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Remediation of Dentists in Difficulty Guidance notes for the management of remediation cases by Dental Postgraduate Deaneries in England September 2009 Remediation of Dentists in Difficulty Contents 1. Introduction ................................................................................................... 1 2. Poor performance causes ............................................................................. 1 3. Principles of the remediation process ........................................................... 2 4. Outcome of the remediation process ............................................................ 2 5. Stages in the remediation process ................................................................ 3 6. Roles and responsibilities of deaneries ......................................................... 6 7. Responsibilities of the referrer ...................................................................... 6 8. Responsibilities of the registrant ................................................................... 6 9. Disclosure of information ............................................................................... 7 10. Appeals against the deanery process ........................................................... 7 11. Working party membership ........................................................................... 7 Appendices Appendix 1 Referral routes Appendix 2 Referral information required by a deanery Appendix 3 Assessment form Appendix 4 Selection and training of deanery staff involved in managing remediation cases Appendix 5 GDC revalidation domains and sources of evidence Appendix 6 Examples of remediation options for clinical subjects Appendix 7 Examples of resource material and tools for remediation Appendix 8 Standards for clinical / professional practice Appendix 9 Sources of evidence of professional competence Appendix 10 Example of an action plan Appendix 11 Quality assurance Appendix 12 Evidence of attainment of remediation goals Appendix 13 Appeals against the process Reference material Remediation of Dentists in Difficulty 1. Introduction The Committee of Postgraduate Dental Deans and Directors (COPDEND) has assisted with the remediation of dentists in difficulty for many years. In the past the number of cases being referred to deaneries has been low. The gradual transition to a more litigious society and a heightened awareness of the need to address poor professional performance has resulted in a marked increase in the number of cases requiring remediation. There has been a threefold increase in the number of cases heard by the General Dental Council in the past five years. The National Clinical Assessment Service (NCAS) has received more than 450 requests for advice in the past 7 years. The Postgraduate Dental Deans in England determined that in the interest of protecting the public and in light of the need for appropriate quality assurance of remedial training, it would be beneficial to develop a framework for handling these cases. Following a national workshop of stakeholders involved with dentists in difficulty, COPDEND subsequently established a working party of key stakeholders to prepare guidance on the management of these cases both for deaneries and for those agencies referring to them. The remit of the working group was to develop a framework for COPDEND members and stakeholders to use in order to facilitate the appropriate remediation of registered dentists whose performance has been found to be below accepted levels for the profession and to describe appropriate referral pathways for that remediation, agreeing wherever possible the processes that will be followed to maximise the likelihood of a successful outcome. It was agreed by all the stakeholders that ultimate responsibility for the remediation rests with the registrant. The role of the deanery is to provide assistance in drawing up a remediation action plan, to give advice on resources available to the registrant, to monitor the milestones in the action plan and to report back to the referring agency. The cost of a remediation programme is also the responsibility of the registrant, although support may be available from other sources. 2. Poor performance causes In order to manage the remediation of registrants who are deemed to be performing below acceptable standards it is essential to have an understanding of the factors that are implicated in the poor performance, as these will need to be addressed in addition to any clinical concerns. The issue that brings a registrant to the notice of the authorities is rarely the sole cause but often a manifestation of an underlying problem or problems. NCAS has published comprehensive guidance on the issues relating to poor performance. The clinical manifestation of poor performance may be due to:- Health issues Behavioural issues Clinical issues Contextual/ environmental issues Deaneries should be able to manage the remediation of clinical issues. It would generally be appropriate to develop a remediation plan for clinical activity