programmes that:a) Sets out how competencies within the National Curriculum Framework (NCF) will be achieved.b) Sets out how the posts within the programme, taken together, will meet the requirements of theNCF and what must be taught within each post.c) Reminds postgraduates about the need to have due regard to, and to keep up to date with, theprinciples of Good Medical Practice.d) Sets out how postgraduates will be able to access and be free to attend workshops and courses,access resources and utilise other learning opportunities that form an intrinsic part of their programmeand constitute part of their learning entitlement.e) Sets out how postgraduates requiring additional support are provided with this.f) Indicates where postgraduates should go for career support.g) Indicates where postgraduates should go for personal counselling.h) Sets out the approved assessment system implemented by the LFG.i) Sets out the purposes of each and all components of the approved assessment system.j) Sets out the sequence of approved assessments, matched to the postgraduate’s progressionthrough their career pathway.k) Sets out the points at which regular feedback will be given to the postgraduate on theirperformance within their post.l) Ensures that all postgraduates have a copy of the LFG’s current handbook and that copies havebeen sent to KSS to the appropriate School.

m) Ensures all LFG handbooks are in the public domain by being available on the LEP’s and KSSSchool’s websites for reference purposes.26 Curriculum developmentDomain 5.1, 5.2, 5.4, 6.17The LAB must engage with KSS new curriculum developments and in particular ensure that:a) All Foundation doctors have access to and are released for simulation training during the course oftheir programme.b) Postgraduates have access to clinical audit processes, which includes participating in planning,data collection and analysis.c) Postgraduates have the opportunity to learn with, and from, other healthcare professionals.d) There is a LAB lead for new curriculum developments in:i) Simulation.ii)Careers.iii)Leadership (i.e. Leadership Pairing Scheme, Postgraduate CertificateModule in Leadership etc).iv)Patients with Learning Disabilities.v) The Role of Lay Representatives.vi)The Postgraduate Doctor’s Voice.vii)Medical Humanities.viii)Co-Mentoring.ix)Curriculum mapping.27 Educational assessmentDomain 5.1, 5.5, 5.6, 5.7, 5.8, 5.9, 6.26The LAB, through its LFGs, must ensure that:a) Appropriate opportunities for regular and timely assessment are available for postgraduates to fulfiltheir curriculum requirement.b) All assessments are appropriately documented to ensure that sufficient information is available forthe Annual Review of Competence Progression [ARCP] process and for recruitment.c) Educational Supervisors regularly review each postgraduate's learning portfolio and meet withthem at timely intervals to provide feedback and support, in order to ensure that they are progressingappropriately.d) All assessors have the practical experience and are able to use the in-work assessment tools tomake judgments on the progress of postgraduates.e) All assessors record their assessments in a timely fashion, using the appropriate portfolio or e-portfolio.f) An up-to-date database of assessors, their qualification to undertake the assessment role and thedate on which they qualified, is maintained by the LEP.

28 Study leave availabilityDomain 5.4, 6.19, 6.20, 6.21The LAB, with its LEP’s HR Director and its LFGs, must ensure that:a) Study leave appropriate to the career choice of each postgraduate is available, and operates withinKSS Study Leave Guidance and the relevant Terms and Conditions of Service for Hospital MedicalStaff, so that the process for applying for study leave is fair and transparent, and information about theKSS appeals process is readily available.b) All postgraduates are given or have access to KSS and/or the LEP local study leave guidance,including guidance on how to apply for study leave.c) All postgraduates are guided as to appropriate use of study leave funding and time, and are madeaware of appropriate courses and funding within the LEP.29 Study leave for Staff and Associate Specialist [SAS] and Trust Grade doctorsDomain not applicableThe LAB must ensure that:a) Where study leave and/or funding is provided by the LEP for SAS and Trust Grade doctors, whoseeducation may be recognised by the medical Royal Colleges, similar systems must be used to thosefor postgraduate doctors.b) Where LABs administer those arrangements, their LEP must ensure that administrative costs arefunded.

Domain 6: Support and development of postgraduates and local facultyPostgraduates must be supported to acquire the necessary skills, and experience throughinduction, effective educational supervision, and appropriate workload and time to learn.30 lnduction to the departmentDomain 6.1The LAB, through their LFGs, must ensure that:a) Every specialty, unit or department provides an induction programme which ensurespostgraduates:i) understand the approved curriculum.ii)understand how their post fits within their educational programme.iii)understand their duties and reporting arrangements.iv)are told about departmental policies.v) meet key staff.vi)receive details of well-organised handover arrangements, which ensurescontinuity of care at the start and end of periods of day or night duties.b) Up-to-date copies of Departmental Induction Programmes are lodged with the LAB.c) Induction to the specialty, unit or department must be prioritised in order to ensure postgraduatesare fully prepared to provide effective patient care in their first hours on duty.d) Induction to the specialty, unit or department provides each postgraduate with an opportunity to selfassess their abilities putting patient care as their first concern.31 Educational supervisionDomain 6.3The LAB, through its LFGs and the LEP’s HR Department, must ensure that:a) All postgraduates are allocated an Educational Supervisor at the start of their programme, withname and contact details provided as part of each postgraduate doctor’s induction.b) All Educational Supervisors know who their new postgraduate is, where they will initially beworking, and how long they will be working within the LEPc) All Educational Supervisors have sufficient time in their job plans to undertake the Educationalsupervision of their postgraduates in accordance with the tariff document (.25 SPAs perpostgraduate).32 Education plansDomain 6.2, 6.4, 6.5The LAB, through its LFGs, must ensure that:a) Within four weeks of starting post, each postgraduate has agreed with their EducationalSupervisor:i) The educational framework and support systems in the post.ii) Their respective responsibilities for teaching and learning.iii) A learning agreement and educational plan setting out agreed learning and careerobjectives in line with the requirements of the local and national approved curriculumb) All postgraduates must have access to an appropriate log book and/or learning portfolio relevant totheir current programme which they discuss with their Educational Supervisor.c) All postgraduates must have the opportunity to experience leadership at an appropriate level andto be assessed on this so that the assessment forms part of their portfolio.

d) Postgraduates should be allowed time to attend teaching sessions.33 Education development meetingsDomain 6.6, 6.15, 6.16The LAB, through its LFGs, must ensure that:a) Postgraduates have further, fully documented meetings with their Educational Supervisor at leastevery three months, to discuss their progress in relation to their educational plan, their outstandinglearning needs and how to meet them.b) Postgraduates are able to attend relevant, timetabled, organised educational meetings and haveprotected time for this.c) Postgraduates are able to access training in generic professional skills at all stages in theirdevelopment.34 Clinical supervisionDomain 6.13, 6.25The LAB, through its LFGs, must ensure that:a) All postgraduates are allocated a clinical supervisor for each element of their programme.b) Clinical supervisors meet their postgraduate within the first 2 weeks of their clinical placement toensure that both the clinical supervisor and postgraduate have a mutual understanding of theexpectations within the post. This may include attendance at theatre sessions, or outpatient clinics asappropriate, departmental teaching, clinical audit processes, and confirming ways in which thepostgraduate can learn in the workplace.c) Clinical supervisors advise the postgraduates Educational Supervisor and the LFG if they have anyconcerns about the ability of their postgraduate or concern for patient safety, or any other issues orconcerns for the postgraduate.d) Clinical supervisors judge the appropriate level of exposure to clinical responsibility for theirpostgraduate, commensurate with delivering safe patient care.e) Clinical supervisors have undertaken QESP Part 1 or as a minimum have had other education ortraining recognised by the LFG and LAB as stated in the KSS Recognition and Qualification forClinical Supervisors (2010) guidelines.35 Academic educationDomain 6.22, 6.23, 6.24The LAB, through its LFGs, must ensure that:a) Postgraduates are exposed to the academic opportunities available in their specialty.b) Postgraduates who recognise that their particular skills and aptitudes are well suited to anacademic career should be encouraged and guided in that endeavour.c) Postgraduates who elect and who are competitively appointed to follow an academic path, aresited in flexible approved programmes of academic education that permit multiple entry and exit pointsthroughout their education, from other programmes.

36 Workplace bullyingDomain 6.11The LAB, through its LFGs and the LEP’s Human Resources Department, must ensure that:a) At commencement of employment each postgraduate receives details of the LEP’s anti-workplacebullying policy and how it is implemented when necessary.b) Copies of this and other policies are maintained on the LEP’s website and details of where theycan be found are available within all LFG handbooks.c) All instances of workplace bullying or any behaviour which undermines postgraduates’ professionalconfidence or self-esteem are reported, reviewed and progressed in the LFGs’ and the LAB’s AnnualAudit and Review.37 Pastoral careDomain 6.14, 6.18The LAB, through the LEP’s HR Department, must ensure that:a) Occupational health and pastoral care is readily accessible to all postgraduates and that allpostgraduates know where to go for help when needed.b) Access is provided to an independent and confidential counselling service if needed bypostgraduates.c) The Improving Working Lives quality standard is adhered to for postgraduates.38 Faculty development: SelectionDomain 6.32, 6.33The LAB, through its LFGs, must ensure that:a) Faculty members with additional educational roles must be selected and demonstrate ability as aneffective teacher to the standard required by KSS.b) GP trainers are trained and selected in accordance with the General and Specialist MedicalPractice (Education, Training and Qualifications) Order 2003.39 Faculty development: CPDDomain 6.25, 6.32, 6.34The LAB, through its LFGs, must review the CPD needs of all Faculty members at least annually toensure that they:a) Can enable postgraduates to learn by taking responsibility for patient management within thecontext of clinical governance and patient safety.b) Understand and demonstrate ability in the use of the approved in-work assessment processes andbe clear as to what is deemed acceptable progress.c) Have knowledge about, and comply with, national regulatory frameworks.

40 Faculty development: Job PlansDomain 6.30The LAB, with its LEP’s CEO, must ensure that Faculty members have adequate support andresources to undertake their educational roles.41 Faculty development: Qualified Educational Supervisor Programme [QESP]Domain 6.27, 6.28The LAB, through its LFGs, must ensure that all Educational Supervisors have completed or are inprocess of completing QESP so that they are accredited as being able to:a) Ensure that clinical care is valued for its learning opportunities.b) Ensure that learning and teaching is integrated into service provision.c) Regularly review postgraduate doctors’ progress.d) Adopt a constructive approach to giving feedback on performance.e) Advise on career progression.f) Understand the process for dealing with a postgraduate doctor whose progress gives cause forconcern.42 Faculty development: assessmentDomain 6.26, 6.30, 6.35The LAB, through its LFGs, must ensure that all those who provide assessment understand therequirements of the programme and are clear as to what is deemed acceptable progress.43 Faculty development: capacity growthDomain 6.29, 6.31The LAB, through its LFGs, must support and develop the capacity of its Faculty by:a) Identifying and supporting Faculty members who wish to follow KSS’s Master’s degreeprogrammes in Education, Leadership, Careers, and Medical Humanities.b) Identifying and supporting Faculty members who wish to take on specific lead roles in KSS crosscurriculumdevelopments.c) Supporting the creation of Special Interest Groups [SIGs] within the LEP and enabling them toshare practice across LFGs and across KSS LEPs.d) Gaining ethical approval for research, development and evaluation as part of postgraduates' andtheir faculty's service improvement projects from the KSS Education Ethics Committee.

