Bi-College Regional Training Provider Accreditation Program

Transcription

1 Bi-College Regional Training Provider Accreditation Program Guidelines The Royal Australian College of General Practitioners (RACGP) Postal/Street Address: RACGP College House, 100 Wellington Parade, East Melbourne VIC 3002 Telephone: or (03) Fax: (03) Website: Australian College of Rural and Remote Medicine (ACRRM) Postal Address: GPO Box 2507, Brisbane QLD 4001 Street Address: Level 2, 410 Queen Street, Brisbane City QLD 4000 Telephone: or (07) Fax: (07) Website:

2 Welcome The RACGP and ACRRM are proud to be partners in this initiative to streamline the accreditation of Regional Training Providers (RTPs). Together ACRRM and RACGP have developed a new accreditation system that we believe is open, fair and consistent. Our aim in developing this accreditation system is to ensure the highest standards of general practice training for those who wish to become specialist general practitioners. This leads to quality and safe health services in the community. The new accreditation system was developed following a highly-consultative process that at every stage involved key stakeholders. There were no precedents for such a system and it is a tribute to all concerned that such a broad consensus has been reached at both a conceptual and operational level. The process of consultation will be ongoing as we continue to seek and to welcome honest and constructive feedback to how we can continue to improve the accreditation system thereby ensuring that our aim of safe and quality healthcare training is achieved. Marita Cowie Zena Burgess Chief Executive Officer Chief Executive Officer Australian College of Rural and Remote Medicine Royal Australian College of General Practitioners 30 May May P age

3 Contents Welcome... 2 Contents... 3 Introduction How to use the guidelines Background information Purpose of accreditation Benefits of the Bi-College accreditation program Bi-College RTP accreditation principles and outcomes Bi-College Accreditation governance and organisational structure Accreditation Governance Program Review Committee Accreditation Program and Management Teams Accreditation Review Team The accreditation process and outcomes Risk Assessment Accreditation outcomes Training provider changes of circumstance Complaints and Grievances Appeals against accreditation decisions Appeals process College appeals policies Feedback and Evaluation Appendix 1: Bi-College RTP Accreditation Principles and Outcomes Appendix 2: The Bi-College Accreditation Conflict of Interest Policy Appendix 3: Sample of a Visit Program P age

4 Introduction Bi-College Regional Training Provider (RTP) Accreditation is a program jointly managed and conducted by the Australian College of Rural and Remote Medicine (ACRRM) and the Royal Australian College of General Practitioners (RACGP), the two specialist medical colleges responsible for setting and arbitrating the standards for general practice training in Australia. All training providers are required to participate in accreditation, review, monitoring, evaluation and reporting processes, according to ACRRM and RACGP standards. RACGP and ACRRM have designed a single process that allows for concurrent accreditation of training providers by both Colleges against their own College s standards. Bi-College accreditation of each of the training providers is jointly conducted by RACGP and ACRRM who share all aspects of the workload and responsibility. The Bi-College RTP Accreditation Program aims to ensure that training providers are providing programs that are educationally relevant, purposeful for all stakeholders, and meet both colleges specialist medical training standards. The program also recognises that training providers are diverse in approach and that they work towards common outcomes but in different ways. To give practical meaning to the different, contextually-relevant approaches towards general practice training, the Bi-College RTP Accreditation Program is outcomes-based. This means the focus of the accreditation is on ensuring that the outcomes have been achieved rather than the means by which the results were reached. Policies and processes are also important because they assist an organisation to reach those outcomes in a robust and consistent manner. For this reason, policies and processes are also reviewed. 1. How to use the guidelines The purpose of this document is to inform training providers of the processes and policies that apply to the Bi-College RTP Accreditation Program. These step-by-step guidelines describe the accreditation process and cover: governance and management of the program; accreditation requirements for the training provider; stages of accreditation; possible accreditation outcomes; grievance and appeal processes; and evaluation of the program. 4 P age