which runs in parallel to those that address health and behavioural issues. If it is established that the 1 Remediation of Dentists in Difficulty major factors are non clinical, the deanery may work with the referring agency and other parties to assist the registrant to deal with all the issues. Poor performance often occurs across many areas of professional practice; remediation may need to take these into consideration. Poor clinical work is often linked to poor record keeping and poor standards of administration. The underlying cause can take time to resolve and the registrant may take time to accept it is their responsibility. They may also need considerable support and assistance in drawing up an appropriate action plan as they are often not aware of the tools and resources available or how to use them. 3. Principles of the remediation process Assure patient safety / public protection Return the registrant to safe practice Have fair, consistent and transparent processes Appropriate Timely Clearly defined measurable outcomes Quality assured Transferable model for use with other groups of registrants 4. Outcome of the remediation process The objective of a remediation programme should be to return the practitioner to safe professional practice at an appropriate and agreed level or, if they do not satisfactorily complete the process, for them to be given advice on future career options. It may not be possible to return a registrant to their original position but to a suitable alternative position after remediation. The remediation process will address the particular issues related to poor performance that triggered the referral and, in addition, the registrant will be expected to have achieved the standards required by the GDC for revalidation. In order for remediation to be deemed successful, the registrant will be expected to demonstrate at the end of the remediation period that they have attained the standards expected of a professional to be revalidated in all the domains, as well as addressing any specific areas of poor performance. Ideally, where clinical operative skills are a concern, a full assessment of a registrant‟s operative skills should be undertaken in their own working environment. However, this may not always be possible but as it could be assumed that most registrants would have operated at an appropriate standard when first registered, the end point of remediation should be to attain the level of competence and professional behaviour required for revalidation. If this end point is defined with the registrant at the start of the remediation process, it is their responsibility to demonstrate to the referring body that they have attained this level of competence at the end of the remediation period. A key principle of revalidation is that registrants should be able to reflect on their work and action; therefore the remediation action plan should maximise opportunities for the registrant to reflect on their own activity and to provide supporting evidence. The role of the deanery is to provide tools and a framework to do this. 2 Remediation of Dentists in Difficulty 5. Stages in the remediation process 1. Referral to the deanery 2. Initial exploration and review of problems raised, including available data on assessments including any health or behavioural issues. 3. Deanery decision whether to accept the registrant into a remediation programme 4. Develop draft action or remediation learning plan 5. Timetable, milestones and approval of the remediation plan 6. Registrant undertakes the action/ remedial plan. 7. Monitoring of the plan 8. Report to referring organisation. 5.1 Referral to the Deanery Deaneries may receive referrals from different sources:- General Dental Council Primary Care Trusts Dental defence organisations Self referral by a registrant Appendix 1: Referral routes Appendix 2: Referral information required by a deanery 5.2 Initial Review On receipt of a request for a remediation programme the deanery will contact the registrant and his/her defence organisation. The deanery will require appropriate assessment reports about the registrant and the areas for remediation. An initial meeting will be arranged with the registrant to establish the issues and identify what assessments have already been undertaken and what data may be needed to plan the remediation. Appendix 3: Assessment form The deanery will nominate a named person to oversee the educational aspects of the remediation process. Appendix 4: Selection and training of deanery staff involved in managing remediation cases 3 Remediation of Dentists in Difficulty The deanery will request the registrant to prepare a portfolio of evidence in advance of the initial meeting to assist with the planning process. This portfolio of evidence should contain the evidence advised by the GDC for the first stage of revalidation. Appendix 5: GDC revalidation domains, sources of evidence and portfolio content Initial review will include:- Issues that led to the referral Review of prior training, learning and assessment of operative skills* Recognition of any health or