44 Faculty development: recordsDomain 2.3, 3.1, 6.31, 9.1The LAB, through its LFGs and LEP’s HR Department, must maintain a current, central record of:a) Faculty members’ currency (renewable every three years) with Equality and Diversity training.b) Faculty member’s currency with Recruitment and Selection training.c) Progression of Faculty members through Assessment training.d) Progression of Faculty members through QESP, including a Register of Clinical Supervisors asper the KSS Recognition and Qualification for Clinical Supervisors (2010) guidelines, showingi) The Specialty/ies they superviseii) The LFG/s to which they belong (with smaller specialties this may be a more generic LFG)iii) Their status as Local Recognition or KSS Qualification as appropriateiv) The date on which they entered the Registere) Compliance by Faculty members with the KSS Advice on Job Planning for Consultants.f) Completion by Faculty members of their annual appraisal and their CPD review.g) Faculty members taking lead roles on cross-curriculum developments.h) Faculty members who have completed or are engaged in KSS Master’s degreesi) All Local Faculty Group meeting must be minuted and copies of all minutes must be sent to theappropriate KSS Specialty School in accordance with Point 10 (iv) page 33 of GEAR V3.

Domain 7: Management of educationEducation must be planned and maintained through transparent processes which show who isresponsible for each stage.45 Management of educationa) The Chief Executive Officer [CEO] of the LEP must ensure that its Local Academic Board (LAB) isconstituted according to the requirements of GEAR [which meets and exceeds GMC Standards] andthat it meets formally at least three times a year.b) The LAB must ensure that non-attendance by members at its formal meetings is notified to theCEO of the LEP and to the KSS Dean Director using the Annual Audit and Review process.c) The LAB must be accountable for the management, monitoring and review of the whole of the KSSContract signed with their LEP.d) A named member of the LEP’s Board attends LAB meetings.e) The LEP’s Board discusses the formal reports of the LAB three times a year.46 Support and career adviceDomain 6.8, 7.3The LAB must:a) Coordinate the provision of career advice and support for all grades and all specialties to ensureappropriate advice is available. This includes liaison with the GP Specialty Training ProgrammeDirectors, who have responsibility for providing appropriate career advice and support to thoseintending or considering general practice as a career.b) With its LEP’s HR Department:i) Ensure that details of how to apply for LTFTT are available to postgraduates.ii) Ensure that timely and effective support and guidance is provided to help postgraduatescomplete the LTFTT application and process.c) Ensure that the DME meets LFG Leads yearly for an educational appraisal.d) Ensure that the DME receives an annual educational appraisal from KSS.47 Postgraduates requiring additional supportDomain 7.3The LAB, with its LEP’s HR Department, must ensure that:a) The LEP has policies and procedures in place to support postgraduates who are experiencingdifficulties with their education, their working environment or their personal lives.b) These policies and procedures are available through the LEPs intranet site and within the specialtytraining handbook which is given to all postgraduates to ensure they are supported at all times.c) All LFG Leads and Educational Supervisors have access to the KSS Postgraduate DoctorsRequiring Additional Support guidance.d) An appropriate Occupational Health Service is readily accessible to all postgraduates, andinformation about this service is available to them at induction.

Domain 8: Educational resources and capacityThe educational facilities, infrastructure and leadership must be adequate to deliver theapproved curriculum.48 Education Centre and LKS facilitiesDomain 7.5, 8.4, 8.5 [Cross-reference to LKS QM Section 3]The LAB must ensure that:a) Appropriate facilities are available to meet the needs of effective management of the KSS Contract,including rooms, equipment and other relevant infrastructure.b) The Education Centre is able to analyse their resources to show percentage use under theheadings required by KSS’s management audit, to ensure that postgraduates have appropriateaccess to meeting rooms and audio-visual aids.c) The LAB must ensure that Education Centres and LKS have a system for maintain communicationsand relationships with other local Education Centres and LKS, where the work of one centre orlibrary affects that of others.d)Staff are released to attend relevant KSS group and project meetings where appropriate andnecessary to ensure continuity of communication with colleagues throughout the region. Minutes ofthese meetings to be provided to the LAB.49 Teaching and learning facilitiesDomain 8.2 [Cross-reference to LKS QM 2.2]The LAB must ensure that:a) Appropriate facilities for teaching and learning are available within the LEP to meet all the needs ofthe KSS Contract.b) Quiet study space is available within the Library and where applicable in the hospital residence andcommon rooms to enable postgraduates to study privately.c) Clinical skills and wet lab facilities are available to enable postgraduate doctors and dentists to fulfiltheir curricular requirements.b) Postgraduates, qualified GP’s, and dentists working in the wider health community haveappropriate access to teaching rooms for education outside normal 9.00-5.00 working.e) Suitable simulation facilities are available in line with KSS policy.50 LEP facilitiesDomain 8.1The LAB, with its LEP Facilities Manager, must ensure that:a) Postgraduates have access to hot food at night, during week-ends and during bank holidays.b) Postgraduates and faculty are secure when moving between parts of the LEP or when using LEPfunded transport.c) Appropriate on-call/rest rooms are made available for use by postgraduates.

51 Education technologiesDomain 8.1, 8.2 8.4, 8.5The LAB must ensure that:a) Faculty members have access to appropriate Audio-Visual (AV) equipment, including videoconferencing equipment that is able to be connected to other teaching areas, at suitable times.b) Educational Supervisors, clinical supervisors, and assessors have appropriate IT facilities to carryout their educational roles.c) AV equipment is maintained to a standard which is consistent throughout the LEP.d) There is a planned programme for upgrading all IT/AV/Video conferencing equipment informed bynew curricular requirements.52 IT facilitiesDomain 8.2, 8.4 [Cross-reference to LKS QM 2.3]The LAB, with its LEP’s IT Department, must ensure that:a) The Education Centre and LKS are part of the LEP IT network.b) At induction, all postgraduate doctors, dentists and preregistration pharmacists are given access toclinical results systems.c) All doctors, dentists, preregistration pharmacists and Education Centre staff have access to theInternet (via NHSnet) and e-mail.d) The LEP provides IT support which is timely and effective.e) All LAB and LEP staff are able to:i) receive emails and attachments from and send emails and attachments to KSS and between eachother without delay or difficulty.ii) utilise the IT packages and versions specified by KSS Schools.iii) fully access the KSS website without difficulty.iv) fully access KSS’s web-based Virtual Learning Environment without difficulty.v) access the Intrepid database for all appropriate staff within the postgraduate and medical HRdepartments.vi) make full use of all of the features of the new IT and web-based Foundation/Specialty programmeeducational resources.vii) request hardware which is sufficient to the staff’s needs within the postgraduate and medical HRdepartment.viii) request software which is sufficient to the staff’s needs within the postgraduate and medical HRdepartments.53 Support staffDomain 7.5, 8.1The LAB must ensure that appropriate support is available for:a) All LAB and LFG administration.b) Administration for Qualified General Practitioners CPD as negotiated by GP Tutor.c) The co-ordination of Qualified Dental Practitioners CPD as negotiated by Dental Tutor.d) All appropriate portering requirements.

54 Workforce planningDomain 8.1The LAB, with its LEP’s HR Department, must ensure that:a) The procedure for workforce planning is clearly defined and involves appropriate representation.b) A prompt and accurate response is made to all KSS requests for workforce planning data for allgrades and specialties of doctors, including consultants, staff grades, overseas doctors, attachmentsand postgraduate doctors.55 Appointment of DME/Clinical TutorDomain 7.5, 8.1The LAB, with its LEP’s HR Department, must ensure that the procedure for the joint appointment ofthe DMEs and Clinical Tutors is in accordance with KSS guidance, which is available through the KSSHR Department.56 Appointment of staff to the PGMDE functionDomain 7.5, 8.1The LAB, with its LEP’s HR Department, must ensure that:a) There is a clearly defined, written LEP policy and procedure for the appointment of staff to allPGMDE functions:b) Processes are in place for ensuring that vacancies are filled in a timely fashion.c) Provision is made for PGMDE staff to have access to funding for overtime or time in lieu for worktaking place outside normal working hours in the delivery of the PGMDE function within the LEP.d) New DMEs, Clinical Tutors and MEMs receive appropriate induction by both the LEP, and throughattendance at KSS programmes.e) Provision is made for support staff within the PGMDE function to attend external meetings andcourses appropriate to their role in order to develop PGMDE within the LEP.57 Budgetary accountabilityDomain 7.5, 8.1 [Cross-reference to LKS QM 5.2]The LAB, with its LEP’s Finance Department, must ensure that:a) DME/ Clinical Tutors are:i) Accountable for the entire Schedule A and Schedule B KSS element of the PGMDE budget.ii) Accountable to the Chief Executive for it.iii) Provide clear accountability for any delegated budgetary responsibilities to the MEM.b) Library and Knowledge Services Managers are:i) Accountable for the entire Schedule C KSS element of the PGMDE budget.ii) Aaccountable to the Chief Executive for it.iii) Provide clear accountability for any delegated budgetary responsibilities.c) Chief Pharmacists are:i) Accountable for the entire budget for Pharmacy Education.ii) Accountable to the Chief Executive for it.iii) Provide clear accountability for any delegated budgetary responsibilities.

58 Annual finance returnsDomain 8.1The LAB, with its LEP’s Finance Department, must ensure that the LAB makes completed AnnualReturns within six weeks of them being requested by KSS in respect of:i) PGMDE Budget.ii) SAS CPD Funding [by the end of March in each financial year].iii) GPSTP funding.iv) GP education support.v) Other budgets both recurring and non-recurring, not covered by the single contract.59 Notification of financial transfersDomain 8.1 [Cross-reference to LKS QM Section 5]The LAB, with its LEP’s Finance Department, must ensure that the LAB records notifications fromKSS when funds intended for the Education Centre and LKS are transferred to the LEP by KSS.60 Expenditure of KSS moniesDomain 8.1 [Cross-reference to LKS QM Section 5]The LAB, with its LEP’s Finance Department, must ensure that the LAB has formal arrangements withthe LEP whereby:a) All monies provided to the LAB by KSS are ring-fenced and can be used for purposes deemedappropriate by the DME/Clinical Tutor, MEM, the Library and Knowledge Services Manager [LSM] orChief Pharmacist as appropriate without delay.b) Monies provided to the LAB by KSS are not used in LEP Cost Efficiency Savings.c) The LEP must have a facility for carrying over eligible funds from one financial year to the next as aprecondition of accepting funding from KSS for educational projects which span more than onefinancial year.d) Educational project funding may not be vired between other KSS budget heads without specificwritten agreement from KSS.e) Educational project funding must be spent on the approved education project or returned to KSS.

Domain 9: OutcomesThe impact of the standards must be tracked against outcomes and clear linkages should bereflected in developing standards.61 Review and improvementDomain 9.1The LAB, through its LFGs, must:a) Review the outcomes of all summative assessments and examinations results for each programmeand benchmark the standards against other programmes locally and regionally.b) Provide an opportunity for programmes to share good practice, through their regular 4-monthlymeetings.c) Seek to improve the provision of education by sharing good practice and seeking to identify goodpractice within other training organisations.

