Systems in place
 to ensure the competence and appropriate training of all clinical staff.
 to identify and remedy poor performance

1.     All grades of medical staff attend a mandatory general induction course on joining the
   To include
    corporate issues
    records of attendance
    follow-up of non-attendees

From April 2004 the Trust will be expected to have an induction policy that outlines the expectations
for induction for each group of staff at a corporate and local level.

2.      All medical staff in training attend a specific induction appropriate to the specialty in
which they are working.
There must be evidence of this (ie. Written records) & it must be a formal process in all specialties that
adheres to a minimum standard set by the Trust, e.g:
Responsibility for the programme
Introduction to staff
Orientation to wards/clinical areas
Expectations of post by consultant
Limitations of role
Familiarisation with equipment and procedures, and appropriate training requirements
Bleep system, resuscitation procedures
Local policies and procedures
Medication and associated regimes common to the area
Sources of help and advice
Minimum period of supervised practice

The programme should apply to joiners at any time, including rotation between specialties.

3.      The Trust has an induction system covering all temporary (locum, bank or agency)
clinical staff to ensure that such employees are competent to perform the duties of their post.
This criterion applies to all clinical staff. The Trust must demonstrate that there are appropriate
arrangements in place to safeguard patients. All locum staff should have a personal handover by the
regular postholder or a more senior person who will explain the basic requirements of the post.
Each specialty should have a “locum pack” giving basic details of the work of the specialty, the chain
of command and the location of key departments, communication systems and resuscitation
arrangements, together with clear detail covering:
What the job is
Who the supervisor is
What the duties and responsibilities are
Bleep arrangements
Pharmacy and local protocols including: prescription, administration and incident reporting
Information should be included on where to seek clinical help. Trusts should consider reviewing
contractual arrangements held with agencies.
4.     Medical staff in training can demonstrate that they are technically competent to
undertake their duties.
There can be no assumption that a doctor in training will have acquired the specific skills necessary to
perform adequately the duties of the post he/she fills. The Senate of Surgery has said “There should
be no learning curve as far as patient safety is concerned”, and we support this view.

This criterion covers the basic technical skills that a doctor in training would be expected to carry out
from day one, not the skills that they have come to the specialty to learn. It also does not cover skills
such as history taking, communication and diagnosis, which are usually found in log books. It includes
reviewing the competence of the doctors in training against identified skills required for that specialty.
Logbooks, such as those provided by the Royal Colleges, may address this criterion, provided that
they are used within the doctor’s first week in the specialty, and identify the specific skills and
competence required to undertake that role - not just a record of skills gained during the placement.

5.     Clinical risk management is included in the general induction arrangements
Trusts should provide training within one month of joining. The Assessor will require evidence, through
documentation and interviews, that clinical staff are aware of the Trust’s clinical risk management
strategy and clinical incident reporting system.
Training via videos and interactive CD roms is acceptable, but stating the strategy is in the staff
handbook or on the intranet only is not.

6.        Relevant clinical staff are competent to perform Basic Life Support
The Trust has a written policy which requires relevant clinical staff to be competent to perform basic
life support whenever called upon to do so, and can demonstrate that there is a system in place to
fulfil the policy and that training records are maintained.
      The Trust should determine which staff should (or alternatively need not) receive appropriate
          training, and this should be expressed in the policy
      This should not be seen as a substitute for training in advanced life support or other
          specialised techniques.
      Training records to identify which of the relevant staff have been trained and when an update is
      The system should include monitoring and follow-up of non-attendees.

7.    There is a procedure to verify the registration and ongoing monitoring of clinical staff.
Mechanisms are in place so that the Trust and the public can be satisfied that all staff are
appropriately qualified and registered.
8.     There is a system which identifies any therapeutic and diagnostic equipment for which
the operator is required to have specialist training.
Any person operating diagnostic or therapeutic equipment must have sufficient understanding of its
use to do so in a safe and effective manner.
    Need to identify the equipment for which specialist training is required, the
potential users, and their training needs.
    Training programmes are in place to ensure that staff operating diagnostic or therapeutic
       equipment can do so in a safe and effective manner.

9.       The Trust’s policy on hand hygiene and hand care is clear, and the Trust is actively
promoting specific initiatives and education programmes on hand hygiene.
All staff have an understanding of infection control practice.

Liz Spencer 14/07/04

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