behavioural issues that may need addressing Referral to other bodies for health and behavioural issues as appropriate (occupational health, clinical psychologists). Prior evidence in relation to revalidation/ recertification Gap analysis of areas of deficiency, skills, knowledge and attitudes. The gap analysis will be self-driven by the registrant with the support of the deanery. *Evidence of the value of operative skills assessment in determining remedial training needs for mature practitioners is not yet well validated. The registrant must be made aware at the initial meeting that he/she is responsible for funding the costs of the remediation process and identifying possible sources of funding available. The role of the deanery is to support and advise on tools and resources to assist. The registrant must be informed about the reports which will be sent to the referring body and when and what will happen if s/he fails to complete agreed actions. 5.3 Decision on whether to accept a dentist into a remedial programme Once the initial review of the case has taken place the deanery will have to establish whether it can develop and monitor a remediation plan. This may depend upon:- co-operation of the registrant funding to support the programme being available complexity of issues to be addressed any health issues that may hinder progress of a remediation plan timeframe for the remediation to be successful availability of deanery staff to draw up and monitor the plan If, after discussion with the registrant, the deanery does not feel able to support a plan it will inform the registrant and report back to the referring agency accordingly. 5.4 Develop a draft action plan / remediation plan Where the issue that leads to the referral does not require external assessment in order to fully identify the training needs, it should be possible to draw up an action plan to work through the issues. It is likely that the registrant will need coaching on how to develop an action plan, especially determining appropriate outcome measures. For more complex matters, perhaps related to health or behaviour, the deanery action plan will set out the clinical and professional issues to be addressed in parallel with plans by any other agencies involved in the process. When formulating the action plan it is essential that the registrant is given the responsibility to draft the plan in the light of the advice about what is required at each 4 Remediation of Dentists in Difficulty stage. This will give the registrant ownership of the plan and thus increase the likelihood of its success. Appendix 6: Examples of remediation options for clinical subjects Appendix 7: Examples of resource material and tools for remediation The plan should identify the major issues that need to be addressed, define the acceptable evidence of the outcome and by when it will be completed. It may be helpful if there is an action plan for each major item giving milestones along the route. Breaking down the project into smaller activities with short deadlines may make the plan more manageable and less daunting for the registrant. To assess areas that may need to be specifically addressed in the action plan, the deanery may ask the registrant or the referrer for additional information. Appendix 8: Standards for clinical/professional practice Appendix 9: Sources of evidence of professional competence The role of the deanery is to assist the registrant in drawing up an appropriate plan, advising him/her of resources to assist in attaining the goals of the plan, agreeing the acceptable evidence required, approving the plan, monitoring progress and reports. Action planning stages- Define: 1. outcomes for each area of remediation specified by the referral body 2. outcome for each domain of the revalidation framework 3. evidence of attainment of the defined outcome 4. actions needed to collect the evidence 5. success criteria for each part of the plan and what will determine the timetable to the outcome and indicate milestones 6. Define what the success criteria for each part of the plan will be and what will happen if the dentist fails to achieve the required outcome 7. Agree the plan with the referring body as appropriate or requested Appendix 10: Example of an action plan Appendix 11: Quality assurance 5.5 Timetable and milestones To be effective, the action plan must have clearly defined milestones for each activity and a date agreed for each milestone. These need to be recorded on the action plan. The milestones should relate to specific actions and should have as short a timeframe to attainment as possible. Appendix 12: Evidence of attainment of remediation goals 5.6 Monitoring of the plan Whilst the final responsibility for monitoring progress lies with the referrer, the deanery will, at agreed intervals, provide the referrer and other parties with a brief report on progress in achieving the milestones in the action plan. The deanery will notify the referrer if it has any concern that the registrant is unlikely to attain the milestones. 