CW Appraisal

Medical Staff Appraisal Policy
(All doctors excluding those with national training numbers)
START DATE: Jan 2019 VERSION: 3.0 NEXT REVIEW: Dec 2021
COMMITTEE Education Strategy Board DATE: November 2018

APPROVAL:
CHAIR’S SIGNATURE: Medical Director – Dr Zoe Penn
ENDORSED BY: HR Director DATE:
DISTRIBUTION: TRUST
APPLICABLE TO: Medical Staff who have a “prescribed connection” with Chelsea and
Westminster Hospital Foundation Trust.
LOCATION:  TRUST INTRANET – HR policies folder

 Online Appraisal System Support Page
RELATED  General Medical Council Good Medical Practice guide

DOCUMENTS:  NHS England Medical Appraisal Guide
 Trust Declaration of Interests and Potential Conflict of Interests Policy
 Trust Handling Concerns about Doctors’ Performance policy document
 Trust Medical Appraisal Guidance Documents and Templates
AUTHOR / FURTHER
INFORMATION: Author: Dr Jackie Durbridge (Associate Medical Director for Professional
Development)
Further Information: Debora Ferreira Lopes (Medical Appraisal and

Revalidation Officer)
DOCUMENT REVIEW Version 1.0 Launched in October 2012 DATE EXPIRED: December
HISTORY: Version 2.0 November 2013 2018
Revised October 2018
Chelsea and Westminster Hospital Foundation Trust Medical Staff Appraisal Policy 1
Contents
1. Introduction
2. Purpose of Appraisal
3. The Appraisal Process
4. Supporting Information for Appraisal
5. Key Roles and Responsibilities
6. Appraisal Monitoring
7. Appraiser Selection, Capacity and Capability
8. Information Management
Appendices
1. Introduction
Each member of medical staff with a “prescribed connection” to this Trust for a period
of one year or more must participate in annual appraisal according to the policies
outlined in this document. Those working at the Trust for less than 1 year should
contact the appraisal & revalidation team to discuss arrangements and will be
supported to have an appraisal or provided with a Medical Staff exit report if working
here for less than 6 months. (see appendix E)
A “prescribed connection” is the relationship between a doctor and a Designated

Body that is described in the General Medical Council’s Revalidation Regulations. A
doctor can have a prescribed connection with only one Designated Body (which in
most cases will be their employing organisation) and it is the responsibility of the
doctor to identify and confirm the organisation with which they have this connection
to the GMC.
Staff working at this Trust that have a prescribed connection with another
organisation, will be appraised through the policies of the organisation with which
they are connected. It is the responsibility of those doctors to inform this organisation
(Chelsea and Westminster Hospital Foundation Trust) in a timely fashion of any
requirements of the Trust they are connected with, (for example, the provision of
clinical governance or performance information) to support their appraisal.
Postgraduate trainee medical staff with National training numbers will have a
prescribed connection to the deanery overseeing their training and are not covered
by the trust appraisal policy. All other trainee, fellow, trust or specialty grade doctor is
required to abide by the Trust appraisal policy.
Doctors working at this Trust as a locum through an agency will have a prescribed
connection with their locum agency. As revalidation applies to all doctors, those
employed in locum positions are required to produce a portfolio of evidence. In order
to support this, the organisation will provide feedback to all locum doctors who work
at the Trust for a total of 20 days or more, in the same role (and within the same
service), within a twelve month period. This feedback will be recorded through the
Medical Staff Exit Report Form contained in Appendix E. It is the responsibility of the
doctor to ensure that their form is completed by the relevant Medical Manager (or a
colleague to whom they have delegated this responsibility).
This document describes the processes, responsibilities and systems through which
the appraisal of medical staff who have a prescribed connection with this
organisation must be carried out and it should be read in conjunction with the
following “core” documents:
 Medical Appraisal Guide (published by the NHS Revalidation Support Team);

 Good Medical Practice guide (published by the General Medical Council).
Other important documents are also referenced throughout this policy.
Revalidation is the culmination of an annual appraisal process over a 5 year cycle as

described in this policy. A revalidation appraisal is not a one-off event or different to
regular annual appraisals.
The policy is not exhaustive and is not intended to contain information on all aspects
of appraisal and revalidation.
Equality Statement
This policy applies to all non-training grade medical staff (GPs, Consultants, SAS and
all other non-training grades) with a prescribed connection to Chelsea and
Westminster Hospital Foundation Trust, irrespective of age, disability, race, colour,
nationality, ethnic origin, religion, gender, sexual orientation or marital status,
domestic circumstances, social and employment status, HIV status, gender
reassignment, political affiliation or trade union membership.
This policy has had an Equality Impact Assessment and is monitored through the
Trust Quality Committee.
2. Purpose and Principles of Appraisal
Medical staff appraisal is a process of facilitated self-review, supported by

information gathered from the full scope of a doctor’s work. At this organisation,
medical staff appraisal has four main purposes:
 To enable doctors to discuss their practice and performance with their

appraiser in order to demonstrate that they continue to meet the principles
and values set out in Good Medical Practice and thus to inform the
responsible officer’s revalidation recommendation to the GMC;
 To enable doctors to enhance the quality of their professional work by
planning their professional development;
 To enable doctors to consider their own needs in planning their professional
development.
 To enhance local systems of quality improvement.
Revalidation is the process through which licensed doctors demonstrate they remain
up to date and fit to practise. It is based on clinical governance and appraisal
processes. Effective annual medical appraisal and subsequent revalidation will
satisfy the requirements of Good Medical Practice and support the doctor’s
professional development.
Appraisal is focused on a doctor’s fitness to practise and professional development to

enhance this. This means that there is a clear distinction between appraisal and Job
Planning, which is focused on determining the quantity and scope of a doctor’s work
to meet service and organisational objectives – and should be a process that is
carried out at a separate meeting. Medical Staff should ensure that they are familiar
with the trust’s Job Planning Policy, which is described in a separate document.
It should also be recognised that Job Planning and appraisal are linked and will
inform each other: for example, an individual’s Job Plan will be relevant to their
appraisal because it helps describe their scope of practice; similarly, an individual’s
Personal Development Plan will be an important consideration in the context of what
clinical, managerial or research work they agree to undertake in their Job Plan.
2.1 Educational Appraisal
This component of annual consultant appraisal (the educational appraisal) should

occur once in 3 years. (See Appendix F for further information)
All doctors are required to include an educational appraisal unless they have no
formal or informal role clinically or educationally supervising other doctors, nurses,
medical students or allied professionals.
The educational appraisal will be supported by the consultant having completed the
Education Portfolio document and uploaded this to the system. Please see appendix
F for detailed information.
GMC survey reports as well as SOLE (Imperial undergraduate feedback) may also
be useful evidence.
2.2 Managerial Appraisal
Those doctors with significant managerial roles should provide relevant supporting
information to facilitate discussion of this aspect of their scope of work and this
should be used to feed into a discussion with their line manager of their performance
and development needs in this role annually.
Supporting information could include evidence of learning activities, outcome of