5 2. Background information 2.1. Purpose of accreditation The Health Practitioner Regulation National Law Act 2009 objective is to establish a national registration and accreditation scheme for the regulation of health practitioners. The accreditation of specialist training programs is an element of this process for the purposes of specialist medical registration. Due to the implementation of the Health Practitioner Regulation National Law in July 2010, there is now a mandatory process for accreditation of specialist medical colleges by the Australian Medical Council (AMC). The AMC develops accreditation standards and assesses programs against those standards on behalf of the Medical Board of Australia (MBA).The MBA approves accredited programs of study for the purposes of specialist medical registration. ACRRM and the RACGP are accredited by the AMC to provide specialist training for general practitioners in Australia. The Commonwealth government provides funds to support general practitioner training in Australia through the following programs: Australian General Practice Training Program (AGPT) delivered by Regional Training Providers (RTPs); and The Remote Vocational Training Scheme (RVTS). These training providers must deliver all aspects of general practice training according to the Colleges standards, including the appointment of supervisors and teaching posts against the RACGP and/or ACRRM standards. Accreditation has two purposes: to accredit training providers for the delivery of education and training in order for a doctor to achieve specialist registration in general practice via fellowship of ACRRM and or RACGP; and to promote continuous quality improvement of the training providers that ensures continually high standards of education Benefits of the Bi-College accreditation program Bi-College RTP accreditation provides: a streamlined accreditation process; training providers with a direct relationship and line of accountability to the Colleges, as required by the AMC; Colleges with access to information and data to demonstrate compliance with AMC standards; clarity around the Colleges role in setting and maintaining training standards and GPET s role as the funder; support for both Colleges aspirations to ensure that training provider accreditation is educationally relevant and purposeful for all stakeholders; Colleges with clear oversight of the training provider accreditation outcomes; and each training provider with useful and relevant feedback from the Colleges regarding ACRRM and RACGP education and training standards. 5 P age

6 3. Bi-College RTP accreditation principles and outcomes While the two Colleges have different approaches and philosophies, they are united in aiming to ensure that quality, safety and relevance are the cornerstones of general practice education. To enable a Bi-College approach to accreditation, both Colleges have agreed to a set of principles and outcomes as a framework to accredit against the current College standards. The Principles and Outcomes have been mapped to the following RACGP and ACRRM standards: ACRRM Standards for Regional Training Providers Recognition 2007 ACRRM Standards for Supervisors and Teaching Posts - Core Clinical Training 2011, Primary Rural and Remote Training 2013 and each Advanced Specialised Training discipline 2011 ACRRM Operational Policies RACGP Standards for General Practice Education and Training - Programs and Providers 2005 RACGP Standards for General Practice Education and Training - Trainers and Training Post 2005 RACGP Standards for General Practice Education and Training - Requirements for Fellowship 2005; and RACGP Vocational Training Standards The accreditation principles and outcomes were also developed with reference to: GPET accreditation frameworks AMC standards for the accreditation of specialist medical colleges Postgraduate Medical Council standards for each state and territory; and principles of accreditation benchmarked across multiple industries and professions. The nine principles focus on the quality of services and outcomes being achieved for registrars, rather than the inputs used to arrive at the outcome. This means that training providers have more flexibility in demonstrating how their individual approaches provide quality training. Appendix 1: Bi-College RTP Accreditation Principles and Outcomes 6 P age

7 4. Bi-College Accreditation governance and organisational structure 4.1. Accreditation Governance The Bi-College Accreditation Program is a single process of accreditation with two outcomes. Each College arbitrates against their own College training standards and makes the final decisions regarding accreditation status, conditions and recommendations. The ACRRM Board determines the training provider accreditation decision on behalf of ACRRM. The RACGP Council determines the training provider accreditation decision on behalf of the RACGP. Each training provider will receive an Accreditation Outcomes Report from each College and an Accreditation Review Report Program Review Committee The Bi-College Accreditation Program is overseen by the Program Review Committee. This committee consists of two representatives each from RACGP, ACRRM, GPET and ACE (RTP CEOs) The key functions of the Program Review Committee as per Clause 9.2(c) in the Bi-College Led RTP Accreditation Deed include: monitor the cost, approve cost recovery arrangements and set fees for the Bi-College led RTP accreditation process; establish and approve the format of reports and related documentation for use in the Bi- College led RTP accreditation process and for the transmission of accreditation recommendations to the Colleges for decision; establish and oversee continuous monitoring, review and evaluation processes for the Bi- College led RTP accreditation process; and establish and administer an appeals body for training providers in relation to Accreditation Decisions Accreditation Program and Management Teams Each College provides staff to support the smooth running of the accreditation process. The Accreditation Program Team is managed by the Bi-College Accreditation Program Manager and includes staff from each College. The role of the team includes: providing the administrative functions required to deliver an integrated, efficient and effective Bi-College RTP Accreditation process; undertaking quality improvement processes to refine and enhance the accreditation process; liaising with the Accreditation Management Team and Program Review Committee on ongoing issues or other relevant areas of concern or risk; working closely with training providers to ensure strong relationships are built and issues managed effectively and collaboratively; developing and maintaining strong relationships with all key internal and external stakeholders; and engaging with and supporting GP reviewers to ensure they are fully briefed and competent to conduct the training provider accreditation including preparation, on-site review and final report preparation. The Colleges have divided the allocation of training provider accreditation administrative duties and when the training provider is due to commence the accreditation process; the training provider will be contacted by the Accreditation Program Team staff member who will be the main point of 7 P age