5 Remediation of Dentists in Difficulty 5.7 Report The deanery will provide a report at the end of the remediation programme confirming the attainment of the action plan items and any concerns about the quality of the evidence of attainment if appropriate. The deanery will not make a judgement on the registrant‟s fitness to practice but merely report on the attainment of agreed actions against the plan. 6. Roles and responsibilities of Deaneries It is the responsibility of the deanery to:- Appoint a named adviser to oversee the case Request a revalidation portfolio from the registrant Advise the registrant on the activities and tools they can use to remediate themselves Assist the registrant in drawing up action plans for their clinical remediation Assist in arranging operative assessments where appropriate Advise the referrer if there are concerns about health, with the consent of the registrant Confirm in writing with the registrant the issues, actions and outcomes associated with the process Agree the plan with the registrant and the referrer, as appropriate Monitor the action plan for clinical activity Report progress in achieving the milestones in the action plan to the referrer Report failure to achieve the milestones to the referrer Report outcomes of the action plan to the referrer Liaise with the registrant‟s defence organisation as appropriate Keep appropriate records during the remediation period and for 11 years afterwards Refer back if the deanery deems it is unable to assist 7. Responsibilities of the referrer It is the responsibility of the referrer to:- Notify the deanery of a request for remediation and a named case worker Provide the deanery with appropriate information in relation to the referral Notify the deanery of their requirements for receiving update reports Monitor progress towards remediation Arrange appropriate assessments with may include occupational health and behavioural assessments Take appropriate action should the registrant fail to attain the agreed outcomes of the remediation process 8. Responsibilities of the registrant It is the responsibility of the registrant to:- attend meetings with the deanery‟s named adviser and staff as requested draft the action plan for deanery approval allow appropriate assessments if required report progress to the deanery against the action plan milestones 6 Remediation of Dentists in Difficulty provide evidence of attainment of the action plan goals respond to deanery requests for information in a timely way fund any assessments and remediation training as determined by the action plan seek medical advice if appropriate fund the plan unless alternative sources of funding are available 9. Disclosure of information At the start of the deanery process, the registrant must be made aware of what information will be disclosed to third parties and at what points during the remediation programme. The registrant must also be informed that disclosures will be made to the General Dental Council if concerns for the safety of patients are discovered during the programme. 10. Appeals against the deanery process Should the registrant believe the deanery action plan is unreasonable, they should consult their defence organisation for advice. If they still feel the process is unfair they may ask for an independent review by a panel comprising a representative from another deanery, a lay person nominated by the deanery who will act as chairman of the review panel and LDC or BDA CAR representative or other membership as approved by the Strategic Health Authority or Health Board. Appendix 13: Appeals against the process 11. Working party membership British Dental Association J Husband Dental Defence Union B Harvey Dental Protection Ltd B Westbury Dental Schools Council Professor P Lumley General Dental Council M Ridler National Clinical Assessment Service J Brooks, C McLaughlin Primary Care Trust C Brown Postgraduate Deans A G Miller, N Ward 7 Appendix 1 Schematic for PCTs dealing with NHS primary care dental registrants about whom there are professional concerns Concerns raised PCT (Governance) about Primary Care Collates information registrants by:- Analyses data Consults NCAS Patient Meets with registrant Complaints / PALS Registrant themselves Interim performance Formal performers panel NCAS assessment Other primary care panel professional GDC Salaried professional registrant‟s employer PASS scheme Other PCT Other source Assessment and NCAS assessment DEANERY determination Remedial education programme Outcome report Notes 1. It should be recognised that not all PCTs will have exactly the same governance structures 2. It is important to recognise that there are crucial decisions to be made at the Interim Performance Panel stage regarding patient safety 3. This may include “contingent removal” from the Performers List, or referral to Regulatory Bodies 4. PCTs may wish to consider seeking NCAS advice at an early stage of the process Back to main document Appendix 2 Referral information required by a deanery The referring body should provide the Deanery with the following information: The name and contact details of the registrant The name and contact