Quality assurance

NHS England’s Professional Standards Report to Ministers, to include results from the 2018/19 Annual Organisational Audit

Revalidation and appraisal is carried out in the NHS to ensure doctors are licensed to practice medicine and supported to develop so care continuously improves. In April 2019 all responsible officers, who are the people responsible for helping doctors with revalidation, were asked to complete the Annual Organisational Audit (AOA) for 2018/19, on behalf of their organisations or ‘designated bodies’. All 862 known designated bodies in England submitted a return, resulting in a 100% response rate for the third year running. The collective results from the exercise provides a level of assurance about the consistency of the appraisal process supporting medical revalidation to patients and the public; and to doctors, responsible officers and the organisations in which they work; to higher level responsible officers in NHS England’s regional teams, the General Medical Council and ministers on the value that medical revalidation brings.  This report also references additional activities to support the professional standards agenda.

Framework of Quality Assurance for Responsible Officers and Revalidation (FQA)

The Framework of Quality Assurance for Responsible Officers and Revalidation (FQA) has been designed to assist responsible officers in providing assurance to their organisation’s board (or an equivalent governance or executive group) that the doctors working in their organisations remain up to date and fit to practise. The process, and collection of information it requires, supports responsible officers in the preparation of their own appraisal portfolios, giving an overview of their performance as responsible officers, whilst also providing a formal record of compliance, which will be helpful in the event of a designated body’s systems and processes becoming subject to challenge at any stage.

All responsible officers are asked to present an annual report (a template can be found at Annex D) to their Board or equivalent management team. The template has been redesigned and has been combined with the statement of compliance for efficiency and simplicity. The statement of compliance should be signed off by the Chief Executive or Chairman (or executive if no board exists) of the designated body’s Board or management team and submitted to the higher-level responsible officer by 24 September 2021.

The purpose of the AOA exercise is to support designated bodies and responsible officers in providing assurance that robust systems and processes are in place, identifying areas in which development will be required over the coming year and engaging Boards and management teams in that endeavour.

Annex A – Core standards (of the Responsible Officer Regulations)

Annex B – Quarterly Report (for designated bodies to report their medical appraisal progress to their higher-level responsible officer).

The collection has been approved by the Burden Advice and Assessment Service (BAAS), formerly Review of Central Returns – ROCR, reference ROCR/OR/2236/001MAND

The BAAS team (formerly ROCR) are keen to receive feedback on central data collections from the colleagues who complete/submit returns. In particular, around the length of time data collections take to complete and any issues, suggested improvements or duplication of data collections. Feedback can be submitted to BAAS using the Data Collection Burden Reduction Service referral form.

Annex C – Annual Organisational Audit (AOA) (for designated bodies to provide a standardised return to the higher-level responsible officer by Friday 7 June 2019)

An email containing a link to an electronic version of the form will be sent out on 1 April 2019. The questionnaire should only be submitted using the electronic version. Please do not use the form available on this webpage for your submission.

Annex D – Annual Board Report and Statement of Compliance (for the boards of designated bodies to monitor their organisation’s progress in implementing the Responsible Officer Regulations)

Annex F – Independent verification (a process by which all designated bodies will undergo to validate the status of their revalidation systems at least once in every 5-year revalidation cycle)

There is draft guidance and a specification available for those who wish to commission an external review.

Annex G – Bench-marking, calibration and checking consistency (the processes in place to enhance consistency across the country, in terms of approach, decision-making and thresholds for intervention)