Saudi Commission for Health Specialties. Central Committee for Accreditation. Training Centers Accreditation Regulations

Transcription

1 Central Committee for Recognition Recognition Section T Saudi Commission for Health Specialties Central Committee for Accreditation Training Centers Accreditation Regulations Page 0ii الهيئة السعودية للتخصصات الصحية Saudi Commission for Health Specialties

2 Prepared by: Central Committee for Accreditation Edited and Formatted by: Vittoriana Crisera SCFHS 2014

3 Saudi Commission for Health Specialties Central Committee for Accreditation Training Centers Accreditation Regulations

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5 Table of Contents Chapter 1 Introduction 1 Chapter 2 Definitions 2-5 Chapter3 Central Committee for Accreditation 6-7 Chapter 4 Surveyors Committee Members for Public and Private Accreditation 8 Chapter 5 Accreditation Request Procedures 9 Chapter 6 General and Special Accreditation Requirements Chapter 7 Obligations of the Training Centre and Division after Accreditation 13 Chapter 8 Training Centres Accreditation Methods, Authority and Responsibilities Chapter 9 Types of Training Centres Accreditation Decisions Chapter 10 Scientific Board and Committees Role in Accreditation of Training Centre 21

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7 Chapter 1 Chapter 1: Introduction These regulations aim to develop standards, conditions and requirements upon which the Saudi Commission for Health Specialties (SCFHS) relies on to accredit hospitals and specialized centres participating in the training programs. The accreditation of training centres ensures provision and harnessing of all administrative, clinical and medical capabilities in the centres for training purposes. This includes, ensuring the participation of qualified consultants and specialists at the training programs in an effective manner which will aid in creating a suitable educational environment for trainees based upon proper basic principles of medical education. This will enable them to receive a high calibre training which will qualify them for safe professional practice in their specialties. These regulations provide public and private health facilities a chance to apply for accreditation based upon the rules, regulations and standards stated therein which have been prepared by the Accreditation Committee and approved by the Scientific Boards and Committees of various disciplines in the SCFHS. Page 1

8 Chapter 2 Chapter 2: Definitions Definition to the terms used within this regulation booklet are mentioned below for elucidation purposes. Commission: The Saudi Commission for Health Specialties (SCFHS). Training Board: It is a group of consultants and specialists working in a training centre who are qualified to provide health training and education pertaining to their respective area of specialization. Training Centre: It is a health facility that meets the criteria for public or private accreditation which has received a certificate of accreditation from the SCFHS; making it eligible to participate in the training programs approved by the SCFHS. Completed Training Centre: It is a training centre that has met all the accreditation requirements for a certain program of the general programs for the Saudi Council Specialty Certificate including all training courses and has also obtained a certificate of accreditation from the SCFHS. Joint Training Centre: It is the training centre which has attained a certificate of accreditation from the SCFHS, only for selected training. It is allied to other training centres to form a training group in order to complete the requirements of a certain training program. Training Program: It is the training program for a specialty approved by the Executive Board of the SCFHS. Scientific Board: It is the main board of specialization formed by the SCFHS which includes consultants representing a number of health sectors in the Kingdom to oversee the training programs in the general and sub-specialty programs. The Scientific Board reports to the SCFHS Deputy Secretary General from an organizational stand point. Page 2

9 Chapter 2 General Accreditation: It is the accreditation of a training centre by the SCFHS upon fulfilling the general requirements for training stipulated by the SCFHS at the health facility. This enables it to participate as a training centre and qualifies the said health facility to submit a request for special accreditation in various specialties. Special Accreditation: It is the accreditation of a certain specialization within a training centre after completing the accreditation requirements and conditions approved by the SCFHS Scientific Board or Committee in the same specialization. Training Centres may apply to receive a special accreditation for more than one specialization. Executive Board: It is a board Chaired by the SCFHS Secretary General and consists of his Deputy, Assistants, as well as the Heads of the Scientific Boards and Central Committees. It deals with the executive decisions taken by the SCFHS. Accreditation Section: It is a division at the SCFHS that takes care of all the administrative aspects of the accreditation process (e.g. coordinating visits, following-up accreditation certificate expiry, circulating accreditation regulation updates, etc.). Central Committee for Accreditation: It is a committee that consists of the Scientific Board members, individually representing their own area of specialization, in addition to the Head of the Accreditation Section and Chairman of the Committee who is appointed by the SCFHS Secretary General. This committee reports organizationally to the SCFHS Deputy Secretary General. Scientific Committee: It the main committee for specialization which consists of consultants representing a number of health sectors in the Kingdom. This committee oversees the branch or sub-specialty training programs and is associated with the competent Scientific Boards. Page 3

