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Health Education and Training Institute 1

Appendices

Standards of Education, Training and Supervision for Prevocational Trainees and Post AMC Supervised Training

September 2011, Version 4.4

TRIM NO: DOC06/468


List of Appendices

List of Appendices 2

Appendix A: The Accreditation Process 3

Appendix B: Position Description: Director of Prevocational Education and Training 8

Appendix C: General Clinical Training Committee Terms of Reference 11

Appendix D: Position Description, Term Supervisors 14

Appendix E: Network Committee Terms of Reference 17

Appendix F: Term Description Template 21

Appendix G: Recommended Prevocational Trainee Handbook Contents 25

Appendix H: Progress Review Form 27

Appendix I: The Appeals Process 34

Appendix J: Intern Policy New South Wales Medical Board 39


Appendix A: The Accreditation Process Background and Purpose of Accreditation The aim of prevocational training is to further the personal and professional development of medical graduates by providing a breadth of educational experiences in the initial two postgraduate years. Training posts should offer a supportive training and administrative structure, well-organised supervision, education and clinical experience, which foster confidence, clinical knowledge and skills, and a maturity of judgement necessary for future medical practice. The first postgraduate year should include close supervision and general medical training, whilst the second postgraduate year should include less direct supervision, more clinical responsibility and preferably include some exposure to subspecialty terms. The Medical Board of Australia, NSW and ACT Health delegates HETI with the responsibility to accredit facilities for prevocational training to ensure high standards of training, education and welfare for all prevocational trainees. This includes all the facilities, and the posts within then, that are utilised to train prevocational trainees (PGY1 and PGY2) employed by NSW and ACT Health. The Prevocational Accreditation Program of HETI determines and monitors standards for prevocational trainees with the aim of promoting the attainment of a universally high standard of prevocational clinical training. Through the process of accreditation, facilities are formally evaluated by a survey team, using the clearly defined and established “Standards of Education, Training and Supervision for Prevocational Trainees and Post AMC Supervised Training version 4.4.” Accreditation helps to ensure that the optimal environment exists for the organisation, supervision and training of prevocational trainees to promote the development of competencies. Accreditation status may be awarded for a maximum of 3 years and can be with or without provisos as determined by the survey team and the Prevocational Accreditation Committee. These provisos promote modifications aimed at the improvement of the training facilities. Understanding the Standards There are three core goals against which the standards are set: Goal 1: The facility ensures prevocational trainees have the appropriate knowledge, skills and supervision to provide quality patient care Goal 2: The facility provides a wide range of educational and training opportunities for prevocational trainees to ensure that they are competent and safe Goal 3: The facility promotes the welfare and interests of prevocational trainees. The standards support each goal. To fulfil the goal a facility must comply with the objectives defined in the standard. Within each standard there are also the following:

• Criteria - the specific actions required to achieve each standard.

http://www.medeserv.com.au/pmc/publications/jmo2002_standards/index.htm


• Specific Requirements - mandatory actions that support the criteria.

• Guidelines - these provide further explanation of the standards and criteria. These actions are not mandatory but may assist the hospital in fulfilling the criteria.

Process of Accreditation The accreditation process has several key steps. These include a pre-accreditation documentation completed by the facility, a review by a HETI appointed survey team and a resulting comprehensive report on the application of standards within the facility. Finally, if all standards are met, the facility is awarded with accreditation of up to three years. If standards are not met, the Prevocational Accreditation Committee will prepare recommendations for meeting the criteria and the award of accreditation will be pending on the compliance with the standards. 1. Accreditation Survey

HETI will liaise with the hospital’s liaison person regarding survey dates, in a particular week and term. Some months before the survey, the facility will receive the standards document to complete. The standards document requests information such as the size of the facility the range of services, the number and mix of medical staff, details of the terms available to prevocational trainees and the Clinical Training Program for prevocational trainees. Along with this, the facility will complete a self-assessment which asks them to rate themselves against each of the criterion in the standards. This is then provided to HETI to be used to aid them in the surveying process. Both the facility and the survey team are asked to assess the training facility using the same rating scale. The facility is also asked to comment on how the criteria have been achieved. The survey team is asked to comment against the criteria when the survey team rates the facility lower. However, it is important to recognise that self-assessment should not be restricted to preparation for the survey process once every three years. Rather, it is an on-going process as part of an overall approach to continuous improvement as it enables facilities to identify and remedy problems as they arise. 2. The Survey Team HETI will normally allocate at least four surveyors to each accreditation survey. One of these will be asked to lead the team. On occasions a two or six person team will be allocated to a survey, depending on the number of prevocational trainees at the facility or the nature of the survey.