8 contact for the process. The Colleges work closely together ensuring each College is up to date with the current status of each training provider accreditation. The Accreditation Program Team is supported by a wider Accreditation Management Team which includes senior staff from each College to ensure the program is fully supported and facilitated from end to end. Members of the Accreditation Management Team comprise of senior vocational training and standards staff members within the RACGP and ACRRM Accreditation Review Team An Accreditation Review Team is established to undertake the accreditation process for each training provider. A Review Team consists of the following: two GP reviewers with knowledge of the Colleges standards, one of whom will be allocated the role of Team Leader; and senior education staff members from either or both College(s) with knowledge of the Colleges standards. The Bi-College Accreditation Program Manager attends all Accreditation Review Team meetings and the onsite accreditation visit. The Accreditation Review Team may invite observers to participate in any aspect of the program from time-to-time for training or quality assurance purposes. Reviewers In addition to participating as members of the Accreditation Review Team, the reviewers: participate in all required training activities to achieve competency to deliver the Bi-College accreditation; undertake the necessary preparation prior to an onsite review, and participate in all Accreditation Review Team meetings; conduct a comprehensive review of the training provider to ensure that they have enough information for a report and to substantiate any recommendations made; and provide clear, concise and relevant verbal and written feedback regarding the delivery of the FACRRM and FRACGP and the attainment by an individual RTP of ACRRM and RACGP standards as outlined in the Bi-College Accreditation principles and outcomes. Accreditation Review Team Leader One of the GP reviewers will be appointed as the Accreditation Review Team Leader. The Accreditation Review Team Leader will be responsible for ensuring that the accreditation visit preparation, conduct of the team during the review and report completion are undertaken to the highest standard. With the support of the rest of the Accreditation Review Team, the Team Leader will ensure the efficient and effective accreditation decision-making in accordance with the governance processes of both Colleges. The Team Leader is the point of contact for the CEO and other senior staff during the onsite review and presents the initial findings to the training provider at the completion of the review visit. The Program Manager is the point of contact at all other times or when the Team Leader is unavailable during an onsite visit, for example, when the Team Leader is engaged in an interview, meeting or focus group discussion. The Bi-College Accreditation Review Team submits a written report to the Accreditation Management Team. This includes the findings, risk rating, commendations and recommendations they identify as part of the accreditation visit. 8 P age

9 Selecting an Accreditation Review Team Appropriate Accreditation Review Team selection is integral to the Bi-College Accreditation Process. Both Colleges recognise the diversity of training providers, therefore the GP Review Team will be selected based on skills, knowledge and experience (including cultural awareness) and geographical spread. When selecting an individual Accreditation Review Team, consideration will be given to conflicts of interest and the experience of the reviewers. Reviewers are required to sign confidentiality agreements whereby they agree not to divulge details of a training provider s accreditation assessment with unrelated external parties. Training providers will be invited to raise any objections regarding an individual reviewer to the Bi- College team in writing within seven days of notification of the proposed Accreditation Review Team. Appendix 2: The Bi-College Accreditation Conflict of Interest Policy. 9 P age

10 5. The accreditation process and outcomes The Bi-College Accreditation Program comprises five stages, each with specific activities: preparation, assessment, reporting, determination, advising and monitoring. Each stage feeds directly into the next stage. Timeframes and the accreditation process Bi-College RTP Accreditation Process Commencement of 3 years Accreditation Expiry Date Year 1 Year 2 Year 3 Program Planning Bi-College RTP accreditation process for individual RTP Individual RTP Accredited for a 3 year cycle Key Activities With notice of 18 months Confirm Schedule Pre-Review meeting via teleconference with RTP CEO. Provide Accreditation Submission template Review RTP Accreditation Submission and supporting documents Request to RTP re any further information required by ART Accreditation Review meeting onsite Provide draft Accreditation Review Findings to RTP CEO Accreditation Review Report finalised and ART sign off ART Reports to AMT and thence ACRRM Board and RACGP Council for determination RTP CEO notified by phone of impending reports transmission Final ART report and Colleges Determinations and Outcome Reports to RTP Accreditation expiry date Timeline (months) Accreditation Stages Stage 1: Preparation Stage 2: Assessment Stage 3: Reporting Stage 4: Determination Stage 5: Advising & Monitoring Stage End Point RTP Accreditation Submission and supporting documents submitted Completion of the onsite Accreditation Review Final Review Report to AMT ACRRM and RACGP decision on Determinations and Outcome Reports Certification, Feedback & Monitoring RTP Accreditation Response Monitoring The triggers for a Bi-College Accreditation Review include: impending expiry of training provider accreditation commencement of a new training provider a material change in circumstances, which could include for example: merger with another training provider significant or persistent breach of accreditation conditions. Each established training provider has a three-year accreditation cycle, unless a shorter period was defined at the previous review or there is a change in circumstances. The accreditation of each training provider is scheduled and once finalised, the schedule is difficult to vary. Therefore, it is important that the training provider anticipate how their accreditation timetable might impact on their business, staffing and other predictable events. If the allocated dates for the accreditation process impacts significantly on the ability of the training provider to meet the accreditation timelines, the training provider is responsible for contacting the Bi-College Program Manager in writing with sufficient advanced warning for any possible adjustments to be made. In the event of unforeseen circumstances taking place, the Bi-College Accreditation Program 10 P age

