Friday, 7 October 2016

Management - performance related issues

The FRCEM has a whole management viva. Here are some of my notes on some of the common themes.

Working practices
Team work
Guidelines / pathways
Lack of insight
Difficult colleagues / colleagues in difficulty

Check the numbers before you speak to people about it - facts often don't reflect reality.

Trainee in Difficulty
a nationally accepted phrase used to describe:
a doctor or dentist on a postgraduate training programme, who for whatever reason, needs extra help and support - beyond that which is normally required - to deal with an issue, or issues, that threaten to impede their progress towards completion of a postgraduate training programme
The purpose of identifying a trainee as being “in difficulty” is not to label them; it is to aid the addressing of relevant issues so that they may complete training successfully and continue to contribute to the work of the NHS.
Doctor in difficulty recognises that it’s not just trainees that might be in difficulty – TID is the new term.

If a problem happens, your role initially is not to investigate. You need to ensure safety of:
The patient – go and review them
The staff – support the SHO
Support the SpR and decide if this is a doctor in difficulty.

10 Signs of a Doctor in Difficulty
- The “disappearing act” -  disappearing; lateness; frequent sick leave.
- Low work rate - leaving late and still not achieving a reasonable workload.
- Ward rage - bursts of temper; shouting matches; real or imagined slights
- Rigidity - poor tolerance of ambiguity; inability to compromise; difficulty prioritising; inappropriate ‘whistle blowing’.
- Bypass syndrome - junior colleagues or nurses find ways to avoid seeking the doctor’s opinion or help
- Career problems - difficulty with exams; uncertainty about career choice; disillusionment with medicine
- Insight failure - rejection of constructive criticism; defensiveness; counter-challenge.
- Lack of engagement in educational processes - fails to arrange appraisals, late with learning events/workbased assessments, reluctant to complete portfolio, little reflection
- Lack of initiative/appropriate professional engagement
the trainee may come from a culture where there is a rigid hierarchical structure and trainees are not encouraged to question patient management decisions by senior colleagues, or demonstrate other healthy assertive behaviours
- Inappropriate attitudes
The cultural background may be very strongly male oriented and the trainees may not be used to working with females on an equal status basis

From isolated incidents it is often difficult to know. It is important to report incidents if and when they happen so pattern can be identified.

Clinical Performance - capability and learning
Health - physical and mental
Personality and Behaviour
Environment - home and work

Early identification of problems
Establish and clarify the facts, with as many sources of information as possible.
Poor performance is a symptom and not a diagnosis.
Clear documentation
Communicate misgivings. Complete records. Remedies must be sought. Progression must be delayed until issues resolved.
Patient safety greater than all

Remain focused on specific problem
Refrain from generalised comment
Deal with the specific behaviour
Try to find positive
Avoid ‘You’ and use ‘I’
Explain how you think
If facing hostility, state their feelings

Avoid confrontation
Use empathic assertion
Active listening
Control anger
Let their anger subside

When to refer to the GMC 
If the Drs illness is impacting his or her performance, and one or more of:
  Drs ill health is posing, or may pose, a risk to patients
  Dr refuses or has failed to follow advice and guidance from his or her own patients, occy health or employer.
 Drs conduct has lead to the involvement of the police/ and or the courts or raised other concerns.
Discuss potential referrals with GMC or NCAS first.


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