10 Chapter 2 Training Committee: It is the committee that oversees and follows up on the training process in the section concerned with training under the Chairmanship of the Training Program Manager and a number of the Training Board members participating in the training process along with a representative for the trainees in the section. Training Program Manager: Training Program Manager is the consultant who supervises the training process and trainees for specialization in the training centre in accordance with the rules and regulations applicable in the SCFHS. Local Supervisory Committee: It is a committee that consists of each Training Group Program Managers in addition to a member representing the trainees under the Scientific Board. This committee is directly responsible for supervising specialization training of each training group in the region. General Specialization: This is the main specialization in any branch of medicine or other health specialties. Branch Specialty: It is any main specialization branching from a general specialization where specializing in this field does not require obtaining a certificate in the general specialization such as (Neurosurgery, Neurology, etc.). Sub-Specialization: It is the specialization that branches from the general or sub-speciality which requires a certificate in the general or sub-speciality in order to specialize in that field, such as: Nephrology or Paediatrics Cardiology, etc.. Capacity: It is a training centre s maximum capacity to accept trainees during the period a program is accredited. Promotion: It is the grading of a trainee from one training year to the next in a training program, after fulfilling the requirements of each training year. Page 4

11 Chapter 2 Training Year: It is a training period that lasts for 11 months. Its beginning is determined by the SCFHS Executive Board. Annual Admission Capacity: This is the number of candidates allowed to be accepted in each training centre annually. This number is adjusted in accordance with the number of trainees who have passed the training program levels or with accreditation of new training centres. Surveyor: Surveyor is a health professional or administrator trained by the Central Committee for Accreditation to evaluate training centres for accreditation. Trainee: Trainee is a health practitioner enrolled for training in one of the training programs approved by the SCFHS. Training Group: A number of accredited Joint Training Centres combine together to fulfil all the training requirements in a specific specialty under the Local Supervisory Committee consisting of all the centres Training Managers. This committee is associated with the Scientific Board for the same specialty. Saudi Specialization Certificate: It is the highest professional certificate awarded by the SCFHS in the general and branchspecialities. Saudi Fellowship Certificate: It is the highest professional certificate that is awarded by the SCFHS in the sub-specialties. Page 5

12 Chapter 3 Chapter 3: Central Committee for Accreditation Formation of the Committee: The Central Committee for Accreditation consists of a representative from each Scientific Board in addition to the Head of Accreditation Section and Chairman of the Committee appointed by the SCFHS Secretary General. The Chairman of the Committee is a member of the SCFHS Executive Board. The committee is associated with the SCFHS Deputy Secretary General. Tasks of the Committee: 1. Follow-up the accreditation requests sent to the SCFHS and oversee the completion of the said requests in accordance with the accreditation requirements needed for training in the applying facility. 2. Approve criteria and forms relevant to the general and special accreditation requirements. 3. Contribute in the development of the SCFHS Accreditation Section. 4. Prepare a trained team of Surveyors to conduct field visits. 5. Specify fixed appointments during the year in order to conduct field visits to the training centres. 6. Specify the names of the centres in the training group/groups in coordination with the Scientific Boards and Committees for training. 7. Specify the maximum and minimum limit of accreditation duration and follow-up on the influences of the accreditation decisions issued. 8. Issue accreditation decisions of training centres and approve by the SCFHS Deputy Secretary General. 9. Discuss the reports presented by the Scientific Boards and Committees regarding the performance of the accredited training centres and take appropriate action to amend any concern. 10. Discuss all inquiries received from hospitals, centres or individuals regarding accreditation. Page 6