11 Manager needs to be informed as soon as possible and any application for an extension will be considered on its merits. Considerations will be determined by the Colleges in consultation with GPET where deemed appropriate. The five stages of accreditation Stage 1: Preparation Stage 2: Assessment Stage 3: Reporting Stage 4: Determination Stage 5: Advising & Monitoring Stage 1: Preparation Stage 2: Assessment Stage 3: Reporting Stage 4: Determination Stage 5: Advising & Monitoring Stage 1: Preparation The preparation stage is the time where the Bi-College team and the training provider commence communicating and planning for the upcoming accreditation. During the preparation stage training providers should expect regular correspondence with Bi-College Program staff, so creating an appropriate system to record important dates, requirements and correspondence is recommended. Communication and planning involves: confirming and locking-in all dates with the training provider an overview and discussion of how the required paperwork and submission template should be completed discussion on how to engage relevant stakeholders outlining expectation about the review, including logistics such as: allocation of key staff as contacts, venues (including area for reviewers) focus groups visit timetable logistics for additional site visits (for example if there is more than one office); and allocating and confirming of the reviewers with the training provider s CEO. Stage 1: Preparation Stage 2: Assessment Stage 3: Reporting Stage 4: Determination Stage 5: Advising & Monitoring Stage 2: Assessment Two months prior to the training provider Accreditation Review, the training provider completes the Accreditation Submission and uploads it to the Bi-College website along with any supporting evidence. At this stage, the website is closed to the training provider and opened to the Accreditation Review Team for their assessment. The Accreditation Review Team reviews the information and holds a teleconference prior to the on-site review to determine any Quality Gap questions and areas of focus for the review from the initial data received. These questions and areas of focus are conveyed to the training provider approximately two weeks before the review visit. 11 P age

12 In the final few weeks, the Accreditation Program Team will require confirmation of the focus group attendees and any changes to the final visit timetable. At the assessment stage a training provider is assessed against ACRRM and RACGP Standards using the Bi-College Accreditation Principles and Outcomes. The Accreditation Review Team will seek evidence from a range of sources to assess compliance with the standards. The review visit includes (but is not limited to): presentations by key staff; meetings with various stakeholders individually and in groups; viewing additional written material and training resources; and viewing databases and other sources of data. It is in the interests of the RTP for key staff to be available during the review period to offer support and information to the Accreditation Review Team as required. During the preparation stage, timeframes and tasks for the key staff would have been discussed and decided, however, if during the visit additional information is required, the Accreditation Review Team may ask for more time to be allocated. It is important for the Accreditation Review Team to talk to a broad range of registrars, supervisors, medical educators and practice managers involved in the delivery of both RACGP and ACRRM training programs. This can take place either in individual interviews or preferably in focus groups. The focus groups are facilitated by a reviewer with another reviewer acting as a scribe. The focus groups comprise members of the same group, for instance: registrars, supervisors and medical educators. Focus groups held by teleconference should involve no more than six participants but if held face to face may involve up to participants. To enable focus groups members to talk openly, it is important that a private, sound proof room is available. It is also important that no staff members or line reports attend focus groups, e.g. DOTs do not attend the medical educators focus groups. The Accreditation Review Team discusses the issues raised during the interviews and focus groups and compares their findings to the information provided by the training provider as a means of confirming the information or identifying any discrepancies that may need to be further explored. Appendix 3: Sample of a Visit Program Stage 1: Preparation Stage 2: Assessment Stage 3: Reporting Stage 4: Determination Stage 5: Advising & Monitoring Stage 3: Reporting The Accreditation Review Team prepares an initial Accreditation Review Report against the Bi- College accreditation principles and outcomes. The Accreditation Review Team works together to ensure that all members agree on the content and that all findings are covered in the draft report. If any issues arise in the content of the report or consensus is not reached, a teleconference will be held after the review visit to discuss the issues. The following three areas are the focus of the report: Does the training provider provide quality and safe general practice training? Is there evidence to demonstrate that the principles and outcomes have been met? What, if any, risks are present and how can they be mitigated? Once the Accreditation Review Report has been drafted and accepted by all Accreditation Review Team members, the Accreditation Review Team report is sent to the training provider for correction 12 P age

