2011-2012 Quality Improvement action Plan (QI
(1st August 2011 – 31st July 2012)
Organisations details:
Organisation name:
Trust Chief Executive’s or
Postgraduate Directors name:
Director of Medical Education’s name
(or equivalents, please state job title):
Specialty Head of School’s name
Report compiled by:
QIP signed off by:
Date signed off:
QIP updates, submission record:
1st QIP update dated:
Report compiled by:
QIP signed off by:
Date signed off:
ction Plan (QIP)
ly 2012)
2nd QIP update dated:
Report compiled by:
QIP signed off by:
Date signed off:
2011-2012 QIP
a) Please refer to the 2011 SAR Guidance Document
and completion percentages.
b) Please remember the QIP is designed to be a live working document. Theref
during the reporting period in response to quality reviews, local surveys, GMC
development of areas or to reflect changes in priorities and timescales.
c) Please ensure all areas of improvement are referenced to your
e) The progress column will be used at the time of providing your organisations m
below, please use the colour code identified in the table.
f) NHS trusts are asked to provide progress updates against their SAR at two int
g) Specialty and postgraduate schools are asked to provide one progress update
h) Organisations are asked to assess the risk to the organisation of not completin
dentified area of improvement. Please see the
i) Organisations are asked to provide a key for the
j) The QIP template is also available in an excel format for colleagues who would
1st update in blue text, for the
QIP updates
period 1 August to 31 October 2011
Trusts 1st November 2011
st
1 update in blue text, for the
QIP updates period 1 August 2011 to 30 April
2012
Speciality
1st May 2012
Schools
Postgraduat st
1 June 2012
e Schools
2011-2012 QIP guidance cover sheet
AR Guidance Document for full guidance on the completion of the QIP template, including referencing
is designed to be a live working document. Therefore additional actions may be added
in response to quality reviews, local surveys, GMC trainee and trainer surveys, further
reflect changes in priorities and timescales.
improvement are referenced to your 2010-2011 QIP if brought forward from the previous year, or from your
e used at the time of providing your organisations mid-point update; submission dates detailed in the
ur code identified in the table.
ovide progress updates against their SAR at two intervals during the reporting year.
e schools are asked to provide one progress update against their SAR during the reporting year.
assess the risk to the organisation of not completing individual actions to address the i
ent. Please see the 2011 SAR Guidance Document for a full explanation on the risk rating.
provide a key for the 1st and senior/management responsible leads.
vailable in an excel format for colleagues who would prefer an excel format to word.
nd
2 update in violet text, for the
Final update submitted with
period 1 November 2011 to 29
2012 SAR in orange text
February 2012
1st March 2012 1st July 2012
Final update submitted with 2012
SAR in orange text
6th August 2012
3rd September 2012
et
, including referencing convensions, risk ratings
revious year, or from your 2011SAR.
ates detailed in the table
eporting year.
Example of a completed QIP
GMC Standard Reference
Area of Improvement
Action Number
Describe the issue which requires action
Number
Ref: domain 6 / standard 7 / 7.3-IC (Foundation)
The 2010 GMC trainee survey identified (with a red outlier indicator) that
1 1, 7 foundation trainees are not receiving adequate induction, initial
investigations have shown that no formal monitoring of trainee induction
is taking place across the trust
Action Detail
What you intend to do to address the identified area of
improvement.
Please use a new line and reference number for each action
identified; e.g. 1.1 / 1.2 etc.
For each action please provide specific timescales
When an action is completed state completed
1.1 Carry out a gap analysis of the current induction arrangements
for foundation doctors entering the trust for both trust induction and
directorates, by 31 October 2011.
COMPLETED – 1 November 2011
1.2 Produce a programme of work to address gaps identified,
detailing specific tasks and those responsible by 30 November 2011.
COMPLETED – 1 December 2011
1.3 Establish monitoring process to ensure all trainees receive
appropriate trust and directorate level induction by December 2011.
COMPLETED – 10 January 2012
New action added – December 2012
1.2.1 Working group to take forward programme of work to
completion and ensure specific tasks completed for March 2012
inductions by January 2012.
Progress Update
Gap analysis carried out by FPM which identified the following:
· Lack of communication between medical staffing and directorates which resulted in all parties being
unaware of which trainees would be expected
· Lack of commitment and leadership from senior medical staff
· Lack of awareness of the importance of induction by both trust colleagues and individual trainees to
ensure patient safety
Programme of work in place, and all relevant individuals notified and aware of their tasks.
Working group established and meetings fortnightly (first meeting 5 December 2011)
Monitoring process designed and implemented:
Check lists in place for all departments
Standard procedure in place
Reporting tool (dataset) established
Working group completed the programme of work. New induction process is now in place and commenced
with foundation doctors who rotated in March 2012. Following first rotation minor changes made, this will
be incorporated in August 2012 induction. Education team now managing process.
of improvement is not addressed
directorate lead / college tutor /
Responsibility e.g. DME / HoS /
should be updated to reflect the
Risk to organisation if the area
Expected completion date for
progress made at the date of
area of improvement (means
1st Line Responsibility e.g.