13 Chapter Conduct periodic review of the SCFHS Accreditation Regulations and deliver amendments as necessary. 12. Seek to increase the number of accredited centres in accordance with SCFHS criteria and requirements in order to implement the SCFHS programs inside and outside the Kingdom. 13. Review international pioneering experiences in the field of accreditation and benefit from them in order to develop accreditation of training centres focusing on the programs of the SCFHS. Central Committee for Accreditation Flow of work A. General Accreditation: 1. Study the requests submitted to the Accreditation Section and ensure they meet the accreditation conditions and requirements needed along with completed forms. 2. Study the visit reports submitted by the Surveyors team. 3. Issue decisions to accredit training centres and forward them to the SCFHS Secretary General for final approval. Provide the centres with the general accreditation certificates in accordance with the administrative measures adopted by the SCFHS. B. Special Accreditation: 1- Study the request submitted to the Accreditation Section which meets the conditions and requirements of accreditation along with completed forms. 2- Notify the Scientific Board/Committee for training to present their comments towards the accreditation request received by the Central Committee for Accreditation. 3- Study visit reports submitted by the Surveyors team. 4- Issue decisions to accredit a training centre as a Complete or Joint Training Centre and submit the decision to the SCFHS Secretary General for final approval. Supply the Scientific Board/Committee for training with a copy of the accreditation decisions in accordance with administrative measures of the SCFHS. Page 7

14 Chapter 4 Chapter 4: Surveyors Committee Members for Public and Private Accreditation Surveyors Committee for General Accreditation: Consists of three Surveyors assigned by the Chairman of the Central Committee for Accreditation. Surveyors Committee for the Special Accreditation: Consists of two Surveyors from outside the specialization and one belonging to the specialization. The Chairman of the Central Committee for Accreditation shall assign the Head or Deputy of the Accreditation Section to participate in some of the field visits without partaking in the voting or evaluation process. Page 8

15 Chapter 5 Chapter 5: Accreditation Request Procedures Procedures: 1. The Health Facility Director or its Academic Affairs Director shall submit a request for accreditation to the SCFHS Secretary General expressing the facility s interest to be accredited for the purpose of training including the nature of the required accreditation (general or special) and determine the specialization. 2. All health facilities that provide general healthcare services, whether it is a hospital or medical city, can obtain the general accreditation if they wish to take part in the training programs. Moreover, they can also obtain special accreditation later on excluding specialized health facilities, such as: dental centres, cardiology diseases and surgery, psychiatric medicine centres and primary healthcare. 3. Special accreditation of a training centre that has fulfilled the requirements for a certain specialization shall be four years. 4. Special accreditation for a certain specialization, in case the centre is among a training group, shall be four years. The accredited training courses should be mentioned in the accreditation decision made. Page 9

16 Chapter 6 Chapter 6: General and Special Accreditation Requirements General Accreditation Requirements A. Physical Facilities and Equipment in the Training Centre: 1. Number of beds in a general hospital should not be less than 150 beds. 2. Available physical facilities and equipment as mentioned in the general accreditation form, in addition to an accreditation received from one of the international or national commissions for health accreditation, such as: JCI, CANADIAN, AUSTRALIAN, and/or CIBAHI. 3. Primary healthcare centres or specialized health facilities such as: dental, cardiac, surgery or psychiatry centres shall be subject to the completion of the requirements specified by the concerned Scientific Boards and Committees. B. Learning and Training Facilities in the Centre: 1. There should be a separate Department for Academic and Training Affairs or Department for Education and Training to oversee the training programs and scientific activities in the training centre. 2. There should be a medical library run by a librarian and equipped with a number of the main medical journals and periodicals as well as the latest editions of the basic medical books. 3. In the event that no medical library is available, as mentioned above, then an electronic library should be made available with wide service subscriptions to satisfy the requirements or provide trainees with internet connection to benefit from the SCFHS e-library. 4. There should be a sufficient number of lecture halls equipped with state-of-the-art devices, classrooms, auditoriums and on-call rooms in various departments. 5. There should be ongoing educational and training activities in medical, allied medical and nursing departments. Page 10