13 of facts by the Bi-College Accreditation Program Manager. The report would typically be ready approximately 3-6 weeks following the visit. The training provider is given two weeks to return the report with any comments on factual errors. Any changes made to the report will be documented. At this point, the Accreditation Review Team Report is final and no further amendment to this report is made. The views of the Accreditation Review Team regarding recommendations and conditions that should be applied is also provided as an ART Recommendations Report to the colleges. The Bi- College Accreditation Program Manager provides the reports to the Accreditation Management Team. RACGP and ACRRM each consider the Report through their respective College governance structures. Progression of the report Draft accreditation report is completed by Review team Report is returned to RTP for correction of facts. Accreditation Review Team finalises reports. PM provides report to AMT Each College reviews the reports College Board/Council makes accreditation decisions Stage 1: Preparation Stage 2: Assessment Stage 3: Reporting Stage 4: Determination Stage 5: Advising & Monitoring Stage 4: Determination of Outcomes The Colleges receive the Accreditation Review Team Report and each College reviews and prepares their reports for their respective Board/Council. The RTP s Bi-College Accreditation Review Team Report and Recommendations Report are considered by the relevant College s governance committee and each College prepares its own Accreditation Outcome Report and Letter of Accreditation Decision. The College Accreditation Outcomes Report and Letter of Accreditation Decision from each College are provided to the Bi- College Accreditation Program Manager. The outcome of the accreditation process is recorded in the accreditation register by the colleges. Stage 1: Preparation Stage 2: Assessment Stage 3: Reporting Stage 4: Determination Stage 5: Advising & Monitoring Stage 5: Advising and monitoring The Bi-College Accreditation Program Manager provides the RTP with the following documents: the Bi-College Accreditation Review Report; the ACRRM Accreditation Outcomes Report (including Letter of Accreditation Decision); and the RACGP Accreditation Outcomes Report and Letter of Accreditation Decision The Accreditation Outcomes Reports specifies the accreditation period (usually three years) and details any recommendations or conditions with required timeframe for action. The Colleges each provide the appropriate Accreditation Certificate from that college to the RTP. GPET are notified that the RTP has or has not been accredited and, if accredited, the length of the accreditation period. If conditions have been applied by either College, GPET are informed that the 13 P age

14 RTP has been accredited with conditions. Information regarding the number or nature of the conditions is not provided to GPET by the Colleges. At this point, the accreditation process is complete and conditions and recommendations are monitored by the Colleges. Conditions/recommendations monitoring Training providers with accreditation outcomes that include conditions and/or recommendations commence a period of reporting. The training provider is advised of conditions and recommendations in each college s Accreditation Outcomes Report and timeframes are set for the training provider to prepare a report to address the conditions or recommendations. Each college reviews the proposed plan(s) and once endorsed, the training provider has its conditions monitored. Recommendations are designed to improve quality and are not punitive; however training providers are expected to work with the Colleges on the areas to be developed. Monitoring can include any of the following actions: verbal reports; written reports; interviews; requests for specific documentation/information; desk top review; and/or face-to-face visit. The Accreditation Management Team monitors progress and will be obliged to report any breach of conditions to the relevant College Council/Board as well as to GPET. 14 P age

15 6. Risk Assessment An accreditation decision is a process that involves weighing up risks and considering their mitigation. The process is designed to enable both the training provider and the accreditation team to realistically assign a risk and describe the best course of action. Risk assessment ensures that the risk management efforts are directed toward the high risk areas. Risk assessment is based on: the probability (likelihood) something unforseen will happen, or something necessary will not happen; and an estimation of the consequences or severity. To arrive at a risk rating, each identified risk is analysed using a risk-ranking table that involves estimating the probability of the event occurring and the level of consequence or impact associated with the event occurring. By combining the two estimates, a risk rating of low, medium, high or very high can be assigned. Risk management strategies may then be prioritised, based on the risk rating. The following scenarios describe how the risk assessment process works. Scenario 1 The reviewer has found that a couple of the training posts have not been visited in the past three years. The training provider catches up with the posts by phone or relies on feedback to monitor their quality. There have not been any complaints and the feedback for each of the posts has been positive. The risk is that the post may not meet quality and safety guidelines. However, based on past experience, the risk is unlikely to occur (<5% probability). Therefore the impact on the training provider, the colleges and the registrars is likely to be minimal. The risk can consequently be tolerated. The risk ranking is therefore low. The current controls (what the training provider currently does to monitor the posts) is satisfactory but a visit in the next few months would be required. The training provider would receive a recommendation to implement a system to monitor training posts and would be required to report in six months on how it is progressing with implementation. Scenario 2 The reviewer has found that feedback from three registrars interviewed about a particular supervisor has been poor. The supervisor is unavailable and doesn t give the registrar a full range of presentations to view. His attitude is patronising and the registrars do not feel supported. The training provider knows about the feedback but has not acted as training posts are scarce. The likelihood of this happening again has a >50% probability. The impact on the colleges, the registrar and the training provider is major if the registrar complains externally or makes a mistake based on poor training. The treatment is to propose terminating the training position and to address the contracts that are deemed very poor if the complaints have not been acted upon by the training provider. These controls require urgent action and a condition would be set to remedy this within a very short timeframe. 15 P age