managerial projects or tasks with reflection with due regard to confidentiality issues.
Specific feedback and reflection on leadership/managerial skills can be sought and
advice on how to do this can be obtained from the revalidation team.
2.3 Scope of Work
An appraisal must cover the doctor’s full scope of work at all institutions that requires
the doctor to have a licence to practice. This will include alternative NHS Trusts,
private practice, other clinical roles (e.g. sports club doctors, charity work) and other
roles for instance providing letters of good standing, medical report writing. These
areas of work will require suitable governance and supporting information to be
provided.
3. The Appraisal Process
There are four stages to the medical appraisal process: Inputs, Meeting, Outputs and
Post Appraisal, as outlined in the schematic below. The Trust uses a web-based
system “Allocate” to capture and record all appraisal information.
Figure 3 – Overview of the Appraisal Process
•• Appraisee should complete

Appraisal
their online Form andForm
Appraisal related
and
documents providing
upload / attach all related
supporting documents online at
least 2 weeks before the
appraisal meeting.
There should be evidence of

reflection upon practice by the
doctor.
 Appraisal meeting must

take place by deadline date
 Meeting expected to last
1-2 hours
 Appraiser facilitates reflection
for appraisee and makes notes
summarising discussion and
captures this in the online form.
 Appraisal outputs must be

completed within 28 days of
meeting date
Appraiser feedback form completed by

appraisee
Appraisal quality checked or audited by
Trust
Feedback provided to appraiser annually
3.1 Inputs to Appraisal
The inputs to appraisal comprise the previous year’s appraisal form and the
supporting information documents with suitable reflection on them. The appraisee
attaches the supporting information to their electronic portfolio. These inputs describe
the doctor’s complete scope of work, including NHS, private work, managerial roles,
educational activities and any other work that is undertaken by virtue of being a
doctor. They should also describe progress against their PDP and (through the
supporting information) provide evidence that their practice meets the requirements
set out in Good Medical Practice. These inputs will be entered onto the online
appraisal form by the appraisee using the Allocate appraisal system.
Previous year’s appraisal documents, if they have been completed using a Word or
PDF document or via an alternative web system, will need to be attached to the
Trust’s online appraisal system, usually in a PDF file format.
The appraisee should complete their sections of the online appraisal form and ensure
any associated documentation is available online to their appraiser at least 2 weeks
before the appraisal meeting. The appraiser must review the form and supporting
documents prior to the meeting, allowing sufficient time for the appraisee to be
informed if any other information is required.
3.1.2 Declaration of Interests and Potential Conflict of Interests Form
Appraisees should ensure that they complete the Declaration of Interests and
Potential Conflict of Interests Form (Appendix G) and upload it to their online
appraisal form. Any information that needs to be provided to supplement the
declaration should be submitted separately to the doctor’s appraisal, using the
process and documentation described in the Trust’s “Conflicts of Interest , anti-
bribery and corruption policy” document found here http://connect/policies-
guidelines/policies-procedures/ This declaration must be completed annually.
3.1.3 Trust Values
The Trust has developed organisational values and behaviours through consultation
with staff, patients and members of the public. The appraisal process is an
opportunity for staff to articulate how they demonstrate the organisation’s values and
associated behaviours in their work.
Therefore, within the online appraisal form, medical staff should address the following
questions, providing evidence where possible (e.g. referencing colleague or patient
feedback):
 How have you demonstrated each of the following trust values?
o Putting patients first

o Responsive to, and supportive of, patients and staff
o Open, welcoming and honest
o Unfailingly kind, treating everyone with respect, compassion and
dignity
o Determined to develop our skills and continuously improve the quality
of care.
A template has been provided in the support section of the online system, if required,
to help staff capture this information for inclusion in their appraisal.
3.2 The Appraisal Meeting
The objectives of the appraisal meeting are to:
 Discuss and reflect on the Supporting Information;

 Review the previous Personal Development Plan (PDP) and relevant
progress against it;
 Construct a PDP for the period ahead, ensuring any relevant developmental
needs that have been identified are represented and cover all aspects of the
scope of work;
 Enable the appraiser statements to be completed.
The appraisal discussion is pivotal to achieving a high quality appraisal. The

appraiser is in a unique position to support, guide, constructively challenge and
provide feedback to the doctor, having reviewed the supporting information and
commentary provided.
Participants should ensure that an appropriate period of time is set aside for the
meeting (at least one hour is recommended) and that the meeting takes place in a
private environment, as free from interruption as possible.
Both parties may wish to take notes, but it is the responsibility of the appraiser to
provide an adequate summary of the appraisal meeting using the online form.
3.2.1 Appraisal deadline dates
The appraisal meeting should be held prior to (or on) the deadline date indicated for
each doctor. These deadline dates are related to the month in which the doctor’s
employment at the trust commenced: for example, if a doctor commenced work at
the trust on 4th September 2009, their annual appraisal meeting must take place by
the 30th of September each year. For existing WMUH doctors the deadline day will be
the last day of the month they previously had their appraisal. Appraisal and
revalidation dates (set by the GMC) are not necessarily aligned in the first instance.
An appraisal must be completed within 6 months of the revalidation date; if this is not
the case the appraisee must contact the revalidation team to arrange alignment
usually by deferring the revalidation date until after the next appraisal. An alteration
of the appraisal due date for specific reasons e.g. maternity or sick leave need to be
made via email to the revalidation team using the postponement form sent out.
Appraisal meetings may take place up to 3 months prior to the deadline date set: so
an appraisal with a deadline of the end of September can take place as early as (but
no earlier than) the 1st of July.
There will be an escalation process for delayed appraisals due to non-engagement

which will occur at key intervals on the timeline of the appraisal deadline date, as
follows:
1. Appraisal more than 1 month overdue – formal “reminder” from the

appraisal administrator
2. Appraisal more than 2 months overdue – formal “reminder” from the
Associate Medical Director for Professional Development (AMD for PDPD).
3. Appraisal more than 3 months overdue – formal notification to the doctor
from the RO regarding “risk to engagement in revalidation process”. NB –
these are also logged as “Missed Appraisals” and, as described in the
Medical Staff Appraisal Policy, require investigation
4. Appraisal not taken place within one month of formal RO Notification –

non-engagement notification sent to GMC by RO, with likely consequence
that revalidation date will be brought forward.
3.3 Outputs from Appraisal
Each appraisal will need to provide the following outputs in order to be considered
complete:
 The doctor’s PDP;

