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Why is RACS changing the training post accreditation process?
In 2022 and 2023, the National Health Practitioner Ombudsman (NHPO) reviewed all specialist medical college policies, procedures, and processes for accrediting training sites. In October 2023, the NHPO published Processes for Progress which contained 23 recommendations. Australian Health Ministers then directed that the Australian Medical Council (AMC) work with specialist colleges and jurisdictions to implement the 15 of these recommendations that could be implemented across all colleges.
Since the NHPO report, all 16 specialist medical colleges in Australia and the AMC have been working together to develop and implement a standardised approach to training post accreditation. This is the most significant change to training accreditation in decades.
What is changing
Training post accreditation will now be assessed against four key documents:
- AMC Model Standards
- AMC Model Procedures
- College Specific Requirements (CSR)
- RACS Training Post Accreditation and Administration Regulation
The Model Standards assess against four key domains:
- Trainee Health and Welfare
- Supervision, Management and Support Structures
- Educational and Clinical Training Opportunities, and
- Educational Resources, Facilities and Equipment
Further detail of each domain and criterion can be found in the AMC Model Standards
Common Terminology
Under the new framework, there will be a change to common terminology for assessing against the Model Standards. Outcomes will be given one of the following findings:
- Met
- Substantially Met, or
- Not Met
New terminology will also apply to accreditation outcomes:
- Accredited
- Conditionally accredited, or
- Not accredited
For newly accredited sites, Provisionally accredited will be used for up to the first 12 months. This outcome may also be applied to existing sites.
When referring to Not accredited posts, the terminology used will be either Refused (for new sites) or Revoked (for existing sites)
My hospital is interested in applying for accreditation of a training post. What do we need to do?
Identify the surgical specialty your hospital is interested in applying for, then contact the organisation responsible for supporting the accreditation process in that specialty to obtain the application form and accreditation standards. For more information, please see the table on the main accreditation page.
What is the due date for submissions for new posts?
When does the hospital need to submit documentation for reaccreditation?
When accreditation is first obtained, the Specialty Training Board will advise on the number of posts accredited, their training level and the duration of the accreditation, including any conditions placed on the hospital.
In the year prior to the expiration, the organisation responsible for accreditation in the relevant specialty will contact the CEO and nominated specialty supervisor(s), inviting a submission for reassessment of the accredited post(s).
What is the administrative process once applications are submitted to the College or relevant specialty society? Is it different if the application is for new posts or reaccreditations?
Once an application to accreditation is received, whether for a new post or for the reaccreditation of existing posts, the following steps will occur:
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Acknowledgement of receipt will be issued.
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The hospital submission will be checked for completeness.
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The relevant specialty training board will contact the person nominated on the application to arrange for a mutually convenient inspection time., or where deemed sufficient, may conduct a document-based or virtual assessment.
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Following the inspection, the inspection team will draft a report.
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The draft report will be sent to the head of unit and supervisor of training at the unit inspected.
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Hospitals will have a specified period to respond to any factual errors in the report.
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Following response from the hospital, the inspection team will finalise a report, including a recommendation for the specialty training board.
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The specialty training board will consider any comments and make a final recommendation for ratification by the Board of Surgical Education and Training.
What if posts in the same specialty are due for reaccreditation in different years?
Where possible, the specialty training boards will be work to accredit all posts in the specialty at the same time. This may not always be possible, as posts in different units may require earlier review.
The criteria now include the requirement for supervisors to have protected administrative time and support. How much time should a Supervisor need?
Standard 4 of RACS’ accreditation standards provides information on the minimum requirements we expect hospitals to have in place to become a training post relating to Supervisors and Trainers. In particular, against Criteria 20, the minimum requirements are:
“The designated Supervisor of Training in each specialty is provided with paid, protected administrative time to undertake relevant duties appropriate to the specialty and in accordance with the SET Surgical Supervisors Policy. This should be related to the number of trainees but should be at least 0.2 EFT if there are five Trainees under supervision.”
As an accredited training post, it is essential that the supervisor of training has dedicated protected time to complete their supervisory duties to ensure that Trainees progress safely through the SET program. As a hospital, we would expect you to work with your Supervisors to make sure that they’re supported to complete their duties. Supervisory duties can be found within the RACS Surgical Supervisors policy, (PDF 102.2KB) and the broad Standards for Supervision (PDF 421.39KB).
Depending upon which specialty you are applying for accreditation with, there may also be specialty supervisor regulations to adhere to. For more information, we have a dedicated Supervisor Support Hub on the RACS website with links to specialty resources, policies and professional development information.