Completion % (this figure
Measure of Success
Senior / Management
clinical tutor / TPD
Detail how you will know the action taken
submission)
final date)
Director
has addressed your initial area for improvement.
The 2011 GMC trainee survey score for the key
indicator ‘induction’ is not a red flag and shows
trainee responses within the mean percentile
New induction process in place by January
2011, to be used for March rotation
Jan-12 FPM DME RED 100%
Monitoring process embedded within the
organisation and standard work by March 2012
1 Actions to address organisation wide issues
GMC Standard Reference
Action Number Area of Improvement
Describe the issue which requires
Number
action
Action Detail
What you intend to do to address the identified area of improvement.
Please use a new line and reference number for each action identified; e.g. 1.1 / 1.2 etc.
For each action please provide specific timescales
When an action is completed state completed
Progress Update
Expected completion date
for area of improvement
(means final date)
1st Line Responsibility e.g.
directorate lead / college
tutor / clinical tutor / TPD
Senior / Management
Responsibility e.g. DME /
HoS / Director
for improvement.
Measure of Success
Detail how you will
know the action taken has
addressed your initial area
Risk to organisation if the
area of improvement is not
addressed
Completion % (this figure
should be updated to reflect
the progress made at the
date of submission)
2 Actions to address specific foundation training issues
GMC Standard Reference
Action Number Area of Improvement
Describe the issue which
Number
requires action
ecific foundation training issues
Expected completion date for
area of improvement (means
Action Detail Progress Update
What you intend to do to address the identified area of
final date)
improvement.
Please use a new line and reference number for each
action identified; e.g. 1.1 / 1.2 etc.
For each action please provide specific timescales
When an action is completed state completed
1st Line Responsibility e.g.
directorate lead / college tutor /
clinical tutor / TPD
Senior / Management
Responsibility e.g. DME / HoS /
Director
improvement.
Measure of Success
your initial area for
Detail how you will know
the action taken has addressed
Risk to organisation if the area
of improvement is not
addressed
Completion % (this figure
should be updated to reflect the
progress made at the date of
submission)
3 Actions to address specific specialty training (including general practice) issues
Please ensure it is clear to the reader whether an issue affects one set of trainees or all traine
paediatrics and affects only GP trainees indicated this by writing in brackets (Paeds
write (Paeds – core); if the issue affects higher specialty training write (Paeds
GMC Standard Reference
Area of Improvement
Action Number
Describe the issue which
Number
requires action
c specialty training (including general practice) issues
the reader whether an issue affects one set of trainees or all trainees. For example: if the issue
GP trainees indicated this by writing in brackets (Paeds – GP only); if the issue affects core trainees
ssue affects higher specialty training write (Paeds – higher); if the issue affects all trainees write (Paeds
Action Detail
What you intend to do to address the identified area of improvement.
Please use a new line and reference number for each action identified; e.g. 1.1 / 1.2 etc.
For each action please provide specific timescales
When an action is completed state completed
sue is in
cts core trainees
rite (Paeds
Progress Update
Expected completion date for
area of improvement (means
final date)
1st Line Responsibility e.g.
directorate lead / college tutor /
clinical tutor / TPD
Senior / Management
Responsibility e.g. DME / HoS /
Director
Measure of Success
addressed your initial
area for improvement.
Detail how you will
know the action taken has
Risk to organisation if the area
of improvement is not
addressed
Completion % (this figure
should be updated to reflect the
progress made at the date of
submission)
4 Actions to address specific dental training issues
GMC Standard Reference Number Area of Improvement Action Detail
Describe the
Action Number
issue which requires
action What you intend to do to address the
identified area of improvement.
Please use a new line and reference
number for each action identified; e.g. 1.1 / 1.2
etc.
For each action please provide specific
timescales
When an action is completed state
completed
Progress Update
Expected completion date for area of
improvement (means final date)
1st Line Responsibility e.g. directorate
lead / college tutor / clinical tutor / TPD
Senior / Management Responsibility e.g.
DME / HoS / Director
improvement.
your initial area for
will know the action
Detail how you
taken has addressed
Measure of Success
Risk to organisation if the area of
improvement is not addressed
Completion % (this figure should be
updated to reflect the progress made at
the date of submission)
5 Actions to address specific undergraduate training issues
Area of Improvement Action Detail Progress Update
What you intend to do to
GMC Standard Reference Number
Describe the issue
address the identified area of
which requires action
improvement.
Please use a new line and
Action Number
reference number for each action
identified; e.g. 1.1 / 1.2 etc.
For each action please
provide specific timescales
When an action is
completed state completed
Expected completion date for area of improvement
(means final date)
1st Line Responsibility e.g. directorate lead / college
tutor / clinical tutor / TPD
Senior / Management Responsibility e.g. DME / HoS /
Director
improvement.
your initial area for
Measure of Success
Detail how you will know
the action taken has addressed
Risk to organisation if the area of improvement is not
addressed
Completion % (this figure should be updated to
reflect the progress made at the date of submission)