16 7. Accreditation outcomes At the conclusion of the accreditation process, the training provider will be issued with an accreditation status. Accreditation The outcome of accreditation is provided in an Accreditation Outcomes report by each college and is advised in a letter of determination. The training provider may or may not have recommendations that are to be addressed. Recommendations generally do not negatively impact on the accreditation status of the training provider. The training provider will be accredited for three years but will need to report to one or both of the Colleges on the progress of addressing the recommendations. Timelines and any other requirements will be clearly defined and communicated to the training provider. Accreditation with Conditions A training provider will be issued Accreditation with Conditions if, in the opinion of one or both Colleges, the principles and outcomes are not being met satisfactorily. The risk management process described above will determine if conditions are set and, if so, the timeframes in which these must be addressed. Conditions are more serious and the training provider must meet conditions within the specified timeframe in order to maintain accreditation. The period of accreditation may be less than three years depending on the number and type of conditions. The process will be very carefully monitored by one or both of the Colleges through the Accreditation Program Team depending upon the College/s that set the conditions. The College/s will support and work closely with the training provider to make sure that the conditions are met as this is in the best interests of the registrars and in meeting the vision of safe and quality general practice training. Dis-accreditation In the very unlikely event that the training provider fails to meet the conditions, the matter will be referred to the Colleges, GPET, the Program Review Committee and the training provider risks deaccreditation. Were this to occur the training provider would no longer be able to deliver training for specialist general practitioners. Accreditation Status Summary Accreditation status Provisional accreditation Accreditation Definition Provisional accreditation is applied at the formation of a new training entity, for a period of one year. At the expiration of the provisional accreditation period, the training provider goes through the full accreditation process. Recommends continuation of accreditation, for a period of three years, in the absence of significant change during that time. The provider may or may not have recommendations. 16 P age

17 Accreditation with conditions Accreditation with conditions is issued where the training provider is not meeting the standards of one or both Colleges and that failure to meet these standards has the potential to be a significant risk for registrars. Conditions need to be met to maintain accreditation. Period of accreditation awarded may be less than three years. Dis-accreditation If a training provider fails to meet conditions or is found to be operating in a way that compromises safety, quality and the integrity and reputation of general practice, the training provider can be dis-accredited. This is an extraordinary step and would only occur after all other possible remediation steps have been exhausted. 17 P age

18 8. Training provider changes of circumstance Training providers are required to inform the Bi-College Accreditation Program Manager immediately if there is a material change of circumstance in the structure or function of the training provider that may have the potential to impact the quality and/or breadth of service provision. The Program Manager will advise both Colleges and GPET. This requirement is referred to as an Advice of Circumstance Change and may trigger an audit activity. An audit can include the following actions: verbal reports; written reports; interviews; request specific documentation/information; desk top review; and/or conduct of a face-to-face visit. 18 P age

19 9. Complaints and Grievances The Bi-College Accreditation Management and Program Teams and the Colleges wish to foster a productive and harmonious working environment where accreditation-related concerns or grievances are managed promptly, impartially and justly. Relevant stakeholders and staff can seek information and advice about matters of concern without being required to lodge a formal grievance. The aim is to resolve a perceived / potential grievance as early and effectively as possible and avoid any undue escalation. A grievance is any real or perceived problem, or any significant question, dispute, difficulty, claim, complaint or concern raised by one or more persons in relation to the Bi-College RTP Accreditation Program and includes or may be related to decisions or actions taken or not taken, systems, processes or the physical environment, that have not been resolved through normal day to day communication. Some example of grievances may include (but not limited to) the following: issues with the operational aspects of the program e.g. program, accreditation visit, logistics or administrative procedures; perceived lack of impartiality by a reviewer or reviewers; and/or concerns that a process was not valid or fair. Grievance Process If you feel comfortable speaking to the person(s) with whom you have the grievance, then you should do so as this can sometimes be the easiest way of resolving the issue. Under normal circumstances, this discussion should occur as close to the time of the relevant event as possible. If you don t feel that you can approach the person(s) directly, you can escalate to the Bi-College Accreditation Program Manager at any time. If you have followed the steps outlined above and you do not get a satisfactory response to your grievance, then you should direct your grievance, in writing, along with details of the process followed and decisions made in steps above, to the Chief Executive Officers (CEO) of both Colleges. The CEOs will make an assessment of the situation and determine the next steps. The treatment of grievances will be guided by the principles of confidentiality, timeliness, transparency and procedural fairness. It is expected that all parties, including RTPs, the Colleges and GPET, will be guided by these principles in dealing with a grievance, allowing reasonable opportunity for the grievance to be dealt with appropriately. 19 P age