Educational Governance:KSS Contract Review2012-13Local Academic Board StrategySpecificationThe KSS Deanery 7 Bermondsey Street London SE1 2DDTel: 020 7415 3400 Fax: 020 7415 0044 www.kssdeanery.ac.ukDean Director Professor David Black MA MBA FRCPHead of Education Professor Zoë Playdon BA(Hons) PGCE MA PhD MEd DBA FRS

NameLocalAddressTelephone numberWebsiteNumber of sitesChief ExecutiveMedical DirectorDirector ofMedical EducationMedical EducationManagerChief PharmacistLibrary ServicesManagerNameContact detailsPlease give the following details for each siteClinical TutorGP TutorDental TutorCapacity ofteaching roomsSimulation facilitiesLibrary facilitiesEducation Provider [LEP] Summary

CONTENTSGMCDomains

Results of Action Plan 7, 8Educational Management Audit 81 Support for Educational Roles 62 Attendance Audit of Local Faculty Groups [LFGs] 3, 4, 73 Developing Local Educational Capacity 64 Medical and Dental Staffing 3, 4, 75 External Visits and Inspections 7, 96 Linking Undergraduate and Postgraduate Medicine n/a7 Appraisal and Continuous Professional Development 68 Education Centre Usage 3, 4, 79 Educational Technologies 3, 4, 710 LEP Management Continuity 3, 4, 711 LEP Management Infrastructure 3, 4, 712 SPOC for KSS Finance 813 LAB ‘Metrics’: regional RAG rating All

Results of Action Plan 2011The KSS request:Please list the Action Agreed from last year’s Action Plan, annotated appropriately to show progressunder the following headings:Action CompletedAction in Progress: a short statement of progress to date, including action discussedin your Business Analysis and Strategic PlanAction attempted: a short statement of what action was taken and why it was notcarried through to completionAction not taken: a short statement explaining why action was not taken.

Education Management Audit1 Support for Educational RolesIn 2010 KSS re-issued formal Advice on Education and Job Planning for Consultants, setting out the usual contractual requirementsnecessary for consultants to undertake educational roles. Please record the numbers of consultants in your LEP compliant with thisbenchmark, using the format below, for the roles of: Educational Supervisor; Clinical Supervisor; Local Faculty Group Lead; RecruitmentSupport; STC, Head of School, or Training Programme Director; and for cross-curricular roles in Simulation; Leadership; MedicalHumanities; Careers; and Undergraduate Medical Education.Numbers CompliantKSS SchoolTotalNºESTotalNºCSTotalNºLFG LeadTotalNºRecruitsupportTotalNºHoSTotalNºTPD Total N STCACCSAnaestheticsEmergency MedicineIntensive Care MedicineMedicineObstetrics & GynaecologyOphthalmologyPaediatricsPathologyPsychiatryRadiologySurgeryOther Specialties

Cross-CurricularRolesNumbers CompliantSimulation Leadership MedicalHumanitiesCareersUGME2 Attendance audit of LFGsPlease update and include your attendance chart from your LAB Annual Audit andReview to show:- the Local Faculty Groups [LFGs] that report in to the LAB showing:- the number of members of each LFG;- the number attending each LFG for its last three meetings.Please list additional LFGs that you plan for the future with their start dates3 Developing Local Educational CapacityTo support LABs in their faculty development role, in line with the requirement of Liberating the NHS:Developing the Healthcare Workforce that workforce development should be ‘professionally informedand underpinned by strong academic links’ (p. 9), KSS makes available a suite of MA programmesspecifically relevant to postgraduate medical education. Please report on the number of people in yourLEP who have either completed or are currently attending a KSS Master’s programme or anequivalent with other providers, using the following format.Programme KSS Other Provider(Please specify)Education in Clinical SettingsLeadership in ClinicalSettingsManaging Medical CareersMedical HumanitiesOther Master’s or Doctoralprogrammes (please specify)Totals4 Medical and Dental Staffinga) the numbers of doctors and dentists currently supported by the LAB, including Trust doctors.Please explain any differences in numbers in your funding breakdown.Grades Medicine DentistryConsultantSASFY1

FY2CM1CM2CS1CS2HSTGP1GP2GPST3+DF1DF2Clinical AttachmentsUndergraduates [average p.a.]Other (specify)b) Medical and dental staff turnover in the last fiscal year: this is important to establish that the LABhas sufficient permanent career grade doctors to provide robust educational supervisionGrades No at start of fiscal year No at end of fiscalyearNo of posts filledduring yearMedicine DentistryMedicine Dentistry Medicine DentistryConsultantSASTrust Gradec) Number of unfilled posts by grade and specialty.KSS School StR (H) StR (L) F1 F2Foundation

Acute Care Common StemAnaestheticsEmergency MedicineGeneral PracticeIntensive Care MedicineMedicineObstetrics & GynaecologyOccupational MedicineOphthalmologyPaediatricsPathologyPsychiatryPublic HealthRadiologySurgeryDentistry5 External inspections and visitsKSS request:To allow us to audit our records, please report on the external visits and inspections you havereceived since 01 January 2010:Date & Type of visitSpecialty(s) inspectedDate of previous visit forspecialties involvedVisiting bodyPart of programme of visitsTriggered visitYES/NOYES/NO

Were there actions as aresult of visitYES/NOTimescale to resolve actionsDate(s) of future visitsSpecialty(s) to be inspected6 Linking undergraduate and postgraduate medical educationOperational Relationship Yes NoDoes your LEP receive SIFT?Is SIFT in the DME’s budget?SIFTDoes the DME influence the expenditure of SIFT incollaboration with the undergraduate tutor whereappropriate?Is there a LFG for undergraduate medicine?Do clinicalplacements:UG/PG linksHave a nominated Educational Supervisor?Follow a formal written curriculum?Do Educational Supervisors meet undergraduateTutors to discuss the programme and outcomes?7 Appraisal and Continuous Professional Development [CPD]In line with the requirements of Liberating the NHS: Developing the Healthcare Workforce for‘competent and capable staff’ and ‘adaptive and flexible workforce’ (p. 12-13), please report on yourcurrent arrangements for appraisal and CPD for your MEM team (including the Academic Registrarand LFG Administrators) and DME team (including Clinical tutors and LFG Leads) by post (not byperson)Appraisal Process Currentand CompletedCPD Programme AgreedDME Team (please list posts)MEM Team (please list posts)Pharmacy Team (please listposts)Library and KnowledgeServices Team (please list

posts)8 Education Centre Usage during the last yearPlease provide a percentage breakdown of usage of your Education Centre using the categoriesprovided below. It is important that you use the categories below to enable us to make comparisonsbetween KSS LEPs. If you have more than one site, please provide data for each.Centre Users% usagePostgraduate Medical EducationUndergraduate Medical EducationProfessions Allied to MedicineDental EducationMulti-Disciplinary Team MeetingsCareer Grades CPDPrimary Care EducationNHS Trust Management and TrainingCommercial lettingsOther usersTOTAL9 Education TechnologiesPlease:a) Report any problems experienced with educational technologies, including accessing e-portfolios, e-learning, and other web-based resources;b) Briefly outline the measures you have taken to deal with any problems you have experienced;c) Please state your level of satisfaction with the outcome of the measures you have taken.

10 LEP Management continuityIn post for more than one year Yes NoCEOHuman Resources DirectorFinance DirectorDMEMEMLibrary Services ManagerPre-Registration Pharmacist Training ManagerMedical DirectorIT/Operations Director or equivalentDirector of Nurse Education11 LEP Management infrastructureFunction Yes NoThere is an LEP Strategy Group [or equivalent] that includes atleast the DME; MEM; Head of Training; Director of Nurse Education;Library Services Manager; Chief Pharmacist; and meets regularly.LEP senior executive committee regularly takes reports from the LABand contributes to LAB Strategy.DME is a full member of the LEP senior executive committee OR hasequivalent arrangements for direct, regular and frequent meetings withthe CEO (please specify)DME has direct access to the CEO.

Medical Education Manager is a full member of an appropriate LEPsenior HR committee OR has equivalent arrangements for direct,regular and frequent meetings with the senior education executivegroup within the LEP (please specify)Academic Registrar manages support for LAB and for all LFGs.MEM has an effective Medical Staffing Contact12 Single Point of Contact for KSS FinanceDuring the last year, KSS has experienced some difficulty in transferring funding for eligibleeducational projects to some LEPs. Please identify a named member of your LAB as your single pointof contact (SPOC) for all financial transactions related to the KSS Contract. Your SPOC must havethe authority to ensure that transfers of funding between KSS and your LAB are managed in a timelyfashion and that their expenditure is timely and transparent.LAB SPOC for FinanceShort term cover for SPOCPlease provide name, post title, email, address, andtelephonePlease provide name, post title, email, address, andtelephone13 LAB ‘Metrics’: regional RAG ratingThe LAB ‘Metrics’ provides a self-assessment for your LAB in twelve areas identified by the KSSQuality Management Steering Group [QMSG] as particularly significant performance indicators. KSShas completed your data for the first six of these areas. Please:a) Complete your data for areas 7 to 12. Any of those areas which you do not complete willautomatically be rated as Red.b) Sign off your data as accurate on the proforma as follows:Indicator 1Indicator 6Indicator 7Indicator 8Indicator 9Indicator 12QESP to be signed off by the Medical Education ManagerPAs for education in the job plan to be signed off by the Director of MedicalEducation after discussion with the Medical DirectorLFG Meetings to be signed off by the Medical Education ManagerAdequate tracking of training data to be signed off by the Medical EducationManagerAbsence of postgraduate doctors to be signed off by the Medical StaffingManagerBoard-level engagement to be signed off by the Director of Medical Education

7 Bermondsey StreetLondonSE1 2DDMain Tel: 0207 415 3400Main Fax: 0207 415 3686Business Analysis1. Your LEP’s Executive Statements (Notes for Guidance 3:6)Briefly summarise the broad corporate identity, direction, and priorities of your LEP, as they relate tothe KSS Contract, listing the documents where these are set out.LEP’s corporate identityLEP’s planned directionLEP’s priorities2. Your LAB’s Executive Statements (Notes for Guidance 3:7)Briefly state your LAB’s Vision (where you aim to be in three to five years time); Mission (your mainmeans for getting there); and Unique Selling Proposition [USP] (the marketplace identity that makesyou distinctive from other LABs)LAB’s VisionLAB’s MissionLAB’s USP3. Marketing Analysis (Notes for Guidance 3:8-14)Please provide a narrative summarising the results and implications of your Marketing Analysis andreferring to the six headings set out in the Notes for Guidance and discussed in the Workshop: SWOT Analysis Marketplace Segmentation Ansoff’s Planning Matrix Product Life Cycle Boston Portfolio Matrix Marketing MixWith our partnersChair, Deanery Board - Professor Sir David Melville CBEDean Director - Professor David Black

In your narratives, you should tell us about areas such as: the demographics of your area what you do and what your service offers your competitors (e.g. private hospitals, other training providers) what sets you apart from them your teachers your facilities interprofessional learning use of facilities for external income generation what your LEP, faculty, and learners think of you who your partners are in achieving your goals who influences your service delivery sell your service – what have you achieved in the last year?Please provide separate narratives for your internal and external markets and have available your fullMarketing Analysis for reference at your Contract Review Visit.Results and implicationsfor LAB’s internal market(faculty and LEP)Results and implicationsfor LAB’s external market(learners)4. Human Resource Analysis (Notes for Guidance 3:15-17)Please provide a narrative summarising the results and implications of your Human ResourceAnalysis and referring to the seven headings set out in the Notes for Guidance and discussed in theWorkshop: Task Analysis Job Plans Short-term cover Multi-tasking Succession planning Appraisal CPDIn your narrative, you should tell us about areas such as: your staffing structure your arrangements for short term cover for key tasks the SPA arrangements, allocations, and plans for your teaching faculty your revalidation arrangements for your teaching faculty your arrangements for succession planning your arrangements for ensuring all staff and learners are up-to-date with statutory training whether your workforce is adequate and appropriate for providing your services to the levelrequired at present?

