Educational Supervisor S Structured Report: Submission to the Annual Review of Competence

Wessex Deanery Intensive Care Medicine Educational Supervisor’s Structured Report:

A report should be completed for each period of training – i.e. 1 report for each 3 month block of Step 1 training and 1 for each 6 month block of Step 2 training. Achievements since the previous report should be detailed. On completion this form should be submitted to the ARCP panel via the Deanery by the trainee’s ES or College Tutor (CT). If this form is emailed, it should be sent from a secure (NHS) address and the box at the end of the document should be marked to confirm that the trainee has seen it. If sent by post then the trainee should countersign it. If a completed form is not received by the deadline stated, the ARCP panel will issue an outcome 5 (incomplete evidence presented – additional training time may be required) and a face to face ARCP will be held at a later date. No exceptions will be allowed.

Name of person submitting report:

Position:

Training unit [hospital(s)]

Trainee’s name:

GMC number:

Base speciality: CCT date:

Curriculum: 2007 / 2010 / 2011

Previous placements in ICM programme (to include complementary training where appropriate):

Training Unit Dates (dd/mm/yy to – from)

Current placement:

Dates of last ARCP (dd/mm/yy):

Exam status (with dates):

Intermediate / Advanced training (please indicate period being reported) 2

Workplace based assessments completed (minimum number required for intermediate, advanced):

Assessment Number completed this Total number completed for attachment stage of training DOPS (2,1) CEX (2,2) CBD (2,3) ACAT (1,2) MSF (1,1)

Experiential outcomes

1. Log-book summary (must be annualised)

Expected activity achieved / not achieved

2. Audits: briefly describe each one and indicate (with dates where appropriate): completed/not completed, presented/not presented, loop closed

3. Patient safety project:

4. Research projects:

5. Publications:

6. Teaching:

7. Management development:

8. Presentations:

9. Courses attended (list in chronological order):

10. Competencies (please complete table below) – refer to curriculum: http://www.ficm.ac.uk/_assets/pdf/the_cct/cct%20in%20intensive%20care %20medicine%20-%20part%20iii%20syllabus%20[2010].pdf

Competency Achieved How achieved (Y/N) Clinical Self directed learning Formal teaching experience 1. Resuscitation and initial management of the acutely ill patient 2. Diagnosis, assessment, Investigation, Monitoring and Data Interpretation 3. Disease Management 4. Therapeutic interventions / Organ system support in single or multiple organ failure 5. Practical procedures 6. Perioperative care 3

7. Comfort and recovery 8. End of life care 9. Paediatric care 10. Transport 11. Patient safety and health systems management 12. Professionalism

Other outcomes ( please add comments as appropriate )

Details of concerns/investigations:

Are you aware if this trainee has been involved in any conduct, capability or Yes/ No Serious Untoward Incidents/ Significant Event Investigation or named in any complaint?

If so are you aware if it has/ these have been resolved satisfactorily with no Yes/No unresolved concerns about a trainee’s fitness to practice or conduct?

Comments, if any:

Reflective Notes: (this section should be used for the trainee to write a brief summary of his or her achievements since their last ARCP outlining the high points and also any difficulties encountered and how they were, or are being addressed) 4

ICM Multi Source Feedback (MSF) Team Assessment of Behaviour (TAB)

Number of completed Role of assessor assessments Educational supervisor Consultant ST3+ FY1/2 or CT1/2 Nursing staff AHPs Clerical TOTAL s n r e c s n n o r C e

c s n u s o o i n C r r

r e e S o c

n n r i o o

) o s o j r a N o Domain f s ) M s s o )

r e s r r s o e s s o b s a s

s e f m s e o s u

s r s a n ( e a

b f o m r u e n ( b m u n ( 1. Maintaining trust/ professional relationships with patients

2. Verbal communication skills

3. Team working/ working with colleagues

4. Accessibility

Summation of comments related to excellence of doctor’s professional behaviour: 5

Summation of comments related to minor or major concerns of doctor’s professional behaviour:

Were there any concerns about this doctor’s probity or health? Yes No If YES please provide details: If necessary please continue on an additional sheet

MSF-TAB completed satisfactorily? Yes No If NO please provide date for required completion of further TAB:

Agreed areas for improvement:

General comments about overall progress:

Potential to obtain a consultant post:

Areas for development during next attachment:

Recommendations for panel:

I confirm that this is an accurate description/summary of this trainee’s learning portfolio, covering the time period from __/__/_____ to __/__/_____

Signed by ______Date______(ES or CT)

Signed by ______Date______(trainee)

(It is essential that the trainee should have seen and agreed with the contents of this structured ES report before its submission for the ARCP. Please seek advice from the Deanery staff or TPDs if necessary). 6