Hetv quality Management of Medical & Dental Education & Training

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HETV Quality Management of Medical & Dental Education & Training



Ratified by:

  • Quality Management Committee

  • Postgraduate Medical Education

  • Senior Leadership Team

Date ratified:

August 2014

Name and title of originator/author(s)

Associate Dean for Quality

Name of responsible Director:

Mr John Clark, Director of Education & Quality

Date issued:

8 September 2014

Review date:

May 2015

Target audience:

Key stakeholders and regulatory bodies

Document history:

Approved by the Oxford Deanery Executive Team: August 2009

Reviewed & updated: February 2011

Reviewed & updated: June 2013

Reviewed & updated: June-August 2014

Document status

This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet, and copied to the internet, is the controlled copy. Any printed copies of this document are not controlled.

As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet.

Executive summary

This policy sets out the processes designed and implemented by Health Education Thames Valley to quality manage medical and dental education and training within the region. It includes details of key lines of responsibility and reporting structures, including the models for quality assurance and quality control, and summarises the relationship between the medical quality management model and the non-medical quality management model.

In a number of places, the policy refers to ‘Oxford Deanery’ and ‘Deaneries’. These are either historical references or are quoting from documents published by external bodies which HETV has no version control over.

The policy seeks to demonstrate how HETV fulfills General Medical Council standards for education and training.

The Trainee Doctor, GMC

Standards for Deaneries, Standard 3

Postgraduate deaneries must have structures and processes that enable the GMC standards to be demonstrated for all foundation and specialty training, and for the trainees, within the sphere of their responsibility. Contents
Paragraph Page

  1. Introduction 5

  2. Purpose 5

  1. Scope 5

  1. Definitions 6

  1. Duties 6

  1. Visits 8

  1. Information from trainees 11

  1. Annual Trust Reports 11

  1. Annual School Reports 12

  1. Autumn Reviews, Quality Grading and Interim Reviews 12

  1. Externality, and External Scrutiny 13

  1. Internal Scrutiny 15

  1. Equality Impact Assessment 17

  1. Education and training requirements 17

  1. Monitoring compliance and effectiveness 17

  1. References 17

  1. Appendices One – Ten 18 - 34

  1. Introduction

Health Education Thames Valley [HETV] is one of 13 Local Education & Training Boards in England. HETV is responsible for workforce planning and development, and education and training of the healthcare and public health workforce in the Thames Valley region, and has incorporated the functions carried out by the Oxford Deanery/Oxford Postgraduate Medical & Dental Education.

HETV is responsible for the quality management of medical education and training and is accountable to the General Medical Council for ensuring a robust quality management framework.

The Trainee Doctor, GMC; Standards for Deaneries, Standard 3

Postgraduate deaneries must have structures and processes that enable the GMC standards to be demonstrated for all foundation and specialty training, and for the trainees, within the sphere of their responsibility.

This policy sets out the processes, principles, roles and responsibilities, and governance frameworks for the quality assurance, quality management and quality control of postgraduate medical and dental education and training within Health Education Thames Valley. The paper also summarises the HETV multi-professional model for quality management to provide additional context.

  1. Purpose

The purpose of this document is to provide a detailed overview of the established quality management processes in line with regulatory standards. The GMC has published The Trainee Doctor, a set of standards for training, and educators, and LETBs [which incorporate the former Deaneries]. The GMC expects LETBs to quality manage postgraduate education in accordance with these standards.

There are five overarching standards for LETBs set out in The Trainee Doctor;

  • The postgraduate deanery must adhere to, and comply with, GMC standards and requirements;

  • The postgraduate deanery must articulate clearly the rights and responsibilities of the trainees;

  • The postgraduate deanery must have structures and processes that enable the GMC standards to be demonstrated for all foundation and specialty training, and for the trainees, within the sphere of their responsibility;

  • The postgraduate deanery must have a system for the use of external advisers;

  • The postgraduate deanery must work effectively with others.

  1. Scope

The GMC take a regional approach to quality assurance and will consider themes that emerge across all stages of undergraduate and postgraduate medical education and training. HETV is committed to ensuring that all trainees have access to excellent clinical training that meets the standards set out in The Trainee Doctor. This policy covers the education and training provided to HETV trainees by LEPs, including by those outside of the Thames Valley region where there are cross-LETB rotations.

The GMC takes a risk-based approach to quality assurance, in line with the Better Regulation Executive’s five Principles of Good Regulation. Building on the Better Regulation Taskforce’s key principles, quality management of PGMDE in HETV should be:

  • Proportionate: appropriate to the risk posed, costs identified and minimised;

  • Accountable: clear lines of accountability;

  • Consistent: joined up and implemented fairly;

  • Transparent: available for all to access on the HETV website;

  • Targeted: risk-based and focused on current and potential problems; and

  • Outcome-based: focused on strategies that improve trainee and patient safety, outcomes and experience.