With reference to your Marketing Analysis, how you will ensure that your workforce is adequateand appropriate for providing the level and kind of services you plan for the future5. Resource Analysis (Notes for Guidance 3:18)Please provide a narrative summarising the results and implications of your Resource Analysis andreferring to the seven headings set out in the Notes for Guidance and discussed in the Workshop: Space required Technologies required Management access required Liaison required Travel and subsistence required Other essential resources6. Management Analysis (Notes for Guidance 3:19)Please provide a narrative summarising the results and implications of your Management Analysisand referring to the six headings set out in the Notes for Guidance and discussed in the Workshop: Line Management Functional Management Autonomy Networks Partnerships Task, Role, Boundaries, Expectations for all of above7. Finance Analysis (Notes for Guidance 3.20)Please:a) use the chart below to summarise the results of your Finance Analysis

FinanceLong-termRecurrentShort-termTemporaryWholly fundedIncomegenerationCharitablefundsWork Areasb) provide a narrative summarising the results and implications of your Finance Analysis. You shouldtell us about areas such as: your lines of financial management your relationship with your finance department the access you have to funds the decision-making you exercise on expenditure your ability to carry-over eligible funding from one financial year to the next your financial audit arrangements plans for major expenditure in the next year plans to manage potential budget reductions8. Ethical Analysis (Notes for Guidance 3:21-35)Please provide a narrative summarising the results and implications of your Ethical Analysis andreferring to the seven headings set out in the Notes for Guidance and discussed in the Workshop: Free exchange of expertise with other groups – the Gift Economy Purchaser Supplied Programmes Pareto Principle Ethical issues and solutions Business issues and solutions Contractual reference points Participative consultation processes used Decisions on actionIn your narrative, you should tell us about areas such as: new collaborations development of new LFGs your use of educational programmes to develop your faculty areas for future investigation areas for immediate action areas of conflict between ethical and business imperatives proposals to resolve such conflicts

9. Arrangements for your LAB to review your Business Analysis (Notes for Guidance 3:34)Please state your arrangements for your LAB to review your Business Analysis on a regular basis.

LAB Strategy Specification 2012Notes for Guidance 3Business AnalysisThe KSS Approach1. These Notes for Guidance describe the KSS Approach to Business Analysis. Like your EducationAudit, your Business Analysis must take account of both ethical imperatives and businessdeterminants. It must ensure that the bottom line of income and expenditure is translucent to themoral dimension encapsulated by Kant’s Categorical Imperative.2. This is particularly important since postgraduate medical and dental education [PGMDE] operatesto very different business determinants from mainstream industry and commerce. In commerce,business analysis begins with the assumption that it will be possible to secure a supply of rawmaterial of a uniform quality, in order to create products that will operate in a predictablecompetitive marketplace. Ethics are generally regarded as an externality, apart from concernssuch as reputational risk or ‘greenwash’ promotional strategies, and every marketplace isconsidered to be potentially accessible.By contrast, PGMDE has little control over the circumstances of learners and patients, and lesscontrol still over national and regional budget-setting. It operates at the politically volatileintersection of health and education, in a strictly limited marketplace, within a range of stringentregulatory frameworks. It is an invisible investment – most people do not know that half thedoctors in a hospital are postgraduate doctors – and it requires a high level of tailoring to theindividual needs of learners. Further, medicine and dentistry are personal services in which theprofessional provider is in an immediate relationship with the user. In particular, therefore, PGMDEis ethically bound, with the effects of ethical breach being experienced directly by each doctor anddentist.3. The KSS approach to business analysis thus has a moral dimension as well as a financial one.However, it meets the same broad purposes as business analysis in commerce and industry. Itprovides a range of ways of understanding your business, so that you can increase yourawareness and predictability, and thereby reduce risk. This sensitivity analysis also allows you toproduce rapid, successful response to sudden change. Of course, it only offers hypotheses aboutthe future and its forecasts must be reviewed regularly against actual business, and the planadjusted accordingly. As we discussed in the Workshops, it has to be produced by an iterativeprocess, but once it is produced, it meets a range of purposes, informing your Strategic Plan,establishing employment security, and supporting funding applications and research proposals.4. Your Business Analysis involves working through the five business areas that you used in yourEducation Audit: Marketing, Human Resource, Management, Resource, and Finance. However, italso requires two additional areas of consideration, a series of Executive Statements about yourVision, Mission, and Unique Sales Proposition [USP]; and an Ethical Analysis.5. These two additional areas – the Executive Statements and the Ethical Analysis – are importantbecause the purpose of business success is to ensure ethical success. In the business ofPGMDE, financial efficiency may not be achieved at the expense of educational effectiveness orclinical appropriateness. All three indicators – efficiency, effectiveness, and appropriateness –have to be achieved in order to ensure that learners and their patients are happy and are doingwell. What is more, this is not just a matter of individuals doing well. PGMDE takes place in anintegrated team context, and an important performance indicator is whether or not there aredeveloping Communities of Practice within your organisation, such as Local Faculty Groups. It is

at this point that the gift economy is foregrounded, with the free exchange of expertise andexperience. The first part of your Business Analysis, therefore, enables you to ensure anadequate, well-managed infrastructure for PGMDE. Your Ethical Analysis provides purpose to therest of your Business Analysis: it tells you that you are using your resources and infrastructure toproduce high quality education and best patient care.Individual Components in your Business Analysis6. PGMDE is located within, and embodied by, the clinical services provided by your LEP to itshealthcare communities. These provide the faculty, patients, and context that make up your localcurriculum in action. In short, the affordances for teaching and learning PGMDE are extended orlimited by your LEP’s clinical engagement. Your LAB’s Executive Statements, therefore, must bemade within the context of your LEP’s Executive Statements. So, your starting point should be thedocuments that set out the broad corporate identity, direction, and priorities of your LEP.7. Within this corporate context, you need to articulate your LAB’s Executive Statements: your Vision,Mission, and USP. Your USP is especially important in establishing your identity and particularstrengths as a provider of PGMDE.8. Your Marketing Analysis requires you to step back from your LEP and your LAB and to look at itcritically. Each of the six key elements that we discussed in the Workshops provides a different‘lens’ for viewing your work. Your Marketing Analysis should consider:a. Your ‘internal markets’ – your Faculty and LEP;b. Your ‘external markets’ – your learners.9. Your SWOT Analysis asks you to start with a broad overview of all the programmes you provide –you will already have recorded these data in your Education Audit. Their strengths, weaknesses,opportunities and threats may be related to a range of factors:a. Your LEP’s corporate identity, direction, and priorities;b. The demographics of your area;c. Competition from other education providers;d. The facilities you have;e. Your reputation, for example, reflected by GMC Surveys or KSS Visit Reports;f. Other factors reflected in your Education Audit.10. Marketplace segmentation focuses on identifying key features of the patients and learners whocurrently come to your LEP. Why do they come to you? What are their alternatives? Are they thedemographic that you wish to attract?11. This Planning Matrix invites you to consider your future development. Much of what your LABdoes will be Repeat Business, of course, but you will also have ideas for new developments. Anexample of Market Development would be setting up a new LFG, operating to existing systems,but for a new group. An example of Product Development might be Revalidation, where you will berequired to provide new services to your existing faculty of learners and teachers. An example ofTotal Diversification might be providing Higher Specialty Training for the first time: this takes youinto a relatively high risk area, since you have never provided these programmes to these learnersbefore, and you would manage that risk by identifying resource to support it.12. The Product Life Cycle suggests that everything has a finite life before it is taken over by newdevelopments. New areas of education may have relatively slow uptake at first but then gothrough a period of growth, before having a longer-term, stable take-up. Eventually, though, theywill go out of date unless they are revised, updated, and relaunched to meet contemporaryrequirements. The time-frame for the operation of the Product Life Cycle is likely to be differentfrom one area of work to another, in response to policy or financial interventions. For example,

Leadership moved very rapidly from Launch to Growth, aided by Lord Darzi’s national initiativeand the funding associated with it. Strategically, it is very important not to assume that everythingwill continue as it always has, and the Product Life Cycle is a useful reminder to identify the areasof your work that are in decline.13. This matrix, developed by the Boston Consulting Group, invites you to consider your portfolio ofprogrammes by considering how many people might apply for them (Market Size) and how manypeople actually do apply for them (Market Share). If a lot of people wish to follow a programmeand most of them prefer to follow it with you, then it is a Star. You need to consider why it is a Star– what is it that you have that others don’t have – if you are going to retain it, since it is businessthat everyone else may wish to take from you. Similarly, if very few people want to follow aprogramme, and you can never recruit them to yours, you need to consider why that is, and whyyou are continuing to offer it in this form.A Prop, where only a small number of people wish to follow the programme, but they all come toyou, is typical of a small or sub-specialty. It is interesting in business development terms, since ifyou can gain access to other markets, you might be able to develop your Prop into a Star.A Problem Area, where many people want a programme but none of them want it from you, is alsointeresting in business development terms. Since there is clearly a large market size, if you can fixthe problem, you may be able to develop a Star. Fixing the problem very often involvesconsidering your Marketing Mix.14. If you are dealing with a Problem Area or setting up a new programme as part of yourdevelopment strategy, it is helpful to consider the Marketing Mix, often called the ‘4 P’s’ . Its aim isto analyse your programme in comparison with the provision made elsewhere, either to replicatebest practice, or to compete. These comparisons concern:a. Programme content;b. Place where the programmes are offered;c. Promotional strategy you use to inform learners about them;d. Price, both as a direct, personal cost and an opportunity cost.15. Whether you are reviewing existing Job Plans or creating new posts, the starting point for yourHuman Resource Analysis is a Task analysis. This will enable you to assess potential for shortterm cover, multi-tasking, and succession planning, provide a practical basis for appraisal, andsupport agreement of an appropriate plan for CPD. It is also important ethically, to ensure thatstaff are not overstretched or exploited, and thus to protect the learners and patients that theyserve. Financially, it provides an important part of contract negotiation.16. Task Analysis begins by identifying the time elements required for CPD and for routine meetings:these may be common across a range of staff. It then identifies the key tasks to be carried out,how long each task takes, and their frequency in the working year, identifying any key or peakdates for specific tasks. This allows you to identify the skills, knowledge, and experience requiredfor the tasks and thus for the overall job role. It also allows you to produce a balanced Job Planreflecting the time needed to carry out the tasks required.17. Task Analysis can also help you to develop a flexible workforce, to provide short term cover, multitasking,and succession planning. This is especially important in complex environment, likePGMDE, where key tasks – such as Revalidation – must be carried out by a nationally-set,statutory, due date. As well, by identifying change and development in key tasks in a particular jobrole, you can agree CPD programmes with individuals that are specific to their needs.18. If you have the staff you need, then Resource Analysis checks that you have the tools to the workthat is required. This includes material resource, such as the space and the technologies required,