 A summary of the appraisal discussion;
 The appraiser’s statements.
All of these should be captured electronically using the online system.
The Appraiser and Appraisee will be required to sign off the appraisal and its outputs
within 28 days of the appraisal meeting.
A sample of completed appraisals will be reviewed, for quality assurance purposes

by the AMD for PD, who may offer feedback to the Appraiser or Appraisee, if
required.
3.4 Doctors “in Difficulty”
Performance issues will normally be dealt with as they arise by the Doctor’s
line/service manager in accordance with the Trust’s policy “Handling concerns about
a Doctors performance” and “Maintaining High Professional Standards in the NHS”
document.
If a doctors performance is currently or has (since the previous appraisal) been

managed under these policies then it is expected that they volunteer this information
and discuss the issues during their annual appraisal.
If during the appraisal discussion it becomes apparent that a doctor is ‘in difficulty’
(i.e. there are concerns regarding their conduct or capability) and the appraisee is not
currently being managed under the above policy, the appraiser must escalate this to
the relevant Clinical Director without delay.
It may be appropriate to delay an appraisal under such circumstances, but a doctor’s

appraisal for adherence to revalidation standards has to take place annually within
the financial year. If an appraisal is delayed for these reasons, arrangements should
be made as quickly as possible for the appraisal to be rescheduled. Records of the
circumstances and action being taken must be kept by the appraiser and timescales
clearly documented. The appraiser should inform the AMD for PDPD and/or the RO
of the concerns and what actions have been taken.
If concerns are raised during the appraisal discussion about the conduct or
performance of a third party the appraisee should be advised to discuss with their or
the person concerned line/service manager directly to initiate the appropriate
investigation and support.
4. Supporting Information for Appraisal
The purpose of Supporting Information is to enable the doctor to provide evidence

that their practice meets the requirements set out in Good Medical Practice. The
schematic below outlines the six types of Supporting Information.
Figure 4 – Types of Supporting Information for Medical Appraisal
The GMC and the Academy of Medical Royal Colleges (AoMRC) have set out broad
guidance on what type of information should be collected by doctors to inform their
appraisal and Revalidation.
(https://www.gmc-uk.org/registration-and-licensing/managing-your-
registration/revalidation/guidance-on-supporting-information-for-appraisal-and-
revalidation)
Each of the Medical Royal Colleges and Faculties has also set out more detailed
specialty-specific guidance pertaining to what activities they would expect their
members to participate in and also what performance information they should collect.
Consultants and Specialty Grade doctors should ensure that their Supporting
Information portfolio complies with the guidance of the Medical Royal College or
Faculty(s) relevant to their scope of practice. Trust Grade doctors, Clinical Fellows
and similar grades of doctors should discuss and agree with their Medical Manager,
at the outset of their employment, what scope of Supporting Information is most
appropriate for their role and duties.
4.1 Multi-source Feedback (MSF)
4.1.1. Colleague Feedback
The purpose of colleague feedback is to gather information from a doctor’s

colleagues to evidence the extent to which their practise meets the expectations set
out in Good Medical Practice and, where appropriate, inform the doctor’s PDP. We
also believe that the inclusion of and reflection on this type of information can help
embed our PROUD values.
Doctors at this trust must collect colleague feedback on a minimum of one occasion
in each revalidation cycle and include the report of this feedback in their portfolio of
Supporting Information. Each doctor will be informed by the Appraisals Team when
an MSF should be undertaken.
Feedback should be collected from a minimum of 15 colleagues, typically comprising:
 4 consultants;
 3 Junior Medical Staff, Specialty Grades, Trust Grade or equivalent medical
staff;
 5 clinical staff, which can include midwives, therapists, nurses, technicians
and theatre staff (as appropriate to the doctor’s scope of work);
 3 management or administrative staff, including at least one of the following:
Service Director, Operational (e.g. Theatre manager) or General Manager;
Divisional Director of Operations.
In order to ensure that this minimum number is met, doctors should be encouraged to
invite 20 or more colleagues to provide feedback, in case some do not respond.
Where medical staff work at more than one site, staff from other locations of work
should be included where possible, broadly in proportion to the work done at these
other sites. Anyone with an email address is able to provide feedback not just Trust
staff.
Staff chosen to provide feedback (also referred to as “raters”) should be those who
work regularly with the appraisee and have done so for a minimum of 3 months.
These raters should be an appropriate balance of colleagues from within the doctor’s
specialty or sub-specialty area of work.
Doctors cannot ask the following for feedback: their appraiser; their Responsible
Officer; appraisal administrators, a family member or business partner.
Specialty and sub-specialty teams may also agree local guidelines to supplement
these policy provisions: for example, recommending that all surgical doctors include
an anaesthetist with whom they work regularly as one of their raters. Service and
Clinical Directors are responsible for developing these local policies as appropriate.
Each doctor should complete a self-assessment questionnaire to initiate the MSF

collection process. The results of the self-assessment form will be included in the
final feedback report.
The appraisee will provide a list of raters for approval via the online system. Once the
list has been ratified by the revalidation team, raters can be invited to provide
feedback online.
Providing the criteria for rater selection set out above have been met, the team
should approve the rater list. The team should explain the reason for non-approval of
any rater to the appraisee and invite them to nominate a suitable alternative.
Colleague feedback can only be provided electronically by the rater using the IT
system adopted by the trust for this purpose. Guidance on how to complete the
feedback will be provided to all raters, who will have a maximum of four weeks to
complete their feedback. Doctors should not be able to identify raters from any of the
information provided. Administrative support, through the Revalidation team, will be
made available to facilitate this process.
Colleague feedback will be collated into standardised reports for discussion during
the appraisal meeting. These reports will include the ratings and text comments
provided by the doctor’s colleagues. The appraiser and appraisee will receive a
report to review and discuss at the appraisal meeting. The report will need to be
pulled through to the appraisal module on the online system as supporting evidence
for the appraisal. Appropriate reflection on the feedback by the appraisee needs to
be documented.
In line with GMC guidance, no doctor will be recommended for Revalidation without
having undertaken at least one round of colleague feedback. If issues are identified
in an MSF it is encouraged to repeat it within a revalidation cycle to demonstrate
improvement or change.
4.1.2 Patient Feedback
Feedback should also be collected from patients for reflection and development,
where appropriate.
Doctors who do not see patients as part of their medical practice are not required to
collect feedback from patients: doctors who consider that they fall into this category
must have this approved by their Responsible Officer as soon as possible or at the
time their employment at this trust starts. The Responsible Officer will write to the
doctor and their appraiser to confirm or decline the exemption from collecting patient
feedback and this will be logged on the online system.
Patient feedback will be collected for doctors with whom the organisation has a
prescribed connection if they are substantive members of staff, are with us for more
than 1 year or have an upcoming date for revalidation and have not previously
collected feedback. Patients in various settings (including outpatients, inpatients and
day-case areas) should be invited to provide feedback about doctors using a
standardised questionnaire approved by the GMC. A minimum of 20 patient
questionnaires will need to be completed for each doctor to enable a report to be
produced.
Ideally all patient feedback should be provided anonymously and securely using the
paper forms, generated via the Allocate system. Doctors will be provided with
relevant information about the process at the appropriate time by the Revalidation
team.
Patient feedback will be collated at the same time as the colleague feedback to
provide combined reports to inform the doctor’s appraisal. Therefore, doctors can
expect to discuss formal patient feedback during their appraisals at least once in 5
years however informal feedback from all sources should be discussed at each
appraisal and documented.
4.1.3 Managerial feedback
Doctors with substantial managerial/leadership roles are encouraged to elicit