17 Chapter 6 6. It is preferred to have a section or activity for scientific research. C. Commitment Follow-up and Supervision over Training Programs in the Training Centre: 1. Appoint a Training Program Manager as well as a Deputy Manager for each program according to the criteria of the SCFHS to oversee the training process in a concerned department and follow-up the implementation of the work done by the Training Program Manager. 2. A committee should be formed consisting of Program Managers under the supervision of the Academic Affairs that is concerned with the training process. 3. Support the section Training Program Managers and Training Committees to follow-up educational activities and oversee training programs in the centre plus allocate special time to follow-up training and/or other financial incentives. 4. Activate the role of the Academic and Training Affairs in order to follow-up the educational activities in various sections in the training centre by ensuring uniformity and quality of the training programs using lectures, patients rounds, clinical training, scientific journals club and other activities. 5. Comply with the system of documenting attendance and absence of trainees, follow-up on their training and academic tasks through the implementation of the SCFHS electronic tracking system. 6. There should be a special secretariat for each training program, if necessary, as decided by the Surveyor's team. Special Accreditation Requirements 1. Receive general accreditation for centres which require such accreditation excluding those mentioned in Chapter 5 (point #2). 2. Meet the requirements of the special accreditation for the required specialization as stated in the accreditation forms for each specialization proposed by the Scientific Boards and Committees after they are approved by the Central Page 11

18 Chapter 6 Accreditation Committee published in the electronic webpage of the SCFHS. 3. The specialized training centres that are not required to receive general accreditation should meet the requirements stated in Chapter 6, section A (points #2 and #3); as well as the requirements related to training in the nature of the specialization as mentioned in the first point. 4. Form training committee inside the department in order to track the training process and perform ongoing evaluation on the performance of the trainers and trainees as well as promote the quality of training in accordance with the conditions and controls of the SCFHS. 5. Comply with what is stated in the trainees duties and rights documents approved by the SCFHS Executive Board. 6. Maintain ongoing communication and coordination between the Program Director, Training Committee, and the Local Supervisory Committee in order to confront challenges and develop the training process. 7. The SCFHS electronic tracking system should be implemented to document attendance and absence of trainees as well as track their training and academic tasks. Page 12

19 Chapter 7 Chapter 7: Obligations of the Training Centre and Division after Accreditation 1. Continue the provision of material and human training requirements after receiving the accreditation. 2. Implement training programs accredited by the SCFHS. 3. Comply with the implementation of all academic activities written down in the core curriculum on an ongoing basis and comply with its objectives. 4. Make sure that all topics of the core curriculum have been covered during the training period. 5. Facilitate the visit(s) of the Surveyor team to conduct performance evaluation of training centre during the period of the accreditation or upon requesting accreditation. 6. Implement the instructions and decisions issued by the SCFHS regarding the programs. 7. Comply with the statement of the SCFHS regulations regarding training, supervision, trainees rights and responsibilities, as well as the statement of the executive regulations for the Scientific Boards and Committees. 8. Allow the admission of trainees in the program from outside the training centre and allow the trainees of the training centre to spend external training periods based upon the decisions of the Scientific Boards/Committees and Local Supervisory Committees. 9. Assign trainees to attend academic courses and activities accredited by the SCFHS for the specialization and to take part in the educational activities. 10. Track the enrolment of the trainees on an annual basis in the SCFHS during the program and pausing further training unless they achieve the said conditions. 11. Document the achievements of the trainees clinical and academic requirements using the electronic system approved by the SCFHS. Page 13