20 10. Appeals against accreditation decisions Appeals process Any training provider that is the subject of an accreditation decision may, within 30 days from receipt of written advice of the accreditation decision, lodge a written appeal with the Colleges CEOs (joint Chairs of the Program Review Committee) to have their accreditation process reviewed and the decision considered by an Appeals Committee if they believe that: relevant and significant information that was made available to the Accreditation Review Team was not considered in the final report; the report of the Accreditation Review Team was inconsistent with the information put before the team; and/or information provided by the accreditation team was not duly considered in the recommendation/conditions of the Colleges; and/or the process of their accreditation review was seriously flawed. Once received by the Program Review Committee, the written documentation will be forwarded to the Accreditation Review Team Leader and Bi-College RTP Accreditation Program Manager for written comment. A meeting will then be arranged for the Appeals Committee to consider the appeal. The Appeals Committee The Appeals Committee is an independent group convened and appointed by the PRC, responsible for reviewing the accreditation recommendations regarding the training provider making the appeal. The Appeals Committee will comprise a minimum of three Fellows of the Colleges: a Chair; three other Fellows; and a Bi-College staff member performing the function of Secretary to the Appeals Committee but is not part of the Appeals Committee. Each member of the Appeals Committee must: have at least three years experience as an accreditation reviewer; not be a part of the RTP Accreditation Review Team of the training provider that was accredited; and not be an employee, contractor or Board member of the training provider being accredited. The Appeals Committee must act according to the laws of natural justice and decide each appeal on its merits. The Role of the Appeals Committee The Appeals Committee will examine all relevant documentation that will include: the last accreditation of the training provider if available; responses from the Accreditation Review Team; documentation from the appellant training provider; and any other relevant documents. The Appeals Committee shall be entitled to consider all relevant information that it sees fit. No personal representation to the Appeals Committee is permitted. Only written submissions will be considered. 20 P age

21 The Appeals Committee will make a recommendation to the PRC that either: 1. confirms that the agreed process by which the Accreditation Review Team reached their findings has been followed; or 2. dissents from the Accreditation Review Team s findings when reasonable doubt has been established as to a flaw in the process by which the Accreditation Review Team made its findings. In the event that the Appeals Committee dissents from the findings of the Accreditation Review Team, it shall formulate a report to the PRC including recommendations on whether the accreditation review should be repeated in part or full. Repeat review Should a full or partial repeat of an Accreditation Review be conducted: the Appeals Committee would normally conduct the accreditation visit, however, may choose to recommend the establishment of a new Accreditation Review Team; the new Accreditation Review Team report will be issued to the Colleges and may be called upon by the training provider as supporting evidence for any appeal to the Colleges against the original decision; and the outcomes following any repeat review will be final and not subject to further appeal. Findings the proceedings of the Appeals Committee will be governed by its Terms of Reference and the Appeals policy; the Appeals Committee will make a recommendation to the PRC for consideration; and the training provider will, during the appeal process, retain any accreditation status granted to it at its last completed accreditation. Costs Should the Appeals Committee as in 1. above, recommend upholding the Accreditation Review Team findings, then all associated costs for the Appeal will be borne by the training provider as Appellant College appeals policies The Colleges independently make the accreditation decision, therefore the Colleges appeals processes will apply. The findings of the Accreditation Appeals committee simply seek to inform the Colleges appeals processes. Refer: ACRRM: RACGP: The Colleges will determine dates by which applications must be lodged for appeals against the outcome of accreditation in line with the policies. The Colleges appeals policies describe the rules and administrative procedures for appeals brought by training providers, including the: context in which appeals against individual College decisions may be made; grounds upon which such appeals may rest; rules and processes for the submission and processing of appeals; and terms of reference for the Appeals Committee of either ACRRM or RACGP. 21 P age

22 11. Feedback and Evaluation The Bi-College RTP Accreditation Program will be evaluated both during the implementation of the program, for the purposes of quality improvement and at the completion of the program. Independent evaluation consultants will be engaged in the design and/or conduct of the evaluations. Feedback by any stakeholder on any aspect of the program is welcomed and may be provided to the Bi-College RTP Accreditation Program Manager at any time. 22 P age