and communication systems, such as management access and lines of liaison, as well as basicitems such as travel and subsistence and other essential resources.19. Your Management Analysis aims to make sure that your business is carried on in an even,uninterrupted fashion. It is particularly important that within any activity, you are absolutely clearabout the Tasks that each person will undertake; their Role in relationship to every other personinvolved in the Task; the Boundaries of their authority; and the Expectations that are set for theirperformance.20. Your Finance Analysis is aimed at assessing the viability of your operations. It asks about thenature of the money available, and the terms on which it is available, including any penalties fornon-compliance. In particular, it seeks to establish the accounting base to which you are working –what counts as ‘success’ within your LEP. Because this is part of a Business Analysis, it also asksabout the relationship between price and quality, which is meaningful only when you compare itwith other organisations providing similar programmes.Ethical Analysis21. The focus of the Business Analysis is on the chain of contractual relationships between KSS andthe LEP and the LEP and its employees, through which the business of PGMDE is transacted. Butwhile this transactional economy is necessary to PGMDE, it is not sufficient to describe itsbusiness. Crucially, PGMDE also operates through a gift economy, in which one professionalfreely exchanges experience and expertise with another, for the benefit of learners, patients, andhealthcare communities. This gift economy is one of the factors that defines professionalenvironments, such as medicine, dentistry, and education, as distinct from commercialenvironments. The major purpose of effective and efficient management of the transactionaleconomy, then, is to remove impediments to the gift economy and thus allow it to thrive: this ispart of the meaning of ‘professionalism’. Of course, this also means that there may be a necessarytension between organisational competition and individual collaboration, and this, too, is typical ofprofessional environments.22. A particular kind of gift economy is represented by programmes that are supplied by KSS to itsLEPs. Technically, in quality terms, these constitute what is called ‘purchaser supplied resource’ -resource provided by a Purchaser to their Contractor to use in fulfillment of the Contract. The aimof purchaser-supplied resource is to provide a guaranteed quality at a favourable marketplaceprice and KSS meets those aims through the teacher education programmes it offers, which formpart of its quality management system. Strategically, the aim is to develop educational capacitylocally, as part of our collaborative continuous quality improvement.23. Just as your financial analysis reviews the rest of your Business Analysis to see if it is affordableagainst the business bottom line, so your ethical analysis reviews your Business Analysis to see ifit is affordable against the ethical bottom line. This illustrates the point that we kept returning to inyour Workshops: the financial bottom line is indubitably necessary but in our sector, yourBusiness Analysis is only sufficient if it protects you from moral bankruptcy. The role of theEthical Leader, therefore, is to hold the moral vision for the organisation or group and to enact thatby example. This may require negotiating with difficult people; resisting unacceptable proposals;and being creative in developing new solutions. This, in turn, will require collaboration andconsultation – it is not something that can be done alone.24. The Pareto Principle, or 80/20 Rule, provides a first line of ethical analysis. This rule of thumbsuggests that 80% of your business runs unproblematically but 20% may be problematic. Forexample, eight out of your ten LFGs might operate smoothly but the remaining two never seem to

form or work effectively. The 80/20 Rule goes on to suggest that, in consequence, you spend 80%of your time trying to manage this inefficient 20% of your business. Clearly, the inefficient 20% areincurring disproportionate resource and opportunity costs that are unfair to the rest of thecommunity, which is, in effect, paying for their ineffectiveness. A first line of ethical analysis,therefore, is to identify any work area that falls into the 20% category and to plan to investigate it,with the aim of remedying the problems and thereby making a substantial business gain.25. Often, the issues may fall into one of two categories: they are either ethical problems or they arebusiness problems. Ethical problems are those in which compliance with the proposed actionwould be to the substantial disadvantage of patients, learners, the staff directly involved, or thelarger healthcare community. The requirement here is to find creative ways of meeting both theethical and the business needs of the organisation – to create the Third Space – so that the issuescan be resolved to the reasonable satisfaction of all. The moral principle at play is the question‘What concession can you make in order to get on with the rest of the community?’26. Business problems are those in which a particular person or group is resistant to proposed actionwithout being able to demonstrate any negative effects on patients, learners, staff, or thehealthcare community. These issues are sometimes called ‘cultural problems’ but unless theyrelate to a specific, recognised culture, defined by one of the protected categories in the EqualityAct (2010) they are not cultural per se. They may represent an educational lacuna, perhaps anabsence of information about the rationale for the action required, or an inability to appreciate theconsequences of ignoring the action required. Equally, however, they may represent a powerfulindividual or individuals, misusing their authority, and breaching lines of management, to imposetheir personal views on colleagues and on the LEP. That is a kind of bullying and doubtless behindit lies fear, inadequacy, and personal anxiety, which is in itself a kind of educational problem.27. Where the business problem is caused by an educational need, then the requirement is for aneducational process, a professional conversation to explore with the individuals the issues athand, their rationale, and their consequences for the rest of the community. Where the businessproblem is caused by a power struggle, there is also an educational need, since the individualsconcerned are clearly focussing solely on their own defended egos, to the exclusion the needs ofthe rest of the community, perhaps including patients and learners. But extreme cases may alsorequire a contractual reference point, since the work of the LAB is defined by the KSS Contractsigned between the LEP and KSS, and carried out through the Contracts of Employment betweenthe LEP and its employees.28. It is very important to note that if a contractual reference point is needed, then your LEP’s MedicalDirector and Head of Human Resource should be involved in your discussions and decisions. It isalso very important to note that while KSS Education Department may be able to offer educationalsupport and advice to teachers with additional needs, KSS cannot discuss the performance of anyindividual employed by your LEP, since this could be a violation of their employment rights: theexception, of course, is where patient safety may be compromised. Finally, such rare and extremecases may mean that you decide that you are unable to offer training posts of a certain kind, andthat a Contractual Variation is required between your LEP and KSS. Such a Contractual Variationshould be discussed in detail with the relevant KSS Head of School and the KSS Chief OperatingOfficer by the LAB’s Chair. Exceptionally, it may be necessary to involve the LEP CEO and theKSS Dean Director.29. A second line of ethical analysis is provided by the change points you have identified in yourMarketing Analysis; Human Resource Analysis; Resource Analysis; Management Analysis; andFinance Analysis.30. Your Marketing Analysis deals with two groups, your learners and your faculty. For each group,you will have identified Repeat Business, that is, work for each that you will continue to carry out

as you have in previous years. You will also have identified three potential areas of change forlearners and for faculty:a. Existing services that you will provide to new learners or new faculty;b. New services that you will provide to existing learners or existing faculty;c. New services that you will provide to new learners or new faculty.31. Building on this, your Human Resource Analysis will have identified the amount of time required bystaff with particular skills, knowledge, and experience, to provide the services set out in yourMarketing Analysis. Your Resource Analysis will have identified the space, IT, and other resourcesneeded by those personnel and your Management Analysis will have identified their functional andline management. Finally, your Finance Analysis will have indicated that these business ambitionsare affordable within the financial bottom line.32. Of course, this is your Business Analysis and your views and conclusions. Ethical Analysisrequires that you consult fully and transparently with the people whom it will affect, both facultyand learners, through your LFG structure. The aim is to develop their participation in the designand provision of your Strategic Plan, by showing them the broad analytical basis on which you areworking.33. Typically, opportunities for participation should be offered in three ways:d. Prior documentation and a short presentation to LFG Leads, to discuss with theirfaculty of teachers and learners, and to feed back to you within a stated time;e. Opportunities for direct contact with the DME and MEM for individual learners or facultymembers to discuss issues specific to them;f. A regular email or newsletter updating everyone on how you have progressed mattersin response to their views, and identifying a permanent location where they can readrelevant documentation.34. The key questions that you are asking are:g. Does this analysis and its broad directions work to the disadvantage of patients,learners, staff, or the larger healthcare community?h. If so, is the disadvantage caused by the proposals per se or by the implementationprocess proposed?i. What proposal do you make for an alternative course of action.It is important to note in your presentation to LFG Leads that while they are free to ask forclarification on any point, if they find the proposals problematic then an alternative proposalmust be made. This could include setting up a sub-group to inquire further into the issue.35. This process of consultation and participation should continue throughout the business year, sothat each time the LFGs report in, they can indicate their progress on the work agreed for thisyear. In turn, the LAB should review its own progress at each meeting, making appropriateadjustments to its Business Analysis and Ethical Analysis as it implements its Strategic Plan.

LABStrategic DevelopmentQuality Manual VerificationPlease identify action arising from your Quality Manual Verification processTargetDateTargetOwnershipProgressRAGEducation Management AuditPlease identify action arising from your Education Management Audit, including your ‘metrics’Business AnalysisPlease identify action arising from your Business Analysis, including both cross-LEP targets andtargets the LAB has set for its LFGsKSS ContractStrategic DevelopmentRevalidationNotes for GuidanceYou MUST support the KSS Dean Director in his role as Responsible Officer by providing ALLinformation for Revalidation for ALL postgraduate doctors. This is a most important addition to theLAB’s management responsibilities and while responsibility for its successful completion remains withthe LAB Chair, its operationalization will usually form part of the role of the Academic Registrar. Draftindicative KSS Collective Exit Report and KSS Exception Exit Report forms, which may be replacedwhen the GMC approves a final national format, are provided at Appendix A.KSS RequirementPlease identify targets in order to:a) Complete the KSS Collective Exit Report for ALL Postgraduate Doctors, indicating whetherthey were named in complaints or involved in conduct or formal SUI/SEA investigations, forreturn to KSS twice a year at the beginning of May and the beginning of November in time forthe ARCP Panels.b) Complete the KSS Exception Exit Report for ALL Postgraduate Doctors named in complaintsor involved in conduct or formal SUI/SEA investigations, for return to KSS twice a year, at theTargetDateTargetOwnershipProgressRAG

eginning of May and the beginning of November, in time for the ARCP Panels. At the sametime that a KSS Exception Exit Report is sent to KSS a copy of it should be provided to thepostgraduate doctor concerned. Your return to KSS should ensure that KSS Exception ExitReports are accompanied by the KSS Collective Exit Reportc) Create a formal procedure so that the Dean Director is informed IMMEDIATELY of anysignificant concern about a postgraduate doctor, irrespective of when the KSS Collective ExitReport or the KSS Exception Visit Report are submitted to KSS.Educational Capacity DevelopmentTeacher EducationNotes for GuidanceThis year’s focus is on the accreditation of Educational Supervisors and Named Clinical Supervisors;and on developing and utilising educational capacity to Master’s degree level.KSS RequirementPlease identify targets in order to:a) Continue to manage the QESP process for Educational Supervisors and Named ClinicalSupervisors.b) Identify succession planning for current Educational Supervisors and Named ClinicalSupervisors.c) Audit the number of clinicians holding Master’s degrees in Education in your LEP.d) Utilise to the best effect the clinicians holding Master’s degrees in Education in your LEP.e) Plan to extend the number of clinicians holding Master’s degrees in Education in your LEP.f) Ensure information is disseminated to all career grade doctors about the KSS part-time MAEducation in Clinical Settings, including details of KSS Open Evenings.g) Provide progress reports on Teacher Education to the LAB for each of its formal meetings.TargetDateTargetOwnershipProgressRAGLeadershipNotes for GuidanceThis year’s focus is on ensuring that the LAB manages all Leadership initiatives for KSS Contractworkstreams (Medicine, Dentistry, Pharmacy, Library and Knowledge Services); has an overview ofother Leadership initiatives in the LEP to reduce the possibility of duplication of effort; and on

developing and utilising capacity to Master’s degree level.KSS RequirementPlease identify targets in order to:a) Ensure that LAB membership and attendance includes a Leadership Tutor who: coordinates allLeadership initiatives for KSS Contract workstreams, including the Pairs initiative and theattendance of postgraduate doctors at the KSS Leadership Postgraduate Certificate ModuleLeadership in Clinical Contexts; has an overview of other Leadership initiatives in the LEP; andprovides progress reports to the LAB for each of its formal meetings.b) Ensure that the LAB manages finance for all Leadership initiatives for KSS Contractworkstreams.c) Audit the number of clinicians holding Master’s degrees in Leadership in your LEP.d) Utilise to the best effect the clinicians holding Master’s degrees in Leadership in your LEP.e) Plan to extend the number of clinicians holding Master’s degrees in Leadership in your LEP.f) Ensure information is disseminated to all eligible staff about KSS part-time accreditedprogrammes in Leadership, including details of KSS Open Evenings.Managing Medical CareersNotes for GuidanceThe management of medical careers is becoming increasingly professionalised and KSS is supportingthat process by offering nationally a part-time Postgraduate Certificate; Postgraduate Diploma; andMaster’s degree in Managing Medical Careers. This year’s focus is on initiating or extending thatprofessionalisation process in your LEP.KSS RequirementPlease identify targets in order to:a) Ensure that LAB membership and attendance includes a Managing Medical Careers Leadwho: coordinates all Medical Careers initiatives; has an overview of other Careers initiatives inthe LEP; and provides progress reports to the LAB for each of its formal meetings.b) Audit the number of staff holding Postgraduate Certificate; Postgraduate Diploma; andMaster’s degree qualifications in Managing Medical Careers in your LEP.c) Utilise to the best effect the staff holding Postgraduate Certificate; Postgraduate Diploma; andMaster’s degree qualifications in Managing Medical Careers in your LEP.d) Plan to extend the number of staff holding the KSS part-time Postgraduate Certificate;