feedback on this aspect of their role from colleagues using an alternative non-clinical
questionnaire. Please contact the Revalidation team for further information.
4.1.4 Educational Activity Feedback
A formal educational appraisal is required every 3 years for educational and clinical
supervisors, a professional development framework document (available in the
support section online) should be completed and attached as supporting information
to the regular clinical appraisal document. Supporting evidence may also include
SOLE feedback or other relevant lecture or course feedback. For further information
please see appendix F.
4.2 Clinical Governance Report, Significant Events, Complaints and Claims
The Clinical Governance report (CGR) will include information for events and
complaints pertaining to practice at CWFT and will be provided for each doctor from
the trust Clinical Governance recording system. It will include significant events
(SUI), complaints and claims related to the doctor’s practice but also where the
doctor has participated in an investigation, notified an incident or where a member of
junior staff under the consultants authority has been involved in an incident,
complaint or claim. These reports will be emailed to each doctor and their appraiser
approximately 6 weeks before the appraisal deadline date. If you have not received
this report at this time (or if your appraisal is occurring much earlier than the deadline
date), you should email the Revalidation team directly.
Information about significant events (this is defined as an event that has required a
subsequent investigation) and any complaints in which the doctor has been involved
must be included in each annual appraisal, along with the doctor’s reflections on this.
Doctors are expected to include other events which they may have reported,
investigated or been aware of to demonstrate reflection and learning.
Information regarding significant events and complaints covering practice at other

healthcare providers – NHS and Private and other organisations must also be
requested and provided with reflection. Appendix A provides details on how and
when this information should be requested.
4.3 Quality Improvement Activity
Quality Improvement Activity, such as Case Reviews or Audit, in which the doctor
has participated should also be captured and summarised in the Appraisal Form.
Once again, the MRCFs have provided guidance on recommended activities and
some have provided templates for capturing this activity. For internal purposes, we
have modified the RCP form for generic use by any doctor and this can be used
instead of (or in addition to) any other templates. The templates are available in the
support section of the online system.
4.4 Compliments
Emails or letters of compliment to doctors can also be included in the Supporting

Information and these should be scanned into electronic formats so they can be
uploaded to the online appraisal form. NB – as with all other information included in
the appraisal form, staff should take care to ensure that no patient identifiable
information is included in their submission.
4.5 CPD
Participation in Continuing Professional Development (CPD) is a requirement for all

medical staff. Each of the Medical Royal Colleges and Faculties (MRCF) have
provided guidance on the expected types and duration of CPD activity for their
members and many have also developed standardised templates to capture the
activity undertaken. It is the responsibility of each doctor to ensure they are aware of
these requirements and include a summary of the relevant CPD activity as
Supporting Information in the appraisal form.
Trust Mandatory Training reports must be attached to the online appraisal form:
these will be emailed to each doctor approximately six weeks before the appraisal
deadline date. Staff are required to be up-to-date with organisational and local
training requirements: any gaps are expected to be addressed in the doctor’s PDP. In
order that a positive Revalidation recommendation be made the doctor must be up to
date with the following 10 elements of mandatory training: BLS/ALS, infection control,
information governance, fire training, health and safety, safeguarding adults,
safeguarding children, conflict resolution, moving and handling and equality and
diversity as a minimum.
4.6 Reflection on Supporting Information
An important theme of all the Supporting Information is that it is used for reflection by
the doctor and that this is discussed during the appraisal. Reflection should address
the following questions:
What?
Focus on thoughts at the time of an experience. It allows exploration of the thought

processes when a particular action or decision was taken and how those may have
impacted on actions and feelings. e.g. ’what was I thinking when I took the actions or
made the decision that I did’
So what?
Involves considering the significance of what happened as well as the values and
feelings at the time of and prompted by the experience, and why these may influence
future learning or actions. e.g. ‘How did I feel at the time of and after the experience,
why was it important?’
Now what?
Enable the individual to look at the processes and opportunities that can help
learning from the experience and identifying future actions, reflection on those
actions, and how to use these to develop further. e.g. ’What can I learn from or do
differently next time’
We have modified a number of templates (originally developed by the RCP) for
internal use by all doctors, regardless of specialty. These are to help capture the
relevant information and cover the following topics:
 Significant Incidents;
 Multisource Feedback (Patient and Colleague Feedback);
 Case Review;
 Complaints and Claims;
 Compliments.
Staff may, of course, use alternative templates or formats: the key objective is that
the information is captured.
5. Key Roles and Responsibilities
5.1 Responsible Officer
The Medical Profession (Responsible Officers) Regulations 2010 legislation and the
associated guidance from the Department of Health (The Role of Responsible
Officer) provide detailed descriptions of the purpose, role and responsibilities of the
Responsible Officer.
The Responsible Officer (RO) at this trust is the Medical Director. The key
responsibilities of the RO are as follows:
 Implementation and operation of appraisals for all non-training grade Medical

Staff with a “prescribed connection” to the organisation (Consultants, SAS,
Trust Doctors and all non-training grade posts) – for which she or he is
personally accountable to the Board;
 Making recommendations to the GMC on doctors’ (those for whom she or he
is the RO) fitness for revalidation, based on an assessment of their practise
through annual appraisal;
 Ensuring that arrangements are in place so that information held by the
organisation on each doctor’s practice within the organisation is made
available to them on an annual basis and in a timely manner.
The Responsible Officer’s appraisal will include a review of their RO role, as well as
any relevant clinical duties they perform. Recommendations for revalidation will be
made by the RO at NHS England– as agreed by the GMC and Department of Health.
5.2 Associate Medical Director for Professional Development
The AMD for PD is appointed by the Trust for a period of 3 years and reports to the
Medical Director.
Their key responsibilities include:

 Briefing colleagues periodically (as appropriate) regarding relevant
developments in Revalidation and appraisal policy;
 Identifying appraiser learning and development needs and facilitating input
(internal or external) to address these, including dissemination of lessons
learned and good practice concerning appraisal;
 Reviewing coverage and quality of appraisals conducted at the trust.
5.3 Appraiser
Appraisers have a vital role in delivering high-quality appraisals through reviewing the
information provided to them and facilitating a doctor’s reflection on this information
and development of a PDP.
Appraiser responsibilities include:
 Ensure that appraisals are carried out in line with trust policies and guidance,
in particular that all the required Supporting Information is included in
the online appraisal form;
 Organise all their appraisals to meet the deadlines relevant to each of their
appraisees;
 Review appraisal documentation and evidence before the appraisal interview
takes place, identifying key areas for discussion;
 Ensure all the relevant outputs of appraisal are completed and signed-off as
required on completion of the appraisal meeting;
 Report any issues encountered with any of their appraisals directly to the RO
in a timely fashion;
 Undertake appraisal training and attend periodic updates as required;
 Take part in reviews of appraisal processes and outputs, including feedback
on performance in their role as an appraiser.
 The Trust will collect and provide feedback for individual appraisers for
inclusion in their own appraisal
Section 6 describes how the quality and coverage of appraisals will be monitored,
whilst section 7 describes the selection of, training for and support available to
appraisers at this organisation.
5.4 Appraisee
The doctor is the person upon whom the appraisal is focused: it is their practice, their
development and (in the context of Revalidation) their licence to practice that is at the
core of the objectives for the appraisal process.
Appraisee responsibilities include the following:
 Ensuring that they participate in annual appraisal, in line with the policies
articulated in this document and the deadlines indicated – in particular, that
all relevant Supporting Information is included in their online appraisal
form;
 Ensuring their practice and appraisal documentation meets the requirements
of Revalidation as set out by the Responsible Bodies (GMC, Medical Royal
Colleges and Faculties) relevant to their areas of work;
 Maintaining a professional portfolio that includes feedback from each of their
employers (including the independent sector), records of their training,
reflective practice and additional documentation as specified by the GMC or
Trust;
 Ensuring that the documentation relevant to their appraisal (appraisal form
and any relevant associated documents) is made available to their Appraiser
at least two weeks before the date of the appraisal via the electronic system;
 Informing any other employing organisations in a timely fashion about the
type of information required by this organisation to support their appraisal,
using the standardised trust communiqués provided (see Appendix A);
 Completing and submitting feedback forms about their appraisal when
requested.
For university academics, with honorary contracts, Follet principles (those articulated
in Annual appraisal for clinical academic consultants: II: The Follett Review,
published by the DH) apply, so these staff should clarify as soon as possible with
their appraiser how their joint appraisal will be managed, including who from other
organisations may need to attend.
Appraisees should discuss and agree arrangements for appraisal and Revalidation
with the Revalidation team when maternity leave or other breaks in service, for
whatever reason, have occurred during a Revalidation cycle.
Failure to engage with and participate in annual appraisal will mean that the RO will
not be able to recommend a doctor for Revalidation.
5.5. Medical Appraisal and Revalidation Officer (MARO) and

Appraisal/revalidation team
The MARO & team will provide administrative support to the Responsible Officer,
AMD for appraisal & revalidation and Medical Managers at this organisation to
ensure that:
 The list of doctors with whom the trust has a “prescribed connection” is
updated on a monthly basis;
 The appraisal deadline dates for each doctor are up-to-date, reflecting any
changes communicated by other groups of staff;
 The appraiser/appraisee allocations are updated monthly as required and re-
assigned on a 3 yearly basis to meet GMC guidance;
 The list of appraisers at the Trust and the calendar year in which they
completed their most recent set of training is updated on a monthly basis, as
required;
 Monitoring reports showing the year-to-date appraisal rates for each
Directorate in the organisation (along with the detail of which appraisals are
outstanding) are circulated each month to the agreed list of recipients;
 Feedback forms for evaluating appraisals are collated from appraisees and
stored in the appropriate location;
 Clinical governance and mandatory training reports are produced and
emailed to doctors 6-8 weeks prior to their appraisal date.
The MARO will also provide support and advice to doctors with using the online
system and with the collecting of patient feedback.
Information and queries should be emailed to the Revalidation team (see appendix
C).
6. Appraisal Monitoring
In order for appraisal to achieve the purposes set out earlier, all doctors must be
appraised annually and each appraisal must be of high quality: so it is important for
the organisation to monitor both aspects of the appraisal process.
6.1 Monitoring Appraisal Coverage and Quality
The RO is accountable to the Board for ensuring the implementation and operation of
appraisals for all medical staff with whom the organisation has a “prescribed
connection”; it is also a contractual requirement for all medical staff to participate in
annual appraisal. Therefore, the objective will be to maintain an appraisal rate of 90%
for medical staff over a twelve month period.
The MARO will provide monthly reports showing the appraisal rates for medical staff
at organisational, Divisional and Directorate level and also show which appraisals are
overdue. These monthly reports should be circulated to (and should also be a
standing agenda item at the monthly Divisional Board meetings):
 Clinical Directors, Divisional Medical Directors and the RO;

 Director of HR, Deputy Director of HR and HR Business Partners.
6.2 Appraisal Quality
The organisation will be monitoring the quality of the appraisal process and its
outputs through:
 Appraiser self-assessment using standardised forms (Appendix D);

 Appraisee feedback on their appraisal using questionnaires included on the
online system;
 Internal review of appraisal inputs and outputs
 External review of appraisal inputs & outputs to comply with GMC regulation.
Appraisers will also be invited to complete a self-assessment questionnaire and

provided feedback from their appraisees through a one to one meeting with the AMD
for Appraisal & Revalidation. This can then be included as part of their appraisal and
attached to their portfolio of Supporting Information for discussion during their
appraisal: any developmental needs for Appraisers can then be identified during their
appraisal and appropriate actions recorded in their PDP.
The Trust collects feedback via the system using a standardised questionnaire
reviewing the effectiveness of an appraisees’ appraisal and the appraisal process.
A sample of completed online appraisal forms will also be reviewed annually by the
RO, AMD and any other Medical Manager to whom the RO delegates this
responsibility. The sample will comprise one completed appraisal form for each
appraiser at the Trust, which will be selected from the whole set of appraisals each
appraiser has completed over the preceding twelve month period. The aim of this
review will be to assess the content of the appraisal inputs and outputs and the
extent to which they provide evidence of the quality of the appraisal.
Appraiser Selection, Capacity and Capability
7.1 Appraiser Selection
Appraisers are allocated by the appraisal team every 3 years, to comply with GMC
guidance that doctors should not be appraised by the same appraiser for more than 3
years. Cross specialty appraisal is utilised within the Trust.
The following conditions apply to the appraiser / appraisee pairings and appraisers
are expected to declare at the outset if any of these circumstances pertain for their
appraisee:
 No doctor who has a “prescribed connection” with this organisation can be