  1. Definition

The GMC has assigned three levels of quality activity: quality assurance, quality management and quality control. http://www.gmc-uk.org/education/assuring_quality.asp

They are defined as follows:

  • Quality assurance is the overarching activity under which both quality management and quality control sit. It includes all the policies, standards, systems and processes that are in place to maintain and improve the quality of medical education and training in the UK. This is the responsibility of the GMC and is based on their statutory remit.

  • Quality management is the responsibility of medical schools and LETBs. It refers to the processes through which these bodies ensure that the training their medical students and trainee doctors are receiving from local education providers (LEPs), such as NHS trusts, meets the GMC’s standards.

  • Local Education Providers are in turn responsible for quality control, i.e. ensuring that the education they are providing meets local, national and professional standards.

  1. Duties

Figure 1 below provides an overview of the quality framework for postgraduate medical education and training in the UK. This framework provides the basis of quality management for both postgraduate medical and postgraduate dental education and training in HETV, pending the outcomes of work by the General Dental Council.

Figure 1
HETV has an established Quality Management Committee [QMC], which has been in place since 2011. The QMC is chaired by the Associate Dean for Quality. The QMC is responsible for confirming the suitability of posts and programmes on behalf of the Postgraduate Dean. The QMC meets monthly and uses an exception reporting approach, reviewing new concerns and progress against existing concerns. Terms of Reference [including membership] are set out in Appendix One.

HETV has established an Education Quality Assurance Board [EQAB], an HETV-wide multi-professional forum which reviews education quality for both medical and non-medical training. The QMC reports into EQAB and some members of the QMC also sit on EQAB. Terms of Reference are set out in Appendix Two.

Reporting and escalation routes are set out in Appendix Three.

The Postgraduate Dean is responsible for ensuring that postgraduate training is delivered in accordance with the standards set by the GMC. The Dean is accountable for quality management within the HETV to both the LETB Board and the University of Oxford.

The Postgraduate Dental Dean is responsible for ensuring that postgraduate training is delivered in accordance with the standards sent by the General Dental Council.

The Associate Dean for Quality chairs the Quality Management Committee, supports Heads of Schools and Training Programme Directors in their quality management role and makes recommendations to the Postgraduate Dean about the continued suitability of posts and programmes.

The Quality Assurance Manager [QAM] coordinates the medical and dental quality management process, including the development, implementation and evaluation of a robust quality management framework. The QAM reports on all aspects of quality with regard to postgraduate medical and dental education within Trusts and across Postgraduate Specialty Schools in HETV, in accordance with the standards set down by the GMC and Medical Royal Colleges and their Faculties. The QAM is responsible for writing the bi-annual Dean’s Return to the GMC. The QAM works collaboratively with the Assistant Director of Education & Quality [Quality & Performance] to further develop HETV’s multi-professional approach to quality management.

Heads of School are responsible for coordinating the delivery of high quality training across their Schools’ programmes, monitoring the quality of training and providing annual reports to the QMC. These exception reports draw upon data gathered through meetings, visits, trainee surveys, exit interviews or surveys, and ARCPs/RITAs.

Training Programme Directors are responsible for coordinating training across posts and rotations for a specialty, specialties or a stage of training (e.g. Core Medical or Surgical Training). They report to the relevant Head of School and work closely with the Directors of Medical Education in those trusts where their trainees rotate. Their responsibilities include contributing to the trust’s quality control processes and HETV’s and their School’s quality management processes.

Medical Directors are accountable to their Trust Board for the quality of education and training within the trust. The Medical Director is responsible for ensuring that the trust (typically through the Director of Medical Education) provides an annual report to the QMC which addresses any training issues that arise.

Directors of Medical Education (DME), acting on behalf of medical directors, are responsible for the quality control of training within the trust. This includes establishing robust systems and processes to monitor training, improve quality and address any issues that may arise. The DME is responsible for providing an annual report to the QMC, and providing responses where issues have been identified.

The QMC triangulates data from a range of sources which can be measured against GMC standards and used to bring about continual improvements in education and training as well as allowing the Committee to determine whether training is being delivered in accordance with the standards set out in The Trainee Doctor. Key sources of evidence, and the processes involved are set out below:

  1. Visits

HETV’s model for visiting Trusts and LEPs continues to evolve in light of the multi-professional and partnership approach to quality management the LETB.

There are currently three types of visit, Education Quality Visits, School Visits, and Exceptional Visits.