Postgraduate Diploma; and Master’s degree qualifications in Managing Medical Careers inyour LEP.Medical HumanitiesNotes for GuidanceKSS provides nationally a part-time Master’s degree and an MPhil/PhD programme in MedicalHumanities that focuses particularly on professionalism in the doctor-patient consultations and culturalfeatures which shape those values. The focus this year is on developing a minimum level ofengagement with Medical Humanities for each LAB; and on developing capacity to Master’s degreelevel.KSS RequirementPlease identify targets in order to:a) Ensure that LAB membership and attendance includes a Medical Humanities Lead who:attends two half-day KSS Medical Humanities Workshops during the year; develops MedicalHumanities as a cross-curricular element in the LEP; and provides progress reports to the LABfor each of its formal meetings.b) Ensure information is disseminated to all eligible staff about KSS part-time accreditedprogrammes in Medical Humanities, including details of KSS Open Evenings.SimulationNotes for GuidanceThis year’s focus is on ensuring that the LAB manages all Simulation initiatives for KSS Contractworkstreams (Medicine, Dentistry, Pharmacy, Library and Knowledge Services); has an overview ofother Simulation initiatives in the LEP to reduce the possibility of duplication of effort; and onsupporting KSS’s work to develop capacity locally.KSS RequirementPlease identify targets in order to:a) Ensure that LAB membership and attendance includes a Simulation Lead who: coordinates allSimulation initiatives for KSS Contract workstreams; has an overview of other Simulationinitiatives in the LEP; and provides progress reports to the LAB for each of its formal meetings.b) Ensure that the LAB manages finance for all Simulation initiatives for KSS workstreams.c) Ensure LAB progress reports on Simulation are forwarded in a timely fashion to the KSS

Assistant Dean Education leading on Simulation (currently Alison Gisvold).d) Ensure that the Simulation Lead attends KSS Simulation meetings and events as required toenable joint development of Simulation initiatives.Curriculum MappingNotes for GuidanceLast year we asked LABs to review their LFGs to identify which ones had a Curriculum Statement fortheir postgraduate doctors, produced according to the best-practice model supplied by KSS fromFrimley Park Hospital. The focus this year is on ensuring that the LAB manages all curriculummapping initiatives for medicine in the LEP.KSS RequirementPlease identify targets in order to:a) Ensure that LAB membership and attendance includes a Curriculum Mapping Lead who:coordinates all Curriculum Mapping initiatives for medicine; and provides progress reports tothe LAB for each of its formal meetings.b) Ensure LAB progress reports on Curriculum Mapping are forwarded in a timely fashion to theKSS Assistant Dean Education leading on Curriculum Mapping (currently Dr Clare Penlingtonand Dr Elaine Hawkins)Patients with Learning DisabilitiesNotes for GuidanceKSS provides Workshops to develop capacity for your postgraduate doctors and faculty to work withPatients with Learning Disabilities [PLDs]. This is an important aspect of developing professionalism,improving clinical governance, meeting the requirements of the Equality Act, and improving patientcare.KSS RequirementPlease identify targets in order to:a) Ensure that all LFGs include attendance at KSS PLD Workshops as part of their plan forfaculty development.b) Discuss with your LEP its plans to sign up to Mencap’s ‘Getting It Right’ Charter and reportprogress at your LAB.

‘Trainees in Difficulty’Notes for GuidanceKSS has an ongoing commitment to supporting postgraduate doctors with additional needs and webelieve that this is an important element of the LAB’s management role.KSS RequirementPlease identify targets in order to:a) Ensure that LAB membership and attendance includes a ‘Trainees in Difficulty’ Lead who:coordinates all support for postgraduate doctors with additional needs; and provides progressreports to the LAB for each of its formal meetings.Postgraduate Doctor RepresentativesNotes for GuidanceKSS GEAR requires all LFGs to ensure that their postgraduate doctors meet regularly to providefeedback to the Faculty, and to ensure that there is an appropriately trained Postgraduate DoctorRepresentative sitting on the LFG and on the LAB. The focus this year is on developing local capacityfor those functions.KSS RequirementPlease identify targets in order to:a) Ensure that the LAB provides at least one Workshop to train Postgraduate DoctorRepresentatives.b) Ensure a report on the Workshop is provided in a timely fashion to the KSS EducationDepartment Professional Services staff managing Postgraduate Doctor Representatives(currently Jon Nodding).Lay RepresentativesNotes for GuidanceLay Representatives provide an important element of externality to LAB meetings and managementand are required by the GMC Standards. The focus this year is on developing local capacity for that.KSS RequirementPlease identify targets in order to:a) Ensure that the LAB provides at least one Lay Representative to attend the KSS AnnualForum for Lay Representatives.

School Specific DevelopmentGeneral Practice SchoolTargetDateTargetOwnershipProgressRAGARCP DataNotes for GuidanceSince GP Trainees only attend ARCP Panels exceptionally, it is important for all assessment andother reports to be entered accurately and in a timely fashion on the INSITE database. KSS hasfunded administration costs for this specific purpose.KSS RequirementPlease identify targets in order to manage and monitor:a) The collection of data monitoring GP Trainees’ progress towards their ARCP.b) GP trainees’ progress through the RCGP E-Portfolio.c) Arrangements for maintaining the KSS INSITE database regularly in advance of GP LFGmeetings.d) Arrangements for updating INSITE according to the guidance and timescales providedannually by KSS.GP Single EmployerNotes for GuidanceTo ensure consistency in GP Trainees’ employment, KSS has signed a Single Employer Service LevelAgreement [‘the SESLA’] with KSS LEPs. The SESLA provides a single Lead Acute Trust Employerfor GP Trainees following three year programmes and identifies other LEPs where they work andlearn as Host organisations.KSS RequirementPlease identify targets in order to manage and monitor:a) Your compliance with the SESLA.b) Your communication systems, including regularity and frequency, with host organisations.c) Your system for ensuring accurate reports on salary and non pay expenses are made to KSSin the required format and at the prescribed times.d) Your system for collecting information and transmitting to the Single employer acute trust forensuring accurate reports of sickness and absence are made to KSS in the required format

and at the prescribed times.Foundation SchoolNational ReportsNotes for GuidanceThe Collins Report and the Psychiatry Taskforce recommendations provide national standards forFoundation for implementation locally.KSS RequirementPlease identify targets in order to:a) Manage and monitor your Foundation LFG’s compliance with the Collins Report.b) Manage and monitor your Foundation LFG’s implementation of the Psychiatry Taskforce’srecommendations.ShadowingNotes for GuidanceIt is best practice for LABs to provide shadowing opportunities for Foundation doctors. The focus thisyear is on implementing forthcoming new national requirements in shadowing.KSS RequirementPlease identify targets in order to:a) Support your Foundation LFG in developing a plan to meet the new national requirements forshadowing within a month of their publication.b) Monitor progress by your Foundation LFG in implementing, reviewing, and reporting itsarrangements for shadowing.School of AnaestheticsEducational SupervisorsNotes for GuidanceEducational Supervisors’ attendance at LFGs as set out in KSS GEAR is a matter of ethicaleducational practice, professional obligation, and contractual agreement.KSS Requirement

Please provide targets in order to:a) Monitor Educational Supervisor attendance at your Anaesthetics LFG.b) Address all and any issues of attendance that is not compliant with KSS GEAR.Recruitment InterviewsNotes for GuidanceKSS relies on its consultant body to provide expert input to the interview process in order to ensurethat excellent candidates are attracted to work in this region. This year’s focus is on ensuring anadequate support for this important central function.KSS RequirementPlease provide targets in order to:a) Ensure that your LFG Anaesthetics is able to meet the KSS Head of School’s requirements forsupport for recruitment interviews.School of Obstetrics and GynaecologyARCP DataNotes for GuidanceKSS requires Educational Supervisors’ reports to be completed and submitted 2 weeks in advance ofthe ARCP deadline set by the KSS School of Obstetrics and Gynaecology.KSS RequirementPlease identify targets in order to:a) Manage and monitor your LFG Obstetrics and Gynaecology’s completion of EducationalSupervisors’ reports.b) Ensure that these data are submitted to KSS on deadline.Basic Ultrasound TrainingNotes for GuidanceKSS requires all postgraduate doctors to undergo mandatory RCOG Basic Ultrasound Training.KSS RequirementPlease identify targets in order to:a) Manage and monitor your LFG Obstetrics and Gynaecology’s completion of mandatory RCOG

Basic Ultrasound Training for all of its postgraduate doctors.b) Maintain a register of completion of this training and include that in its Annual Report.Obstetric SimulationNotes for GuidanceKSS requires all postgraduate doctors to engage with Obstetric Simulation, which is assessed atARCP.KSS RequirementPlease identify targets in order to:a) Manage and monitor your LFG Obstetrics and Gynaecology’s provision of Basic ObstetricSimulation in the form of Skills Drills or similar activities.b) Manage and monitor your LFG Obstetrics and Gynaecology’s provision of Low-TechSimulation in areas such as perineal repair and laparoscopy.CurriculumNotes for GuidanceKSS requires all postgraduate doctors to follow a planned curriculum that maximises the opportunitiesfor practical and surgical training.KSS RequirementPlease identify targets in order to:a) Manage and monitor your LFG Obstetrics and Gynaecology’s production of a curriculum map.b) Review your LFG Obstetrics and Gynaecology’s curriculum map to ensure that it maximisesthe opportunities for practical and surgical training.TastersNotes for GuidanceProvision of Taster Weeks by LFGs Obstetrics and Gynaecology is an important part of attracting thebest candidates into the School.KSS RequirementPlease identify targets in order to:a) Review your LFG Obstetrics and Gynaecology’s capacity for providing Taster Weeks.