appraised by the RO at this trust;
 No doctor can appraise another doctor who is also appraising them (referred
to as a reciprocated appraiser and appraisee pairing);
 No appraisee who has a “prescribed connection” with this organisation is
permitted to pay an appraiser at this organisation for their appraisal;
 No doctor can be appraised by a member of their family;
 No doctor can appraise a colleague who is their line manager in another
organisation or a colleague with whom they have a business relationship.
Either the doctor or their appraiser may request that an appraisee / appraiser pairing
be changed if there are felt to be irreconcilable issues between the pair that could
compromise the effectiveness of the appraisal.
In order to enable this, either (or both) the appraisee or appraiser should write to the
AMD for PD to request a change, outlining briefly the rationale for the request. The
AMD should then decide whether to decline or uphold the request, in which case they
should also decide who else should perform the doctor’s appraisal. If there is a
change of appraiser, it is the responsibility of the AMD to communicate this
information to the Appraisals Team, so that they can update Trust records
accordingly.
7.2 Appraiser Capacity
Appraisals are likely to become more time consuming than they have been in the
past, as they are conducted to the standards described by the General Medical
Council, Department of Health and Medical Royal Colleges & Faculties.
The evidence suggests that approximately four hours is required by the appraiser for
each appraisal, comprising: 2 hours to review the appraisal form and Supporting
Information and prepare for the appraisal meeting; 1 hour for the appraisal meeting;
and 1 hour to produce the appraisal outputs.
For that reason, this organisation has decided to limit the number of appraisals that
an appraiser may carry out to a maximum of six, which should be exceeded only in
exceptional circumstances. An SPA tariff of 0.2 PA is being offered prospectively for
appraisers who are available for up to 6 appraisals/year. There may be appraisers
that would like to limit the number of appraisals they undertake and in such
circumstances a tariff of 0.1PA is offered for up to 4 appraisals.
It is the responsibility of Divisional Medical Directors, Clinical and Service Directors to
identify suitable doctors to become trained appraisers and send nominations to the
AMD for professional development.
7.3 Appraiser Training
Appraisals of medical staff must only be conducted by medical staff who are up-to-
date with their appraiser training.
Divisional Medical Directors or Clinical Directors should inform the MARO about any
suitable doctors in their areas who wish to train to be appraisers. The MARO will then
inform those doctors about any “in-house” or external appraiser training courses that
a doctor can attend: the costs of these courses will be met by the trust.
Any external course should be followed up by an induction session with the AMD and
the MARO to explain the specific requirements for appraisals within this Trust.
Appraisers should attend “refresher” training courses every three years, provided that
they will be continuing in the role: these courses will be provided “in house”.
7.4 Appraiser Support and Leadership
The trust will provide a range of support for appraisers to:
 Identify individual and collective learning or development needs;

 Discuss and resolve issues with appraisal processes or systems;
 Share lessons learned and good practice.
The self-assessment and feedback questionnaires will be used to discuss and

identify any development needs for individual appraisers, which can then be reflected
in their PDP. Divisional resources can also be used to provide external training to
address any particular needs identified that would not be covered by “in-house”
training.
The trust team will facilitate periodic meetings (Appraiser Forums) to discuss and
resolve issues pertaining to the trust’s appraisal capability, processes or systems.
This group may recommend and implement actions, including training and
modifications to appraisal processes or guidelines. Changes to the appraisal policy
will be ratified by the education strategy board following consultation with the LNC.
Appraisers are expected to attend a minimum of 1 appraiser education event/year

and utilise forums and refresher training to provide supporting information in their
own appraisal. Reflection on these activities may link to items in their PDP.
7.5 Appraiser Indemnity
Appraisers employed by the Trust are covered by NHS indemnity insurance under
the third party liability scheme, providing they have not acted negligently in their role.
The responsibilities expected of an appraiser are summarised in Section 5 of this
document.
8. Information Management
A number of documents will need to be created, transferred and stored to support

appraisal and revalidation. Information Management for Medical Revalidation in
England 4 provides detailed guidance about how access to this documentation should
be managed.
This section describes the relevant aspects of trust policy.
8.1 Access to key documents
The Trust uses an online system for recording appraisal documentation and
information which is accessed with password protected individual user account
logins.
The doctor, their appraiser, the AMD for PD and the RO (or appropriate persons with
delegated authority) are the only individuals within the organisation who are allowed
to view a doctor’s appraisal documentation on a routine basis.
The RO may delegate responsibility for reviewing these documents to another

Medical Manager at the organisation to deal with ad-hoc issues on a case-by-case
basis and also to support the evaluation of appraisal quality. In these circumstances,
the RO should email the person to whom authority has been delegated to ensure that
there is documentary evidence of the delegation.
The General Medical Council can access all information relevant to the licensure of
doctors.
Much of the information held for the purpose of appraisal and revalidation is personal
information; it is therefore protected by the Data Protection Act 1998 and is generally
exempt from requests under the Freedom of Information Act 2000. However, in
certain unusual circumstances (for example, in civil or criminal litigation) personal
information held by the doctor or the designated body may need to be released under
the order of a court or tribunal. In these circumstances, the legal obligation overrides
any objection the individuals may have.
8.2 Document storage and transfer
Appraisal documents should not be stored on portable memory devices or on

personal computers, in line with trust Information Governance policy, as these
devices are not deemed to be adequately secure.
Appraisal documentation should only be emailed to or from secure email addresses:

this means that only CWFT and nhs.net email addresses should be used, so
personal email addresses (e.g. yahoo or hotmail etc) must not be used to exchange
this information.
Appraisal documentation may be shared with another employer (e.g. if the doctor
changes employment), but only following the written approval or request of the
doctor, which should be directed to the RO. Doctors are able to download a PDF
version from the system on leaving the organisation.
Where appraisals are held jointly with another organisation, the appraisee should
provide both appraisers involved in the process with their appraisal form and any
Supporting Information documents. However, it will be the responsibility of the
appraiser from the lead organisation (the organisation with which the doctor has the
“prescribed connection”) to ensure that the outputs of appraisal are completed and
stored on the Trust’s online system.
Following the completion of the appraisal on the online system, the appraiser should
not retain any documentation pertaining to the doctor’s appraisal.
All appraisal and revalidation information required by the RO will be retained by the
trust (within legal parameters and safeguards) until it is agreed that it is no longer
relevant. Information relevant to the current or future evaluation of fitness to practise
will be retained and some information may need to be retained indefinitely.
Appendix A – Requests for information from other organisations
Many doctors work at more than one provider organisation. It is the responsibility of
the doctor to include information from their whole practice in the portfolio of
Supporting Information. At a minimum, doctors being appraised at this trust will need
to include clinical governance reports from the other organisations at which they
work. These reports must include information regarding: Legal Claims; Significant
Incidents; complaints; participation in audit activity.
To facilitate the collation and provision of this information, each doctor must take the
following action to ensure that information can be made available in a timely fashion:
 Email the RO & governance team at each of the other organisations at which
they practice, 8 weeks before their appraisal meeting (copying in their
appraiser to the email), using the suggested template in Figure B1 below.
Figure B1 – External Organisation Request email re Supporting Information
From: [Appraisee]
To: [RO at other organisation]
Cc: [Appraiser]
Subject: Formal Information Request for my Appraisal at Chelsea and Westminster

