What are the criteria for accreditation of a surgical training post?

The Accreditation of Hospitals and Posts for Surgical Education and Training: Process and Criteria for Accreditation (PDF 345.22KB) booklet is published by the College and details the generic criteria for accreditation with links to details on any specialty specific criteria.

The hospital is interested in applying for accreditation. What do we need to do?

Hospitals interested in applying for accreditation will need to complete the relevant application form, depending on the body that is responsible for the administration of the process (see the following table).

Applying for accreditation

Specialty Australia New Zealand
Cardiothoracic Surgery RACS RACS
General Surgery General Surgeons Australia New Zealand Association of General Surgeons
Neurosurgery Neurosurgical Society of Australasia Neurosurgical Society of Australasia
Orthopaedic Surgery Australian Orthopaedics Association New Zealand Orthopaedics Association
Otolaryngology Head & Neck Surgery Australian Society of Otolaryngology Head and Neck Surgery RACS
Paediatric Surgery RACS RACS
Plastic and Reconstructive Surgery Australian Society of Plastic Surgeons RACS
Urology Urological Society of Australia and New Zealand Urological Society of Australia and New Zealand
Vascular Surgery ANZSVS                ANZSVS               

What is the due date for submissions for new posts?

Submissions for new posts can be made at any time. However, while applications received after the last business day in January may be assessed in the same year, they will not be eligible to receive a Trainee in the next training year. Submissions received by the last business day in January will be assessed in that year. Should the relevant Specialty Board and its governing boards subsequently approve one or more posts as a result of the application it will be available in the subsequent training year.

For example submissions received by 30 January 2009 and approved as a training post commenced at the beginning of the 2010 training year. Applications received after 30 January 2009 and approved did not commence as an active training post until the beginning of the 2011 training year.

Hospitals that intend to make a submission but may not be able to achieve the submission date are recommended to contact the relevant Board before the due date to see if other arrangements can be made.

When does the hospital need to submit documentation for reaccreditation?

At the initial assessment of an application the Specialty Board will make a recommendation towards the number, training level and duration of post/s. In the year prior to the expiration of the current posts the College Hospital Accreditation Coordinator or relevant specialty society will contact the CEO and nominated specialty supervisors, inviting a submission for reassessment.

The submission, prepared by the hospital, has to be received by the last business day in January in order to be eligible for reaccreditation in the subsequent training year.

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:

  • Acknowledgement of receipt will be issued.
    The hospital submission will be  checked for completeness.
  • The submission will be provided to the relevant specialty board
  • The relevant specialty board will contact the person nominated on the application to arrange for a mutually convenient inspection time. The relevant specialty board may deem it sufficient to conduct a document-based assessment.
  • Following the inspection the inspection team will draft a report including recommendation.
  • The draft report will be sent to the head of unit and supervisor of training at the unit inspected.
  • Hospitals have a specified period to respond to any factual errors in the report.
  • The Board will consider any comments and make a recommendation to the Board of SET.

If an application is sent directly to a delegated specialty society, all steps will be undertaken by the nominated officer of that society.

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 have concerns that require review in timeframes less than the usual five year cycle.

The updated criteria now include the requirement for supervisors to have protected administrative time and support. Why?

To ensure that the surgical standards expected by the Australian and New Zealand public are maintained, surgical supervisors need to observe trainees, plan educational activities and provide guidance and counselling. This is not always achievable when consultants have significant clinical duties to perform concurrently.

Many training programs, such as those of the College for Emergency Medicine, the Australian and New Zealand College of Anaesthetists and the Royal Australian College of Physicians, already have arrangements for administrative time for supervisors.

Many independent reports, such as the Garling Report in New South Wales, recommend that supervisors have protected time for active supervision of Trainees.

Do all surgical consultants in the unit need to be funded for administrative time?

No. Generally, hospitals nominate one supervisor per specialty program, who is approved by the College. Other consultants in the unit are trainers, and while they should be actively supported in their training activities, this is not a requirement for accreditation at this time.

What is meant by secretarial support?

This is secretarial support to supervisors to assist them in their training activities, and to assist with audit requirements. Supervisors should have appropriate access to computers, the internet, and technical support.

If supervisors are paid for administrative time, what are they required to do?

The duties and responsibilities of supervisors are detailed in the Surgical Supervisors Policy, and individual specialty training boards determine the supervisory tools used. In general, it is expected that supervisors will undertake reviews, conduct Direct Observations of Procedural Skills and Mini-Clinical Examinations, and assist trainees in their progress.

Do private hospitals seeking accreditation of posts for training have to provide paid protected time for surgical supervisors?

Yes. Whether in a private or public hospital, it is important that supervisors are supported in their training role to ensure that trainees achieve the appropriate standards to service the Australian and New Zealand public.