details of the registrants defence organisation The nature of the original complaint The areas identified as needing remediation Any other areas of concern Any advice and guidance sought from NCAS. Any assessments and reports undertaken (NCAS etc) The referring officer who will act as the case handler and monitor Key reporting dates Back to main document Appendix 3 Assessment form Checklist to assist identifying areas for updating / remediation Area of concern Yes/No Rating Clinical Diagnosis and treatment planning Radiology prescription/diagnosis Radiology quality of images Routine conservation Crown and bridge Endodontics Dentures Extraction Minor oral surgery Periodontics Paedodontics Sedation/ anxiety control Records Lack of Poor quality Altered Consent General concerns Specific concerns eg sedation Communication With patients With colleagues With staff Allegations of rudeness Practice management Health and safety Lack of documentation eg IRMER Infection control Concerns raised by PCT/BSA Adverse DRO reports Lack of appropriate NHS forms Concerns re prescribing profile Band gaming Complaints - number and type Previous disciplinary matters GDC PCT Trust Health Previous issues Current issues History from Defence organisation Number of complaints Rating is a numeric score of severity of the issue 0 = no concern 5 = high Back to main document Appendix 4 Selection and training of deanery staff involved in managing remediation cases The deanery clinician appointed to act as the Remediation Advisor to the registrant should have the appropriate skills and knowledge for the role. The following domains in the COPDEND publication „Guidelines for Dental Educators‟ provide a useful source of reference:- Domain 4: Assessing the learner Domain 5: Guidance for personal and professional development Domain 6: Quality assurance Domain 8: Professionalism http://www.copdend.org.uk Back to main document Appendix 5 GDC Revalidation Domains www.gdc-uk.org.uk Suggested sources of evidence for the domains Domain Source of evidence Portfolio evidence Clinical Record keeping Audits Copy DOPs Report Radiographs Photographs, videos & models Recent satisfactory Dental Reference Officer report Communication Multi Source Feedback (MSF) Copies Videos of consultations Copies of letters Copies Professionalism PDP and CPD records Copies MSF, Copies Peer observation reports Copies Minutes of meetings Copies Quality of evidence in portfolio Letters Copies Publications Copies Appraisal notes Copies Involvement with professional committees Minutes Reflective notes Copies Management & Third party accreditation – BDA, FGDP, IiP Certificates/ reports leadership Denplan Excel etc. Minutes of meetings Copy Business plans Copy PDP Certificates Accredited training Copies Audit Copies Third party reports – PCT, Dent Suggested minimum content of revalidation portfolio: a. Evidence of regular appraisal b. A personal development plan c. Evidence of Continuing Professional Development d. Working in an accredited environment e. Examples of reflective practice Back to main document Appendix 6 Examples of remediation options for clinical subjects Area Activity Outcome Validated by History taking Audit of record keeping Report External review Clinical DOP, Audit, video, clinical Report External review examination & photographs, study operative models treatment Accredited Courses Assignments External assessment Practical courses Report Course organiser report CAL material Knowledge External. test General CPD courses Reflective Review log Clinical attachments Report Report from Clinical Observerships supervisor Key skills Communication MSF Summary External review skills Direct observation reports Patients, colleagues staff Course certificates Leadership & MSF External review management Direct observation Report Accredited courses Assignments External assessment Professionalism MSF Report External review Integrity Audit of clinical records Report External review Compassion DOPs Altruism Continuous improvement Excellence Partnership working External review can be provided by any dentist approved by the deanery. It may be provided by dental tutors, dental practice advisors, Dental Reference Officers, defence body representatives, vocational training advisors, suitably trained Local Dental Committee nominee. Back to main document Appendix 7 Examples of resource material FGDP Key Skills Smile-On communication CDs Smile-On clinical governance tools NHS PCT Local Assessment Panel – audit „cook books‟ Denplan Excel BDA Good Practice Scheme BDA Clinical Governance Kit Health issues –PCTs should have access to occupational health services to assist with health matters related to dentists NCAS may be able to arrange access to the Practitioner Help Programme if required. There may be a charge for the PHP service Deanery VT Competency Assessment framework Tools for remediation See COPDEND – Foundation curriculum Framework for Dental Foundation Training p33-37 CPD planner - http://www.bristol.ac.uk/dentalpg/education/pdp/cpdplanner.pdf Back to main document Appendix 8 Standards for clinical / professional