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?

Contact the organisation responsible for supporting the accreditation process in that relevant surgical specialty to obtain details of submission deadlines.

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:

  • Acknowledgement of receipt will be issued.
  • The hospital submission will be checked for completeness.
  • 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.
  • Following the inspection, the inspection team will draft a report.
  • The draft report will be sent to the head of unit and supervisor of training at the unit inspected.
  • Hospitals will have a specified period to respond to any factual errors in the report.
  • Following response from the hospital, the inspection team will finalise a report, including a recommendation for the specialty training board.
  • 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 69.24KB) 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.

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.