Table 1 – Types of visit to local education provider




Education Quality Visits

Multi-professional education and training. Partnership approach

Annual – led by Postgraduate Dean

School Visits

Medical and Dental. Review all open issues and concerns

Triennial – led by Head of School

Exceptional Visits

Medical and Dental. Arranged in response to major concerns

As required – led by Postgraduate Dean

  1. Education Quality Visits

Education Quality Visits occur annually, and involve representatives from both medical and non-medical HETV quality teams. From a medical and dental perspective, HETV visits education providers to review their local quality control processes with the primary purpose being to ensure that there are robust systems and processes to support local quality control in accordance with GMC and other regulatory standards. Following each Education Quality Visit, the Trust will be invited to complete a feedback form [Appendix Four] for HETV to further aid the development of the visiting model.

Trusts are visited at set times of the year:

Milton Keynes Hospital NHS Trust

Early March

Oxford University Hospitals NHS Trust

Late March

Heatherwood & Wexham Park Hospitals NHS Foundation Trust


Royal Berkshire Hospital NHS Foundation Trust


Buckinghamshire Healthcare NHS Trust


Central North West London NHS Foundation Trust – Milton Keynes Locality


Oxford Health NHS Foundation Trust


Berkshire Healthcare NHS Foundation Trust


  1. School Visits

School Visits occur on a triennial basis. School Visits are an information gathering process, are not a regulatory inspection and are a means for HETV to be assured that there are robust systems and processes to support local quality control at hospital level. School Visits also provide trainees with the opportunity to meet face-to-face with senior educators from outside of their current training location, to highlight areas of good practice in their current rotation, and to raise individually, or collectively, matters of concern without fear of disadvantage. Any concerns reported will be anonymised and not attributable to any particular trainee.

The cycle of these visits is proposed by the Quality Assurance Manager and agreed by the Associate Dean for Quality. Typically, School Visits take place in the two/three weeks prior to the Annual Education Quality Visit. This ensures that the preliminary summary report and feedback delivered at the EQV to the Trust Senior representatives is current. Any mandatory requirements set by the School Visiting Team are shared with the Trust, and included in the EQV Report. They also form the basis of the full School Visit report.

Where School Visits occur outside of the 3-yearly cycle it will either be due to significant concerns which warrant a visit sooner than the next 3-yearly visit, or where the visit is an Exceptional Visit.

  1. Exceptional Visits

Exceptional Visits occur outside our routine annual visiting cycle and are at the direction of the Postgraduate Dean. Exceptional Visits can be organised for a number of reasons but occur mainly when HETV is concerned about progress being made by the LEP to address and resolve known major concerns. Participants in exceptional visits will be determined by the specific concerns.

As per School Visits, Exceptional Visits are an information gathering process, and are not a regulatory inspection. For the majority of Exceptional Visits, HETV will invite representatives from the General Medical Council and the relevant Royal College or Faculty to join the visit. These representatives provide a national perspective and are there to support the HETV visiting team. The GMC, as medical regulators, can help HETV ensure that any mandatory requirements agreed at the visit are appropriate and proportionate.

From August 2014, all summaries from School Visits and Exceptional Visits, as well as any mandatory requirements set by the visiting team will be shared with the trainees from the department/specialty being visited, and copied to the Chair of the Trainees Advisory Committee.

Table 2 sets out membership for the EQV and School Visits.

Table 2 – participants in visits



School Visit

Director of Education and Quality

Postgraduate Dean

Associate Postgraduate Dean, Quality Management

Assistant Director of Education & Quality [Quality & Performance]

Head of Business and Operations, HETV

Associate Dean Interdisciplinary Education

Quality Assurance Manager [Medical & Dental], HETV

Quality Manager [Non-Medical]

Head of School


Lay Representative

Trainee Representative

Training Programme Director or Senior educator from within school


Representative from the Local Area Team

Specialty School Manager


*Heads of School are included as part of the EQV if they have visited the LEP in the preceding 2/3 weeks.

  1. Information from Trainees

The GMC National Trainee Survey analysis informs both Annual Trust & School reports. Face to face meetings with trainees, such as School visits, also provide a source of evidence. A number of Schools and Trusts/ LEPs collect additional trainee feedback through their own internal quality management processes, such as specialty-specific/school specific questionnaires and surveys or trainee committees. In addition, a number of Schools circulate pre-visit questionnaires to trainees in advance of their 3-yearly visit.

HETV has an established a Trainee Advisory Committee [TAC], a team of 32 trainee representatives taken from across the 16 Specialty Schools [including Foundation, Pharmacy & Dental]. The TAC has been in place since 2008. The TAC has a two-way function and advises the Postgraduate Dean and Senior Leadership Team of matters of importance relating to trainees as well as to inform trainees of HETV activities and to consider matters suggested for discussion by the Dean and the SLT.

Representatives from the TAC attend the monthly Quality Management Committee, the bi-monthly Head of School meetings, School Boards, School Visits, Education Quality Visits, and Exceptional Visits. The terms of reference for the TAC can be found in Appendix Five.

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