practice The following may assist in setting the standards required of a registrant to show attainment of revalidation standards: Royal College Clinical Guidelines http://www.rcseng.ac.uk/fds/clinical_guidelines FGDP (UK) Standards in Clinical Dentistry. http://www.fgdp.org.uk/publications/ SAMS manual http://www.fgdp.org.uk/publications/ GDC First Five Years www.gdc-uk.org.uk Curriculum for UK Dental Foundation Training http://www.copdend.org.uk/page.php?ref=1164040866 Back to main document Appendix 9 Sources of evidence of professional competence Clinical Environment Dental Practice Department Business DRS Services Authority DPA Dental Reference Service Deanery (VT advisers; practice visits) Dental Practice Advisor Audit* Expert report Governance Clinical observation Monitoring Multi source feedback (including patient input) Denplan Excel BDA Good Practice PCT infection control Audit* CPD records* Self-assessment Calibrated simulation Reflective evidence* Health Behaviour Occupational health Multi source feedback* Private specialist report 360 degree feedback* Complaints Reflective evidence* Psychometric testing Psychometric report Evaluation of communication issues should be drawn from evidence from more than one of the above assessment tools * portfolio evidence Back to main document Appendix 10 Example of an action plan Overview plan Deanery Remediation Case Name GDC No Tel No Email Key areas to be addressed Area Outcome Completion Date 1. 2. 3. 4. 5. 6. 7. Detailed plan Deanery Remediation Case Name GDC No Tel No Email Item Detail Activity Outcome Outcome Date Back to main document Appendix 11 Quality Assurance The deanery should define a quality management and control process for how it handles remediation cases. The process should define: The standards the deanery sets for each stage of the process How these standards are monitored? What review of these standards, processes and monitoring take place on an annual basis? Back to main document Appendix 12 Evidence of attainment of remediation goals It is essential that clearly defined outcome measures are defined in the action plans. The following tools may assist in this process. Audit Assessed training programme (University courses) DOPs, LEPs, MiniCex, CbD, and MSF* (see appendix 5) Clinical attachments and observership reports Peer review reports DRO reports Key Skills Practice protocols Notes of practice meetings On line CPD Multi source feedback Significant event analysis Case based discussion Records of verifiable CPD *Direct Observation of Procedures (DOPs), Longitudinal Evaluation of Procedures (LEPs), Mini Clinical Exam (MiniCex),Case Based Discsussion (CbD), Multi source feedback (MSF). The COPDEND publication „Evidence in support of the development of an assessment framework for Dental Foundation Training‟ gives helpful guidance on the most appropriate use of the assessment tools. Back to main document Appendix 13 Appeals against the process If the registrant feels the process by which the remediation plan is drawn up or monitored is unfair they may wish to appeal. The request to appeal should be made in writing to the Postgraduate Dental Dean managing the remediation process. The deanery will acknowledge the appeal letter within 14 working days. The deanery will then form an appeal panel with a lay representative as chair, a representative from another deanery and an LDC or BDA CAR member or a panel and process approved by the SHA/ Health Board. The panel will normally meet within 30 working days of the initial receipt of the appeal letter. The panel will consider the evidence and advise the Postgraduate Dental Dean of their decision. The appeal panel may find in favour of the appellant and recommend alterations to the programme, dismiss the appeal or advise the programme be re-drawn by another advisor. Back to main document Reference Material National Clinical Assessment Service www.ncas.npsa.nhs.uk/resources/publications/key-publications Investigating performance concerns - Primary care Back on Track - Restoring doctors and dentists to safe professional practice - Framework Document Managing dental underperformance General Dental Council: www.gdc-uk.org.uk Standards for dental professionals GDC – Revalidation Guidance The GDC Fitness to practice procedures COPDEND www.copdend.org.uk Generic Standards for Training (Revised July 2008) Standards for curricula and assessment systems (July 2008) UK Dental Foundation Programme Training curriculum Cross infection control for the dental team e-learning programme Faculty of Dental Practice (UK) www.fgdp.org.uk Standards in Dentistry Selection Criteria for Dental Radiography Adult Antimicrobial Prescribing in Primary Dental Care for General Dental Practitioners Key skills – Clinical record keeping Infection control Legislation and good practice guidelines Medical emergencies Radiography Risk management and communication Team training British Dental Association www.bda.org Advice Sheets series A-E Good Practice Scheme Medical History Forms Practice Compendium Clinical Governance Kit
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