23 Appendix 1: Bi-College RTP Accreditation Principles and Outcomes Principle 1: Training and education systems The Regional Training Provider has systems in place to plan for and deliver quality education and training. Outcomes The Regional Training Provider: 1.1 has a business plan in place that is consistent with achieving the colleges training standards. 1.2 has doctors in training grievance and complaint policies and procedures that are accessible, effective, duly followed and reviewed routinely. 1.3 collects and uses feedback from doctors in training and supervisors for quality review and improvement for the delivery of education and training. 1.4 has written agreements in place with all organisations providing supervisions, assessment and/or education services on its behalf. 1.5 has mechanisms for involving doctors in training in the review and design of their training program. 1.6 has systems in place to deliver customized and regionalised education and training. Principle 2: Records The Regional Training Provider is able to validate and verify its capacity and performance with accuracy, integrity and currency. Outcomes The Regional Training Provider: 2.1 can and does provide current, timely, accurate, evidence-based information on all key aspects of the training program. 2.2 has up to date, secure and accurate doctor in training records. 2.3 has records in place that verify the competencies and experiences of all who supervise and deliver education and training services. 2.4 implements the colleges standards and curricula and adapts when notified of changes from the colleges. Principle 3: Education resources Regional Training Provider education and support staff are competent for the functions performed. Outcomes The Regional Training Provider: 3.1 has human resource organisational structures, policies and procedures in place specific to doctors in training and associated staff. 3.2 delivers education and training services by sufficient and competent people. 3.3 ensures doctors in training have access to relevant and current education resources appropriate to their context and stage of training. Principle 4: Education and assessment 23 P age

24 The Regional Training Provider has education and assessment mechanisms to meet the requirements of the colleges as specified in the standards and curricula. Outcomes The Regional Training Provider: 4.1 delivers education that makes explicit the core competencies, domains of knowledge and skills, national health priorities, scope of general practice competence appropriate to the training pathway undertaken. 4.2 assesses doctors in training for practice readiness, relevant to context and facility has a transparent, continuous, defensible process for completion of training. has processes that comply with the colleges recognition of prior learning policies. 4.5 has processes in place that monitor and assess performance of doctors in training and provides feedback on training progress. 4.6 has systems in place to monitor, review and respond if doctors in training don t pass the requirements of their training program or the college assessments. 4.7 addresses priority areas including Aboriginal and Torres Strait Islander Health, research methodology and critical appraisal. Principle 5: Relevant training Regional Training Providers develop learning and assessment strategies and experiences for each qualification delivered and for each individual doctor in training. Outcomes The Regional Training Provider: 5.1 has mechanisms to analyse their regional context. 5.2 demonstrates how customised and contextualised learning and assessment strategies and experiences respond to regional diversity and variability. 5.3 demonstrates how customised and contextualised learning and assessment strategies and experiences meet the colleges standards. 5.4 has documented learning and assessment strategies and experiences for each qualification and each doctor in training. 5.5 has general practitioners and other relevant education providers central to the design, delivery, assessment and role modelling or education activities. 5.6 builds in the expertise and needs of relevant non-general practice regional stakeholders. Principle 6: Training post management The Regional Training Provider ensures that learning and assessment strategies at the training posts meet the college standards. Outcomes The Regional Training Provider: 6.1 meets the requirements of the colleges standards in recruiting and selecting training posts and supervisors. 6.2 ensures training posts have sufficient expertise, resources and equipment to meet the standards of each college. 6.3 adheres to the requirements of the agreements regarding the delegation of training post 24 P age

25 accreditation with each college. 6.4 ensures an adequate number of training posts are currently available and processes are in place for determining and achieving future needs. 6.5 maintains accurate, up to date records of training posts and supervisors. Principle 7: Professional network Regional Training Providers induct doctors in training with both colleges throughout their training, and with other functions of both colleges. Outcomes The Regional Training Provider: 7.1 provides data as per agreements with each college. 7.2 provides relevant information about each college s training requirements. 7.3 encourages doctors in training to participate in each college s activities. 7.4 has an agreed communication strategy with each college and actively connects with the colleges and the profession. 7.5 demonstrates regular consultation and collaboration with the colleges. 7.6 participates in active communication and marketing connection with the colleges on networking and joint activities. Principle 8: Doctors in training well being Risks to doctors in training are assessed and managed while undergoing quality education and training. Outcomes The Regional Training Provider: 8.1 has processes in place to balance both the personal and professional needs of doctors in training. 8.2 identifies, responds to and supports at-risk doctors in training in a timely and effective manner. 8.3 has implemented approaches to maintain continuing relationships with doctors in training. 8.4 audits compliance with General Practice Training Program National Terms and Conditions where relevant. 8.5 has safety net procedures in place for the at-risk doctor in training. 8.6 ensures doctors in training have an adequate but not excessive patient and non-patient workload. Principle 9: Equity and access The Regional Training Provider applies principles of access and equity in achieving the desired training and education outcomes. Outcomes The Regional Training Provider: 9.1 provides advice and support that is accurate, timely and readily accessible. 9.2 has incorporated principles of equity and access in its policies and procedures. 9.3 provides induction and clear information about access and equity to prospective and current 25 P age