20 Chapter 8 Chapter 8: Training Centre Accreditation Methods, Authority and Responsibilities Methods of Accrediting Training Centres A. First Method This method is based on the distribution of the existing training centres into Training Groups. Each Training Group consists of a limited number of training centres that collectively meet the training program requirements approved for a certain specialization as follows: Category (A): A group consisting of the main training centre which covers 80% of the clinical training requirements, with the participation of a limited number of training centres essential to complete the rest of the training program requirements. The program is supervised by a Local Committee Chaired by the main training centre s Program Director and consists of the participating training centres Training Program Managers. Category (B): A group consisting of a limited number of training centres that participate in presenting the complete requirements of the clinical training at approximate percentages. The program is supervised by a Local Committee consisting of the training centres Program Directors. The committee is Chaired on rotation basis between the participating training centres which is appointed by agreement or ballot. B. Second Method This method is based on the full accreditation of training centres that have completed the requirements of the training curriculum approved for the specialization. A training centre can submit a request for full accreditation (adopting separate training programs) and run the said training programs individually, provided that it meets all the accreditation requirements for the specialization specified by the Central Committee for Accreditation in coordination with the competent Scientific Board. It should accept to fulfil all the obligations related with the autonomy of performance and the program management. It is supervised by a committee Chaired by Page 14

21 Chapter 8 the Program Director in the training centre which has fully fulfilled the accreditation requirements and consists of members from the training centre s training commission with a representative from the Academic Affairs. In each training centre, the capacity is determined by the decision of the Central Committee for Accreditation. However, the implementation of this method is limited to the Saudi Specialization Certificate in the general programs. Note: The level of training in the various centres should be taken into consideration when forming training groups for the courses approved in the training programs, specifying the capacity of each training group. Future coordination should be made with the Scientific Boards and Committees concerned. Authority and Responsibilities of the Complete Training Centre that have Fulfilled the Accreditation Requirements 1. Advertise admission to the accredited programs in the training centre provided that the beginning of the programs should be on a unified date fixed by the SCFHS. 2. Receive applications to join the training programs and compare between the applicants in order to accept the best ones; provided that they pass the comprehensive exam of the SCFHS in accordance with the conditions of comparison approved by the SCFHS. 3. Submit the lists and documents of all accepted trainees to be enrolled after approving the list by the Scientific Board/Committee; provided that the number of the accepted trainees does not exceed the capacity of the training centre specified by the Central Committee for Accreditation. 4. Comply with the implementation of the training regulations and trainees rights and responsibilities document. 5. Supervise trainees throughout the period of the program and submit each trainees annual evaluation report to the SCFHS. 6. Promote trainees from one year to another based upon the results of their final training year exam which is prepared by the SCFHS Examination Committee. Page 15

22 Chapter 8 7. The trainees should be enrolled and re-enrolled on an annual basis with the SCFHS and pay the tuition fees until they complete the program. Trainees should not be allowed to continue training without paying the annual tuition fees. 8. Issue certificate of training completion in coordination with the SCFHS for those who have successfully completed all the requirements of the program, consequently qualifying them to appear for the final two exams (written and clinical) for the Specialization Certificate offered by the SCFHS. 9. Have the right to allow the trainees to attend some training courses outside the training centre. 10. Should comply to accepting trainees from other training groups to attend some training courses in case there is a need to complete a training group. Authority and Responsibilities of a Training Group:- 1. Advertise admission to the accredited programs in the training centre provided that the beginning of the programs is a unified date fixed by the SCFHS. 2. Receive applications to join the training programs and compare between the applicants in order to accept the best ones provided that they pass the comprehensive exam of the SCFHS in accordance with the conditions of comparison prescribed by the SCFHS. 3. Submit the lists and documents of all accepted trainees to be enrolled after approving the list by the Scientific Board/Committee; provided that the number of the accepted trainees should not exceed the capacity of the training centre specified by the Central Committee for Accreditation. 4. Fully supervise the training process inside the group and submit the annual evaluation reports along with the results of the trainees annual examination to the Training Department in the SCFHS in order to promote them from one training year to the next. However, it should not to breach the condition of passing the first part examination held by the SCFHS for promotion to the next level. Page 16

23 Chapter 8 5. Issue certificate of training completion in coordination with the SCFHS for those who have successfully completed all the requirements of the program, consequently qualifying them to appear for the final two exams (written and clinical) to attain the Specialization Certificate offered by the SCFHS. The Training Group is responsible to inform the Scientific Boards and Committees accordingly. Page 17

