MEDEV

School of Medical Sciences Education Development

Introduction

There are several principles of quality assurance in medical education, including principles of accountability, self-evaluation and external peer review. Friedman et al.¹ relates to a comprehensive review at the University of North Carolina School of Medicine.

The process described in the paper highlights the accountability of North Carolina’s School of Medicine because:

• it clearly describes the medical education governance processes and the various committee structures;
• it involves stakeholders in the faculty-student group;
• evidence is sought through the development of standardised questionnaires;
• interviews are held with course directors and evaluations are compared over time;
• the process is subjected to public review;
• action plans are implemented from summary statements.

A similar but more extensive revolution in medical education has occurred in the UK through implementation of both Modernising Medical Careers (MMC) ‘run-through’ training² and of Postgraduate Medical Education and Training Board (PMETB) Generic Standards For Training.³ There are clear lines of accountability with the Deanery acting on behalf of PMETB to ensure standards are being applied, monitored and evaluated at local Trust level through monitoring visits and written evidence.

At Tameside Acute NHS Trust, a district general hospital, we have established clear medical education governance structures demonstrating lines of accountability, mapping with those designed by ¹ in the context of motivation and staff development within the Trust.

It became apparent that we needed to develop more robust processes in order to achieve the standards laid down by PMETB, the “Gold Guide”,⁴ National Association of Clinical Tutors (NACT) recommendations⁵ and other requirements. We have established a specific policy on medical education which underpins medical education governance, including:

• a vision andmission statement;
• the medical governance systems (internal and external);
• roles and responsibilities;
• management of the foundation and specialty programmes;
• quality control processes;
• monitoring and regulation of the educational supervisory process;
• career management;
• managing doctors in difficulty.

Accountability

Our Medical Education Committee (MEC) has become the focal point of the internal medical governance structure. It meets monthly and has been expanded to encompass more stakeholders including a lay person, a Deanery representative, GP tutor, career grades, HR, finance, the career lead, the librarian, multiprofessional services and an increasing number of trainees to represent each of the various training schemes (foundation and speciality, including GP). It reports directly to the Trust Executive Group (TEG) with the Director of Medical Education (DME) and Foundation Leads providing a biannual report to the CEO of the Trust and the Postgraduate Dean. Standing items on the MEC agenda include:

• foundation issues;
• speciality issues;
• European working time directive compliance and 2009 action plans;
• trainee issues;
• library and resources.

In the past the roles and responsibilities of the individuals involved in medical education has been a little haphazard. Our medical education policy clearly demonstrates each individual’s accountabilities including the CEO, Medical Director, Director of HR, DME, Foundation Leads, Royal College/Programme Tutors (RCT), Clinical Leads, Clinical Supervisors, Educational Supervisors and the Medical Education Manager.

It is planned that under the heading of specialty training the College/Programme Tutors will report biannually to the MEC on compliance with PMETB standards of their programmes using a structured proforma that is adapted from NACT. External reports will be disseminated (e.g. PMETB survey, Deanery visiting reports) and action plans developed according to recommendations in the reports.

An enhanced proposal for the monitoring and regulation of the educational supervisory process is contained in the medical education policy. Key clinical staff responsible for delivering training are educationally appraised annually. The process is made more robust by:

• introduction of specific training and education appraisal forms (adapted from Deanery);
• clear personal development plans (PDPs) in training and education being established;
• consultant PDPs in medical education being audited with targeted training established for identified gaps;
• the information to inform job planning has clearer reflection.

Each trainer is responsible for identifying and managing doctors in difficulty. A clear structure with practical advice is summarised in the policy on medical education with reference to Managing Trainees in Difficulty (NACT, Jan 2008)⁶, Guidelines for Managing Under-Performing Pre- Registration House Officers (Dept of Postgraduate Medicine & Dentistry, University of Manchester 2003)⁷ and the Trust Medical Conduct Policy.⁸

Self evaluation

This occurs in several areas including:

• teaching, learning and assessment;
• trainee support and guidance;
• learning resources;
• student progression and achievement.

We have implemented the Postgraduate Hospital Environmental Evaluation Measure (PHEEM) validated questionnaire. This has been introduced to foundation trainees and, following successful data collection and actions, has been extended to speciality trainees. Quality and improvement can only occur if weak areas are identified and rectified. A great advantage of this questionnaire is that further analysis also allows the breakdown scores for each item so that each department can obtain a clear idea about their own strengths and weaknesses. The reports are sent to each RCT together with a letter of explanation, who is asked to produce action plans using the template enclosed. Implementation of these action plans with subsequent regular, repetition of the PHEEM will hopefully demonstrate improvement and maintenance of quality of the training.

We carry out regular audits on a random selection of trainees in each speciality to include aspects highlighted by PMETB and not included in PHEEM (e.g. 4 hours of protected teaching, receiving timely, robust work-based assessments, having 3-monthly appraisals, good clinical experience and appropriate sessions in theatres, outpatients etc.). Results from these audits are used to cross-reference and triangulate the information from the RCT reports.

We have introduced more robust feedback forms for lecture/training sessions, and are now installing systems to:

• ensure more complete feedback (aiming for at least 80% of attendees);
• provide analysis of the results;
• send a timely summary of the feedback to the trainer which they can include in their portfolio.

We will evaluate trainee progression using a variety of methods, including the:

• success of our foundation trainees in completing the foundation programme and entry into specialty training;
• application numbers of qualified medical students to our local foundation programme;
• application numbers of trainees to our local GP specialty training scheme;
• recording of the success rates in postgraduate exam;
• regular auditing of study leave.

Staff development

Medical educators must be fit for purpose. This includes training so that they are able to take up the roles and responsibilities outlined in the medical education policy. Examples include:

• equality and diversity training;
• training in giving feedback;
• mentoring;
• work-based assessments;
• ePortfolio;
• delivering structured reports;
• managing and supporting doctors in difficulty;
• managing appraisal;
• understanding educational theory;
• advice about access to career management;
• supporting delivery of the educational contract.

This is an ongoing process and involves:

• the establishment of databases;
• reports of staff development of consultants by RCTs to the MEC in their biannual report;
• auditing of the annual appraisal of consultants on the aspects of medical education to see if there are training needs that can be delivered jointly by the Trust and Deanery. We are looking to utilise the same appraisal forms as the Deanery uses for their own team.

Teaching and training also forms a significant aspect of consultant application for Clinical Excellence Awards (CEA). Demonstration of excellence in this domain will help achieve monetary gain. This is currently aided by trainers receiving feedback on their teaching sessions but it is envisioned that:

• introducing a teaching dossier as described in the module will help inform consultants in their annual appraisal and in application for CEAs;
• introducing an award system similar to that described⁹ will help motivate trainers firstly by gaining recognition and also by being able to put such an achievement on the CEA application forms.

When educators have clear roles and responsibilities, they are able to recognise what is required. They can understand their own gaps in knowledge, skills or attitude and with robust appraisals can develop personal development plans which include specific study leave time and budget allocation. The Trust can monitor the needs of the staff and help target training to relevant needs.

In summary, academic accountability motivates consultants to improve their teaching and training skills. They know what is expected and have a clear idea of appropriate standards. Continuous monitoring, evaluation, action planning and rewarding are key areas that all need to be addressed in order to make staff development successful within my institution.