School of OpthalmologyLFG EstablishmentNotes for GuidanceThe new KSS School of Opthalmology requires an LFG to be set up specifically for Opthalomology,separate from the LFG for Surgery.KSS RequirementPlease provide targets in order to:a) Establish an Opthalmology LFG operating to KSS GEAR.b) Manage and monitor its progress including its reporting to your LAB and to the KSS Head ofSchool as required by KSS GEAR.SAS DoctorsLocal Faculty DevelopmentNotes for GuidanceKSS values highly the work of SAS doctors and KSS LABs have provided excellent support throughthe establishment of SAS LFGs and the utilisation of SAS doctors in educational, leadership, andservice improvement roles. This year’s focus is on consolidating this work.KSS RequirementPlease provide targets in order to:a) Ensure that your SAS LFG continues to receive appropriate support from and management byyour LAB.b) Ensure that your SAS doctors receive Study Leave and CPD as an entitlement within theirContracts of Employment.KSS Specialty ProspectusesNotes for GuidanceIn order to attract the highest quality applicants to the region, KSS requires regularly-updatedinformation for its Prospectuses. A form for recording and returning these data appears at Appendix B.KSS RequirementPlease identify targets in order to:

a) Ensure an entry per Specialty is provided to KSS Head of Specialty Workforce (AngelaFletcher in post) by October each year for Core posts and by January each year for Higherposts.b) Review content on an annual basis by October and January each year and provide updatedinformation to KSS.Review and ReportingNotes for GuidanceRegular review and reporting by LFGs to their LAB and to Schools is crucial to local quality control,especially in remediating poor performance against the GMC Surveys. Similarly, regular review andreporting of your LAB to your LEP’s senior executive committee and to KSS is crucial to managing thecontinuous quality improvement of PGME locally.KSS RequirementPlease provide targets in order to:a) Ensure LFGs meet, review progress, and report to LAB, including planning to remediate poorperformance against the GMC Surveys, as required by KSS GEAR.b) Ensure your LAB regularly reviews and reports progress to your LEP’s senior executivecommittee in order to manage and improve quality locally.c) Ensure LFG and LAB review and reporting processes are integrated into the LAB’s localprocesses for managing KSS Visits and for producing the Annual Review.TargetDateTargetOwnershipProgressRAG

Library and Knowledge Services Development Strategy(a) Library and Knowledge Services StrategyThe KSS request:Please provide a copy of your current strategy and highlight your key priorities for thecoming year and how your service will ensure it can deliver on them.(b) Collaborative WorkingThe KSS request:Please describe your strategy for embedding library and knowledge services inresearch, education, clinical and corporate governance, service planning and directpatient care and other relevant processes in local NHS organisations.(c) Marketing and PromotionThe KSS request:Please describe your strategy for raising awareness and increasing usage of yourservices among users and non-users in your local Trusts and amongst otherstakeholders.(d) Participation in Local Academic Board and Local Faculty GroupsThe KSS request:Please describe your strategy for active participation with the Local Academic Boardand how you engage with the Local Faculty Groups.(e) SIFT FundingThe KSS request:Please report on the allocation of SIFT Library and Knowledge Services receive percapita and per Higher Education Institution.Higher Education InstitutionPer Capita FundingBrighton and Sussex Medical SchoolSt George’s Medical SchoolKing’s Medical SchoolUniversity of Southampton Medical SchoolOther(f) Non-Medical Education Funding for Students on Clinical PlacementThe KSS request:Please report on the allocation of funding Library and Knowledge Services receivefor non-medical education students on clinical placement per capita and per HigherEducation Institution

Higher Education InstitutionPer Capita FundingCanterbury Christchurch UniversityUniversity of BrightonUniversity of GreenwichUniversity of SurreyOther(g) Library and Knowledge Services StaffingKSS request:Please report on any difficulty in filling posts and the impact on services that is likelyto have.(h) Library and Knowledge Services Ideas and IssuesKSS request:We recognise that Library and Knowledge Services are often creative in theirthinking, and equally, that some Library and Knowledge Services may haveparticular issues that do not affect Library and Knowledge Services in general. Itwould be helpful if Library and Knowledge Services could report on:a) major influences on your work at present;b) major proposed developments for the future;c) local concerns and issues which are relevant to Contract Review.

KSS Pharmacy Local Faculty Group Annual Audit and Review.PHARMACY TRAINING TEMPLATE.Trust name:LFG Chair:Pre-registration Pharmacist EPD:Number or Pre-reg Pharmacists:Pre-registration Trainee PharmacyTechnician EPD:Number of PTPTs:Foundation Pharmacist EPD:Number of band 6 pharmacists onFoundation Programme:Local Faculty Group Meetings 1 2 3Date of LFG Meetings:Number of Attendees:Summary of Trainees’ progressAttach confidential spreadsheet

Domain 1Patient SafetyThere must be clear procedures in place to address concerns about patient safety arisingfrom initial pharmacy education and training. Concerns must be addressed immediately.Areas you may wish to comment on:‣ GPhC standards of conduct, ethics and performance and trainees understanding ofthis.‣ Supervision of trainees to ensure safe practice.Notable practice:Areas of concern with time bound targets for action and named responsibility:

Domain 2Monitoring, review and evaluation of initial education and training.The quality of pharmacy education and training must be monitored, reviewed and evaluatedin a systematic and developmental way.Areas you may wish to comment on:‣ The whole curriculum and timetable and evaluation of it.‣ Input from a range of internal and external stakeholders (including patients andpublic) into monitoring and evaluation.‣ Trainees in difficulty and the Trainee in Difficulty policy.Notable practice:Areas of concern with time bound targets for action and named responsibility:

Domain 3 Equality, Diversity and fairnessPharmacy education and training must be based on the principles of equality, diversity andfairness. It must meet the needs of current legislation.Areas you may wish to comment on:‣ Support for any trainees with additional needs.‣ Adjustments to programmes for trainees with disabilities.‣ Any other education and development issues.Notable practice:Areas of concern with time bound targets for action and named responsibility:Domain 4Selection of students and traineesSelection processes must be open and fair and comply with relevant legislation.Areas you may wish to comment on:‣ Recruitment & Selection training and support.‣ Processes for recruitment of trainees.Notable practice:Areas of concern with time bound targets for action and named responsibility:

Domain 5Curriculum delivery and student experienceThe local curriculum must be appropriate for national requirements. It must ensure thattrainees and PG pharmacists practise safely and effectively. To ensure this, pass/competence criteria must describe professional, safe and effective practice.Areas you may wish to comment on:‣ The GPhC pre-reg performance standards, KSSD Pre-registration Trainee PharmacistHandbook and local curricular response to them.‣ Range of educational and practice activities as set out in the local curriculum.‣ Access to training days, e-learning resources and other learning opportunities thatform an intrinsic part of the training programme.Notable practice:Areas of concern with time bound targets for action and named responsibility:

Domain 6 Support and development for traineesTrainees on any programme managed by the Pharmacy LFG must be supported to developas learners and professionals. They must have regular ongoing educational supervision witha timetable for supervision meetings. All LFGs must adhere to the KSSD Trainee in Difficultypolicy and be able to show how this works in practice. LFGs must implement and monitorpolicies aqnd incidents of grievance and discipline, bullying and harassment. All traineesshould have the opportunity to learn from and with other health care professionals.Areas you may wish to comment on:‣ The range of mechanisms to support trainees to develop as learners andprofessionals.‣ Bullying, harassment, grievance and disciplinary issues.‣ Opportunities to learn with and from other healthcare professionals.Notable practice:Areas of concern with time bound targets for action and named responsibility:

Domain 7 Support and development for Pre-registration Trainee Pharmacist PracticeSupervisors and Educational Supervisors.Practice supervisors, educational supervisors and education programme directors shouldhave these roles clearly identified and be trained and competent to undertake them.Supervisors should have time to carry out their role and access to support and trainingincluding identified peer support.Areas you may wish to comment on:‣ Practice Supervisor, Educational Supervisor and Educational Programme Directortraining and support.Notable practice:Areas of concern with time bound targets for action and named responsibility:

Domain 8 Management of initial education and training.There should be transparent processes which show who is responsible for each element andeach stage of training programmes.Areas you may wish to comment on:The responsibilities of all staff involved in the programme.Succession planning for Practice Supervisor and Educational Supervisor roles.Notable practice:Areas of concern with time bound targets for action and named responsibility:Domain 9 Resources and capacity.Resources and capacity are sufficient to deliver outcomes.Areas you may wish to comment on:‣ The availability of resources.‣ Appropriateness of educational facilities.Notable practice:Areas of concern with time bound targets for action and named responsibility:

Domain 10 OutcomesThere should be an analysis of outcomes of assessments benchmarked against others whichis accessible to trainees.These should be an analysis of the outcomes of assessments benchmarked wheneverpossible.Areas you may wish to comment on:‣ An analysis of outcomes of assessments.‣ Comparators and benchmarks.Notable practice:Areas of concern with time bound targets for action and named responsibility:Comment on any difficulties in securing full membership here:

Comment on any issues relating to LFG procedural regulations, difficulties and steps taken toresolve themConfirm that trainees are represented on the LFG and trained for this role.Signed by Chair of Pharmacy LFG:Date:

Appendix AKSS Collective Exit Report for Postgraduate DoctorsTo be completed by the Employer/ Host Training Organisation. In the case of GP trainees in aprimary care placement this Report should be completed by the PCT/ Organisationresponsible for maintaining the local GP Performance List.Use an excel spread sheet or add more rows to the table below to list all the doctorsemployed in each organisation.Postgraduate Doctor’sNameGMCNumberDates of EmploymentStart DateEnd DateInvolved in conduct, capability orFormal Serious UntowardIncidents/ Significant EventInvestigation or named incomplaints (Please state YES orNO)I confirm that I have included an Exception Exit Report for any of the postgraduate doctors listed above whohave been involved in conduct, capability or formal Serious Untoward Incidents/ Significant EventInvestigation or named in complaints whilst employed by this organisation, whether as a postgraduate doctoror as a locum, on the dates specified above.SignatureFull nameName of theOrganisationDateJob TitleName of the MedicalDirector (If the signatory isnot the MD)

KSS Exception Exit Report for Postgraduate DoctorsTo accompany the Collective Exit ReportTo be completed by the Employer/ Host Training Organisation. In the case of GP trainees in aprimary care placement this Report should be filled by the PCT/ Organisation responsible formaintaining the local GP Performance List and by their Clinical/Educational SupervisorPostgraduateDoctor’s Name:GMC Number:Start Date End date Details of Employment/Placements/Locum CommentsDetails of concerns/investigations:Conduct,CapabilityInvestigationThis trainee has been involved in a conduct, capability investigationThis has been resolved satisfactorily with no unresolved concerns about thistrainee’s conduct.If not, please give a brief summary and the anticipated date of the outcome of theinvestigation:YES / NOYES / NOSeriousUntowardIncident/SignificantThis trainee has been involved in formal Serious Untoward Incident/SignificantEvent investigationThis has been resolved satisfactorily with no unresolved concerns about atrainee’s fitness to practiceYES / NOYES / NO

EventinvestigationIf not, please give a brief summary and the anticipated date of the outcome of theinvestigation:Complaints This trainee has been named in complaint(s) YES / NOThis has been resolved satisfactorily with no unresolved concerns about atrainee’s fitness to practice or conductYES / NOIf not, please give a brief summary and the anticipated date of the outcome of theinvestigation:SignatureFull nameName of theOrganisationDateJob TitleName of the Medical Director(If the signatory is not the MD)