24 Chapter 9 Chapter 9: Types of Training Centres Accreditation Decisions Decision of General Accreditation The SCFHS shall issue a decision for general accreditation of hospitals and centres that satisfy the accreditation requirements. The decision is issued only once and does need to be renewed unless the Central Committee for Accreditation receives a reason that requires the suspension of the general accreditation. Special Accreditation Decision a) Training Centre that has fully completed the requirements: The SCFHS shall issue decision for accrediting a training centre which will be valid only for four years after which renewal is necessary. This accreditation is granted to the training centres that have fully met the requirements for accreditation and have also met the requirements for full accreditation of a certain specialty from the general specialties. b) Joint Training Centre: The SCFHS shall issue a decision for the accreditation of a Joint Training Centre within a Training Group depending on the training courses available for a certain specialty. The period for accreditation is only four years after which the training centre will be required to renew the accreditation. Training Group Formation Decision: The SCFHS shall issue a decision for the formation of each training group, specify the category of the group as well as the participating training centres. The decision shall be re-issued in case of any amendment on the participating training centres. Conditional Preliminary Accreditation Decision: This decision shall be issued only for a one year provided that the Training Centre has fulfilled the basic requirements. By fulfilling some of the supporting requirements, the Training Centre will be Page 18

25 Chapter 9 given a one year chance to complete all the requirements need for accreditation. Accreditation Renewal Decision: This decision is issued after the period of the existing accreditation is over and upon confirming the availability as well as continuity of the training program s accreditation requirements. Warning Decision to Suspend Accreditation: The SCFHS shall issue a warning decision to suspend accreditation when there are cases which affect the accreditation requirements but not to the extent of impairing the training process on a large scale. This should be rectified within a period of six months from the date the suspension decision was issued. Accreditation Suspension Decision: The SCFHS shall issue a decision to suspend accreditation of a training centre in one of the following cases: a) Suspension recommendation must be submitted to the Central Committee for Accreditation by the Scientific Boards or Committees stating that there are defaults in the training centre with supporting comments proving that they directly affect the level of the training program. Accordingly, the training centre shall not be allowed to admit new trainees before resolving the negative aspect and defaults within one year from the date the suspension was issued. The training centre, however, shall be allowed to continue training the already enrolled trainees in that centre. The Central Committee for Accreditation shall notify the training centre and trainees of the reasons leading to the accreditation suspension, based on the conditions of accreditation, in coordination with the Scientific Boards and Committees. b) When the negative aspects, stated in the accreditation suspension warning are not resolved by the training centre; the SCFHS shall issue a decision to suspend the accreditation. This shall apply to the training centre, as stated in point no. (a). Page 19

26 Chapter 9 Accreditation Withdrawal Decision The SCFHS shall issue a decision to withdraw an accreditation from a training centre in one of the following cases: a) If a training centre fails to fulfil the requirements after the expiry of the accreditation suspension. The Central Committee for Accreditation shall approve the decision to withdraw the accreditation. b) In case there have been no trainee(s) during the last four years in the program. c) There is recommendation received by the Central Committee for Accreditation from the Scientific Boards and Committees to withdraw the accreditation due to severe default in the level of training which negatively affect the training process and cannot be remedied by directing a accreditation suspension warning. The SCFHS then has the right, based upon that recommendation, to withdraw the accreditation during the validity period of the training centres accreditation. The trainees in the training centre shall be transferred to other training centres in order to complete their training program. Accreditation Renewing Decision The SCFHS shall issue a decision to renew or end the accreditation of a training centre which once had either it accreditation withdrawn or suspended if the said training centre fulfils the accreditation requirements. Page 20

27 Chapter 10 Chapter 10: Board and Scientific Committees Role in Accreditation of Training Centre The various Scientific Boards and Committees play an integral role, with the Central Committee for Accreditation, in the accreditation process of training centres where they perform the following duties: 1. Establish the controls and criteria for specialization accreditation which shall be applied by the Central Committee for Accreditation. 2. Express its views and comments about the new accreditation requests submitted to the Central Committee for Accreditation. 3. Inform the training centre of the accreditation decisions issued by the Central Committee of Accreditation. 4. Periodically evaluate the accredited training centres performance quality and submit recommendations to the Central Committee of Accreditation to take the legal measures toward such recommendations. Page 21

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