Hospital Foundation Trust
Dear [RO Name]
I have a prescribed connection with Chelsea and Westminster Hospital Foundation Trust and
am required by their policies to provide information about my practise at your organisation at
my appraisal.
My next appraisal is on [date month year]. Please can you provide my appraiser (cc’d) and
me with the following information (associated with my practise at your organisation), at least
four weeks before my appraisal meeting:
 Legal claims;
 Significant Incidents;
 Complaints (directed to your organisation);
 Audit (participation).
The information provided should cover the period from (date of previous appraisal) to the end
of the calendar month prior to the date of this email.
Do let me know as soon as possible if you envisage any difficulties in providing this
information. Please copy my appraiser in to any relevant communications regarding this
request.
Many thanks
[Appraisee Name]
Appendix B – Missed Appraisals Investigation Form
All doctors with a “prescribed connection” to the trust for a continuous period of one year or longer must participate in annual appraisal. This appraisal
should take place each year by the end of the calendar month in which the doctor’s employment started. Any appraisal that has not been completed
within three months of the deadline will be considered a “missed appraisal” and must be investigated.
The RO will notify (by trust email) the doctor, their appraiser and their Clinical Director (if that is a different person to their appraiser) of each missed
appraisal: these must be investigated through completion of the form below by the Appraisee and Appraiser, who should return the completed form to
the MARO. The MARO will discuss the responses with the MSAL and agree what the Overall Findings and Recommendations should be – and these
will be communicated to the RO, the Doctor, their Appraiser and their Clinical Director. Further action, where required, will then be taken.
Figure B – Missed Appraisal Investigation Form
Missed Appraisal Investigation Form – Tick relevant boxes identifying factors causing Missed Appraisal Yes or No?
1 Appraisee factors:
a Absence of appraisee at appraisal due date and not possible to rearrange within timeframe - e.g. maternity/sickness leave
b Incomplete portfolio or supporting information
c Appraisal Form not signed by appraisee
d Factors relating to lack of time of appraisee
e Lack of engagement of appraisee
f Other appraisee factors [description]
2 Appraiser factors:
a Unforeseen absence of appraiser at appraisal due date and not possible to rearrange within timeframe
b Appraisal Form not signed by appraiser
c Factors relating to lack of time of appraiser
d Other appraiser factors [description]
3 Organisational factors:
a Administrative/management factors
b Factors relating to function or failure of electronic portfolio or information system
c Insufficient numbers of trained appraisers
d Other organisational factors [description]
4 Overall Findings and Recommendations:
Chelsea and Westminster Hospital Foundation Trust Medical Staff26

Appraisal Policy
Appendix C – Quick Guides

Appraisal Policy
Appendix D
\\Cw-projects\revalidation & appraisal folders\General Policy & Guidance\Annex J Appraiser tools

assurance tools.pdf
Appendix E – Medical Staff Exit Report Form
This form should be completed for Locum Medical Staff or Medical Staff who have a “prescribed connection” with this trust, but who have not been
employed long enough to qualify for an annual appraisal. It should be completed electronically (i.e. typed) by the relevant Medical Manager or another
doctor to whom they have delegated this task. It is the responsibility of the doctor to ensure that this form is completed for their employment.
Chelsea and Westminster Hospital Foundation Trust – Medical Staff Exit Report Form
1 Details of locum: Name: GMC Number:
Email:
2 Details of locum agency: Name of agency:
Email Contact: Phone Contact:

3 Details of locum’s Responsible Officer: Name: Email:
4 Details of locum role performed: Title/grade/Specialty: Start Date:

End Date:
Brief description of duties [if not standard for the role]:
5 Details of person completing the report: Name: GMC Number:
Title/Role: Email:
6 The doctors performance was (underline as Unsatisfactory Borderline Satisfactory Good Excellent
appropriate):
Please describe issues or concerns:
7 The doctors conduct/behaviour was: Unsatisfactory Borderline Satisfactory Good Excellent
Please describe any issues or concerns:
8 Would you be happy for this doctor to be Yes/No

employed in the same role in the future
(underline as appropriate): If no, please describe reasons:
Additional Information (underline as appropriate):

9 GMC Domain 1: Knowledge, Skills & Performance Unsatisfactory Borderline Satisfactory Good Excellent Unable to Comment
10 GMC Domain 2: Safety and Quality Unsatisfactory Borderline Satisfactory Good Excellent Unable to Comment
11 GMC Domain 3: Communication, Partnership & Teamwork Unsatisfactory Borderline Satisfactory Good Excellent Unable to Comment
12 GMC Domain 4: Maintaining Trust Unsatisfactory Borderline Satisfactory Good Excellent Unable to Comment

Appraisal Policy
Appendix F – Information for Educational Appraisal
 What is educational appraisal?

Annual consultant appraisal needs to include the full scope of practice of a consultant’s work.
For all consultants working in Chelsea and Westminster this will include appraisal of their work as an educator.
 Why are we doing this?
The GMC requires all educational supervisors (ES) and clinical supervisors (CS), as well as those involved in coordinating undergraduate training to
be appropriately selected, trained and appraised for their roles.
We are required to have systems in place now to allow us as an LEP (local education provider) to do this.
The GMC, Health Education England as well as Imperial College will all require this information.
 To whom does this apply?
Educational supervisors
Named Clinical supervisors
Lead coordinators of undergraduate training
Doctors responsible for overseeing students’ educational progress for each medical school.
 What supporting information is appropriate?
The educational appraisal will be supported by the consultant having completed the Education Portfolio document (found in the framework for
Educators document see link below).
This document looks at 7 areas of practice and needs to be supported by evidence.
In order to be able to act as an ES or named CS the consultant needs to have gone on a course which covers all 7 areas.
Courses for experienced educational supervisors are run by PGME.
On-line courses can be found on the new Educator Hub where you can find e-learning modules which are mapped to the Professional Development
Framework for Educators. The Educator Hub can be found on the e-lfh platform at the following link: https://www.e-lfh.org.uk/programmes/educator-
hub/
Once completed, the course needs to be updated every 2-3 years.
GMC survey reports of postgraduate training SOLE (Imperial undergraduate feedback) may also be useful.
Trainee feedback from teaching sessions is strongly advised for evidence of development.
Where do I go for further information?