Appendix BLAB Education Strategy Appendix BTRAINING PROGRAMMETrustHospitalUOAIntroductionTerms of BusinessInclude terms ofbusiness andinformation on workfindingserviceDistinction betweentraining programmeoffer and employmentcontractPost detailsSpecialtyGradeLocation withinprogrammeType of WorkName of the positionand work needing tobe doneQualifications andprofessionalregistration requiredAttach JDAnticipated durationof programmeCommencement dateStandard rotationdetailsEducational SupervisorClinical LeadOutcomeCCT/CESR/CP/CoreOutcome of trainingprogramme i.e. corecompetenciesKSSSample Timetable:Monday AmPmTuesday AmPmWednesday AmPmThursday AmPmFriday AmPm

LocationInfo on likely locationsincluding likely specificsites within rotationsConfirmation oflocation includingspecific info on sitewithin multi-siteemployerPayments/PolicySalary ScaleBasic Pay referring tonational salary scalesTravel and relocationexpenses policyhttp://www.nhsemployers.org/Pages/home.aspxhttp://www.londondeanery.ac.uk/var/relocation

Educational GovernanceContract Review and Development 2012Quality Manual notification of change and verification reportThis form is to be used in conjunction with the Quality Manual 2011.This document is to be used for those LEPs who have been awarded Earned Autonomy forthe Single Contract Review (SCR) process. It is the contractual responsibility of the LAB toensure that the internal verification process is conducted and completed appropriately. ThisQM should be completed with the same rigour and robustness of all SCR documentation toensure that Earned Autonomy can also be awarded in future SCR cycles.Please note that you are only required to note any changes to the Quality Manual whichhave occurred since the last single contract review cycle. However, these changes shouldbe reported as a narrative, (not using bullet points) to ensure clarity and understanding.A member of the KSS Verification Team may contact the MEM if further clarification isneeded on any of the points in this document.Local Education Provider [LEP]Medical Education ManagerI confirm that the processes set out in the Quality Manual 2011 are current and any exceptions to thishave been noted below.Medical Education Manager’s signatureDatePlease prefix any changes to process with the relevant section number from the QualityManual.Domain 1: Patient safety (1-4)Domain 2: Quality management, review and evaluation (5-9)Domain 3: Equality, diversity and opportunity (10-13)Notification of change and verification report Page 1 of 2 Created on08/10/201216/02/2012

Domain 4: Recruitment, selection and appointment (14-23)Domain 5: Provision of approved curriculum including assessment (24-29)Domain 6: Support and development of postgraduate doctors and LFG (30-44)Domain 7: Management of PGMDE (45-47)Domain 8: Educational resources and capacity (48-60)Domain 9: Outcomes (61)Notification of change and verification report Page 2 of 2 Created on08/10/201216/02/2012

7 Bermondsey StreetLondonSE1 2DDMain Tel: 0207 415 3400Main Fax: 0207 415 3686KSS DeaneryContract Review and Development 2011/12Educational GovernanceQuality Manual Verification VisitLocation:Date:Attendance:DOMAIN 1: PATIENT SAFETY1INDUCTION TO THE LEP2 Work Patterns and Intensity 3 Clinical Responsibility 4 Clinical Support Domain 2: Quality Management, Review and Evaluation5 Graduate Education and Assessment Regulations (GEAR) 6 Security of Information 7 Intrepid: Postgraduate Doctor and Dentist Data 8 Intrepid: Monitoring Educational Supervision 9 Short Term Cover for Medical Staffing Functions With our partnersChair, Deanery Advisory Board - Professor Sir David Melville CBEDean Director - Professor Deanery David Chair Black – Name

Domain 3: Equality, Diversity and Opportunity10 Equality, Diversity and Opportunity in Appointments11 Equality, Diversity and Opportunity in Education 12 Less Than Full Time Training [LTFTT] 13 Reasonable Adjustments Domain 4: Recruitment, Selection and Appointment14 Registration of Postgraduate Doctors and Dentists15 Immigration Requirements 16 Specialty Training Posts 17 Selection into Specialty and Higher Specialty Programmes 18 Managing HST Transition into KSS Specialty Schools 19 Recruitment and Selection 20 Local Selection Panels 21 Advertising Placements Locally 22 Contract of Employment 23 Job Description Domain 5: Provision of Approved Curriculum Including Assessment24 LFG Handbooks25 Induction to Educational Programme 26 Curriculum Development 27 Educational Assessment 28 Study Leave Availability 29 Study Leave for SAS and Trust Grade Doctors Domain 6: Support and Development of Postgraduates and Local Faculty30 Induction to the Department31 Educational Supervision

32 Educational Plans 33 Educational Development Meetings 34 Clinical Supervision 35 Academic Education 36 Workplace Bullying 37 Pastoral Care 38 Faculty Development: Selection 39 Faculty Development: CPD 40 Faculty Development: Job Plans 41 Faculty Development: QESP 42 Faculty Development: Assessment 43 Faculty Development: Capacity Growth 44 Faculty Development: Records Domain 7: Management of Education45 Management of Education46 Support and Career Advice 47 Postgraduates requiring additional support Domain 8: Educational Resources and Capacity48 Education Centre and LKS Facilities 49 Teaching and Learning Facilities 50 LEP Facilities 51 Education Technologies 52 IT Facilities 53 Support Staff 54 Workforce Planning 55 Appointment of DME/Clinical Tutor 56 Appointment of Staff to the PGDME Function

57 Budgetary Accountability 58 Annual Finance Returns 59 Notification of Financial Transfers 60 Expenditure of KSS Monies Domain 9: Outcomes61 Review and Improvement

Contract Review Visit 2012Location:Date:Attendance:Director of Medical Education:DSM (QA) and Medical Education Manager:DSM (Ops) and MEM:Clinical Tutor:Clinical Tutor:Clinical Tutor:Dental Tutor:Knowledge Services Manager:Director of Pharmacy:Lead Pharmacist Education and Development:Education Advisor:Apologies:Head of Library and Knowledge Services:Chief Executive:KSS:Assistant Dean [Education]:Deputy PG Dean for Secondary Care:Dental Associate Dean for Secondary Care:Head of Library and Knowledge Services:Head of KSS Pharmacy:Feedback session: as above plusMedical Director:Finance representative:HR representative:

1. Good Practice Examples:a. LKS:b. Pharmacy:c. Dental:d. PGME:2. Quality Manual Verification Issues:a. LKS:b. Pharmacy:c. Dental:d. PGME:Quality Manual Verification Report:LKSPharmacyKSSContractLEP ActionLIBRARY AND KNOWLEDGE SERVICESGMC Domain(s)8

Standard LEP ActionDENTAL EDUCATION MANAGEMENTGMC Domain(s)n/a

KSScontractLEP ActionLOCAL ACADEMIC BOARD STRATEGYGMCDomain (s)Results of 2011 Action Plan 7, 8KSScontract2012 LEP Action GMCDomain (s)1 Support for Educational Roles 3, 4, 72 Attendance audit of LFGs 3, 4, 73 Developing Local Educational Capacity 3, 4, 74 Medical and Dental staffing 3, 4, 75 External Visits 66 UG and PG medicine 3, 4, 77 Appraisal and CPD 3, 4, 78 Education Centre Usage 3, 4, 79 Education Technologies 3, 4, 7

10 LEP Management continuity 3, 4, 711 LEP Management Infrastructure 3, 4, 712 SPOC 7, 913 Metrics n/a

KSScontract2012 Business Analysis12 Your LAB’s Executive Statements3 Marketing Analysis4 Human Resource Analysis5 Resource analysis6 Management analysis7 Financial analysis8 Ethical analysis2012 LAB STRATEGIC DEVELOPMENTRevalidation:Educational Capacity Development:Leadership:MMC:Medical Humanities:Simulation:Curriculum Mapping:Patients with Learning Disabilities:Trainees in Difficulty:PG Doctor Reps:Lay Reps:GP School: ARCP data:GP Single employer:Foundation School:

School of Anaesthetics:Recruitment:School of Obs and Gynae:School of Ophthalmology:SAS doctors:KSS Specialty Prospectus:Reviewing and reporting:

Serious Incidents PolicyA Serious Incident is in general terms something out of the ordinary or unexpected,with the potential to cause serious harm, which occurs on NHS premises or in theprovision of an NHS service, or where there is a cluster or pattern of incidents oractions by NHS staff that have, or are likely to have, caused significant publicconcern.A Serious Incident may be clinical or non-clinical, and will have occurred whenever apatient, member of staff or member of the public has suffered serious injury, majorpermanent harm or unexpected death. A “near miss” may also constitute a SeriousIncident, where the avoidance of a catastrophic outcome required major correctiveintervention, although no actual harm resulted on that particular occasion. Theseevents may indicate system failures that could recur, and require organisationalchange.Examples of Serious Incidents are:Unexpected or avoidable death of a patient or death in unusual circumstancesSerious harm requiring life-saving intervention,Mental health and substance abuseProfessional misconductSafeguarding Children issuesBlood transfusion errorsSerious complaint or allegation against a member of staffBreaches of confidentiality such as loss of dataEquipment failure or misuseDiagnostic failures leading to serious harm or death“Never events”, which are very serious, largely preventable patient safetyincidents that should not occur if the relevant preventative measures havebeen put in place, for example: wrong site surgery; misplaced naso-gastric ororogastric tube not detected prior to use; retained instrument post-operation.The full list of never events can be seen via this link:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132355The National Patient Safety Agency (NPSA) has developed a national framework forreporting and learning from serious incidents requiring investigation:http://www.nrls.npsa.nhs.uk/resources/?entryid45=75173Although deaneries are not mentioned in this document it is a GMC requirement thatthere are clear procedures to address immediately any concerns about patient safetyarising from the training of doctors.

A trainee doctor could be implicated in the Serious Incident in a number of waysincluding: Present at the time, not directly involved in the incident, but personallyaffected by the incident Involved but in a minor way, for example, as part of the team Directly implicated as contributing to the incident Directly implicated in the response to and management of the incident A combination of the aboveAny involvement in a Serious Incident by a trainee including, but not limited to, thoselisted above, should be reported to the Deanery at the earliest opportunity.Reporting to the DeaneryAll KSS Local Education Providers (LEPs) are required to inform the Deaneryimmediately of any Serious Incidents involving trainee doctors, either directly orindirectly. Directors of Medical Education (DMEs) must notify the Deanery using theKSS Serious Incident Preliminary Notification Form. The purpose of this form is tonotify the Deanery that an incident has taken place. We will expect to see the fullfinal report in due course.Both the preliminary notification form and the final report should be sent by email tothe following address: Kensur-dean.SUI@nhs.netThe Deanery will keep a log of all Serious Incidents involving trainees includingactions to resolution. This will allow us to review practice and identify trends andpatterns.It is essential that all serious incidents that involve trainee doctors are reported in anappropriate and timely manner, and handled effectively.The Deanery will offer support and advice to the trainee, if required, during theinvestigation of the Serious Incident. The LEP must notify the Deanery of any impacton the trainee caused by the outcome of the investigation so that any relevantlessons may be incorporated into future training and any necessary support can begiven to the trainee. If the trainee is unhappy with the outcome of the investigation oris involved with any action following the outcome of the investigation, the Deanerywill provide appropriate support and advice.This document does not supersede the normal legal requirements to notify relevantstatutory bodies of certain incidents.

Serious Incident Preliminary Notification FormName of LEP reporting the incident:Name of DME completing this form:Date/Time of Serious Incident:Specialty / specialties involved:Incident Type:Brief description of the Serious Incident:Name, Grade and GMC Number of trainee(s) involved:Please add any further comments you may have regarding this incident, in particular if aninvestigation is underway and when the Deanery can expect to see the final report:Please return your completed form to the Deanery by email to the following address:Kensur-dean.SUI@nhs.net