1. The Invited Review Mechanism

2. Overview Introduction to the Invited Review Mechanism (IRM) What can the IRM tell us about Trusts and surgeons and problems that are experienced How problems can be addressed 2

3. Background to the IRM Independent external review to support local management processes Established in 1998 following events at the Bristol Royal Infirmary Described by BRI Inquiry as: “An admirable process…..” 3

4. Invited reviews we offer Individual reviews Service reviews Case note reviews 4

5. The process 5 Review 2 clinical 1 Lay reviewer 2-3 days Interview and documentation Review 2 clinical 1 Lay reviewer 2-3 days Interview and documentation Report Team produces report Recommendations Quality control via IRM committee input Handed to trust – trust property Report Team produces report Recommendations Quality control via IRM committee input Handed to trust – trust property Monitoring 1, 3 and 6 month follow up/evaluation Take action if recommendations are not implemented Monitoring 1, 3 and 6 month follow up/evaluation Take action if recommendations are not implemented Request CEO or MD Approval by College/ specialty Terms of reference and indemnity Request CEO or MD Approval by College/ specialty Terms of reference and indemnity College support for reviewers Recruitment and training Documentation Quality assurance Dedicated staff support College support for reviewers Recruitment and training Documentation Quality assurance Dedicated staff support

6. Total Reviews 2000 - 2012 2000200120022003200420052006200720082009201020112012 Service142334135311125 Individual2816761412310563 Casenote0000023211822 Total29209941057914 19 30 6

7. Total Reviews 2000 - 2012 7

8. Breakdown of reviews by type 2000 - 2012 8

9. Key points from activity data Numbers of reviews being requested from RCS are increasing. Clear recent shift from requests for individual reviews to service reviews. Too early to tell if this is a “spike” or longer term trend. We are continuing to monitor situation going forward to ensure we meet this demand. 9

10. IMPORTANCE OF LEARNING 10

11. Need to learn from experience College IRM team very aware of need to learn from experience of IRM. Most people can describe “anecdotal” characteristics of “problem” teams or individuals based on personal experience. BUT we want learn from themes of IRM reports in a structured evidence based way. 11

12. What are we doing? Analysing all reviews across defined time period (initially 12 months). Identifying themes from each case. Then identifying themes across the cases, and the learning from this. Plan to then share this learning to improve surgical practice. Work in progress! 12

13. WHAT LEARNING IS EMERGING? 13

14. It is not straightforward… No mono-causal explanation of problems. Rarely simple solutions to resolve issues. Each case needs a tailored response. HOWEVER common themes do emerge. 14

15. Emerging themes Cases often: Have a long standing history with lack of expertise in initial handling. Arise within the context of changes to services (not that change causes problems but does bring issues into sharper focus). 15

16. Emerging themes Cases often involve: Poor clinical outcomes. Poor team working relationships. Poor individual behaviours. Poor clinical leadership. 16

17. Emerging themes Concerns also highlighted are: Ineffective MDT processes. Ineffective M and M processes. Lack of adoption of good practice such as using the surgical checklist. Ineffective audit. 17

18. Emerging themes From a Trust perspective cases often involve: Poor understanding of surgical activity. Ineffective data collection. Ineffective clinical governance / incident reporting and learning. Poor appraisal processes. Lack of ability to resolve issues within Trust 18

19. ADDRESSING PROBLEMS 19

20. Trusts and clinicians need: Robust performance management systems High quality data systems To listen to patients and service users To create a culture of openness and honesty To share information To work together to manage risk To raise concerns early, consider external help, but most importantly ACT. 20

21. Challenges for the profession To set high standards – clinical and behavioural Enable openness and transparency Support surgeons in difficulty Ensure reviews are professionally led Be willing to make robust judgements about peer performance Lead individual and service improvement Implement learning from reviews 21

22. More information rtomlinson@rcseng.ac.uk 020 7869 6223 www.rcseng.ac.uk/standards/irm 22