GMC:
Further information on the recognition and approval of trainer
http://www.gmc-uk.org/education/10264.asp
Educator Hub https://www.e-lfh.org.uk/programmes/educator-hub/
Dr Orhan Orhan (Chelsea) and Ms Tina Cotzias(WMUH) Directors of Medical Education

Appraisal Policy
Appendix G – Declarations of interests and the form
DECLARATION OF INTERESTS FORM
Please print and complete form as per below:

This form should be completed by:
- all new Staff
- existing staff who hold a ‘relevant and material’ interest or who consider that their personal
interests could constitute a significant conflict of interest.
- For a specific group of staff as per 4.1.4 of this policy, an annual declaration will be
requested.
DECLARATION
I have read and understood the Declarations of Interest Policy. I understand that failure to abide by
this policy will render me liable for disciplinary action, including termination of employment and
investigation by the LCFS that may lead to criminal proceedings being commenced.
Please cross out the section which does not apply to you:
1. I do not have any known Conflict of Interest between private interest and my position as an
employee of the Chelsea and Westminster Hospital NHS Foundation Trust
2a. I do have a declared Conflict of Interest between my private interest and my position as an
employee of the Chelsea and Westminster Hospital NHS Foundation Trust (please
complete section 2b. on the next page with details of the nature of your interests)
SIGNED (person making declaration) :…………………………………………………….
DATE: …………………………………………………………………………………………
NAME (in CAPITALS): ………………………………………………………………………
JOB TITLE: ……………………………………………………………………………………
DEPARTMENT/DIRECTORATE: ……………………………………………………………
Section 2b: Nature and detail of your interest
1 Directorships held in private companies, Public

Limited Companies or Limited Liability
Partnerships
2 Ownership or part-ownership of private

companies, businesses or consultancies
3 Majority or controlling shareholdings
4 Position of authority in a charity or voluntary

body
5 Connections with a voluntary or other

organisation contracting for or commissioning
NHS services
6 Connections with an organisation or Company

entering into, or having entered into a financial
arrangement with the Trust
7 Any of the above interests held by a spouse,

partner, close relative, other close associates
or personal friends
8 Additional Employment Employer:

There should be no conflict of interest between
your duties and any other job. If you have Post:
another job and there is a perceived conflict of
interest, you must still declare it Date employment began:
Hours worked:
9 Any other relevant interests
SIGNED (person making declaration): ………………………………… ..
NAME (IN CAPITALS): …………………………………………………….
DATE: ………………………………………………………………………..
Thank you for completing this form.
Email completed and signed form to: Board Governance Manager at

declarations@chelwest.nhs.uk
Registered □ Date ……………………….
If declaration is made: Board Governance Manager to forward to Line Manager to Review
and Return.
I have reviewed the declaration of interest(s) notified above.
*I consider the declaration to be acceptable / *I do not consider the declaration to be acceptable

and have taken the following action.
(*Please delete as applicable)
…………………………………………………………………………………………………………………
……..…………………………………………………………………………………………….……………
…………………………………………………………………..........................................
……………………………………………………………………………………….………………….
Signed……………………………………………………………Date………. ……………………..
Print name ……………………………………Job Title………………………………………………

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Medical Staff Appraisal Policy

(All doctors excluding those with national training numbers)

COMMITTEE Education Strategy Board DATE: November 2018

CHAIR’S SIGNATURE: Medical Director – Dr Zoe Penn

ENDORSED BY: HR Director DATE:

LOCATION:  TRUST INTRANET – HR policies folder

RELATED  General Medical Council Good Medical Practice guide

Further Information: Debora Ferreira Lopes (Medical Appraisal and

3. The Appraisal Process

4. Supporting Information for Appraisal

5. Key Roles and Responsibilities

7. Appraiser Selection, Capacity and Capability

A “prescribed connection” is the relationship between a doctor and a Designated

 Medical Appraisal Guide (published by the NHS Revalidation Support Team);

Other important documents are also referenced throughout this policy.

Revalidation is the culmination of an annual appraisal process over a 5 year cycle as

Medical staff appraisal is a process of facilitated self-review, supported by

 To enable doctors to discuss their practice and performance with their

Appraisal is focused on a doctor’s fitness to practise and professional development to

2.1 Educational Appraisal

This component of annual consultant appraisal (the educational appraisal) should

Supporting information could include evidence of learning activities, outcome of

2.3 Scope of Work

Figure 3 – Overview of the Appraisal Process

•• Appraisee should complete

There should be evidence of

 Appraisal meeting must

 Appraisal outputs must be

Appraiser feedback form completed by

3.1.2 Declaration of Interests and Potential Conflict of Interests Form

3.1.3 Trust Values

 How have you demonstrated each of the following trust values?

o Putting patients first

The objectives of the appraisal meeting are to:

 Discuss and reflect on the Supporting Information;

The appraisal discussion is pivotal to achieving a high quality appraisal. The

3.2.1 Appraisal deadline dates

There will be an escalation process for delayed appraisals due to non-engagement

1. Appraisal more than 1 month overdue – formal “reminder” from the

4. Appraisal not taken place within one month of formal RO Notification –

3.3 Outputs from Appraisal

 The doctor’s PDP;

All of these should be captured electronically using the online system.

A sample of completed appraisals will be reviewed, for quality assurance purposes

3.4 Doctors “in Difficulty”

If a doctors performance is currently or has (since the previous appraisal) been

It may be appropriate to delay an appraisal under such circumstances, but a doctor’s

The purpose of Supporting Information is to enable the doctor to provide evidence

Figure 4 – Types of Supporting Information for Medical Appraisal

4.1.1. Colleague Feedback

The purpose of colleague feedback is to gather information from a doctor’s

Feedback should be collected from a minimum of 15 colleagues, typically comprising:

Each doctor should complete a self-assessment questionnaire to initiate the MSF

4.1.2 Patient Feedback

4.1.3 Managerial feedback

Doctors with substantial managerial/leadership roles are encouraged to elicit

4.1.4 Educational Activity Feedback

4.2 Clinical Governance Report, Significant Events, Complaints and Claims

Information regarding significant events and complaints covering practice at other

4.3 Quality Improvement Activity

Emails or letters of compliment to doctors can also be included in the Supporting

Participation in Continuing Professional Development (CPD) is a requirement for all

I consider the declaration to be acceptable / I do not consider the declaration to be acceptable