The survey team is usually made up of at least one:

• prevocational trainee • medical administrator • medical clinician

The survey team members can be drawn from Directors of Prevocational Education and Training, medical administrators, Attending Medical Officers, prevocational trainees, registrars, HETI and its committees. Where possible, at least one person on the surveying team will be from a facility similar to the one being surveyed. All survey team participants will have completed surveyor training before undertaking an accreditation survey.


3. The Survey and Report The survey team will spend up to two days at the facility. The amount of time needed at each facility varies depending on the number and nature of prevocational trainee terms available. The survey will involve discussions with medical staff managers, the Director Prevocational Education and Training, term supervisors, Attending Medical Officers and prevocational trainees. There may also be an inspection of prevocational trainee facilities and a review of relevant written material and survey documentation. A debriefing session will be held at the conclusion of the survey. The survey team will then complete a comprehensive report, recording the performance of the facility against the Standards. The report will also include commendations and recommendations on the status of accreditation, taking into account the ratings given to the facility by both the survey team and those determined in the pre-survey documentation. The four rating points that are within the standards are summarised below. A low rating should be accompanied by comments and recommendations from both the surveyors and the facility. Where the surveyors’ rating differs from the facilities, an explanation will be provided. Overview of the ratings:

Low Achievement Requirements of standard / criterion scarcely met. Minimal effort made by the hospital to address the standard / criterion.

Moderate Achievement The requirements of the standard / criterion are generally met in most circumstances.

Extensive Achievement: The requirements of the standard / criterion are well met in the majority of circumstances and have been for some time.

Outstanding Achievement The requirements of the standard / criterion are fully met in all circumstances and have been for some time. Innovation and improvement are evident.

The final report is then given to the Prevocational Accreditation Committee at HETI who discuss the findings with the survey team leader. The Prevocational Accreditation Committee will then make a formal decision regarding the accreditation status and any provisos that are attached to the status. 4. Accreditation Status The accreditation status relates to the specific prevocational trainee terms that exist at each facility at the time of the survey and the compliances of the facility against the standards. The facility is notified of its accreditation status within two to three months of the completion of the survey. The Prevocational Accreditation Committee decision is accompanied by a copy of the survey team's report and a certificate of accreditation.


Accreditation status can vary depending on the compliance with standards and can be one of the following:

Three year accreditation indicates substantial compliance with HETI’s standards for prevocational trainees training and supervision. Three year accreditation with provisos indicates substantial compliance with the majority of the standards, but the Prevocational Accreditation Committee requires verification that issues raised by the survey team have been addressed by the facility within a stated period of time. Accreditation is awarded contingent upon the provisos being addressed satisfactorily. Twelve months accreditation is granted to facilities which meet most of the standards but which have significant, specific deficiencies warranting attention. Twelve months accreditation with provisos is granted to facilities which meet most of the standards but which have significant, specific deficiencies warranting attention, and where the Prevocational Accreditation Committee requires verification that certain issues raised by the survey team have been promptly addressed by the facility. Accreditation is awarded contingent upon the provisos being addressed satisfactorily. Six months accreditation is granted to facilities that require immediate action to correct deficiencies identified in the survey. Facilities granted such accreditation will be resurveyed within six months. In such cases a copy of the survey letter is given to the NSW Minister for Health with a briefing note outlining the issues. Six month accreditation with provisos is granted to hospitals which have immediate actions to be promptly addressed by the hospital.

Provisos are aimed at providing verification that certain specific issues raised by the survey team are remedied. If considered appropriate these provisos may be assessed at a focus visit. Facilities which fail to achieve accreditation status or whose accreditation status is withdrawn are not considered suitable for the employment of prevocational trainees. 5. Accreditation of Terms (posts) The individual posts within a facility must be accredited. For a post to have a prevocational trainee, it must be either accredited or provisionally accredited. Facilities can have provisionally accredited and accredited terms with no allocated trainees in them from time to time, but must not allocate any prevocational trainees to an unaccredited position. Provisionally accreditation is usually given to new or revised terms presented to the Prevocational Accreditation Committee between surveys. When a facility changes their term they must ensure that the balance of the overall clinical training program for prevocational trainees is maintained. A term description detailing the new and revised term must be submitted to HETI for assessment and the facility must ensure approval is obtained for the term. The Prevocational Accreditation Committee provides written confirmation of its approval of new terms and changes to existing terms.


Accreditation is awarded based upon the term structure that exists at the time of survey. Giving accreditation to a term after the survey process ensures the term description reflects the education, training and supervision occurring in the post. Provisionally accredited and accredited terms can receive provisos, remain or return to provisional accreditation and be dis-accredited when the survey findings indicate that the post does not adhere to HETI Standards. For further information please see term description policy and procedure. Accreditation of a term lapses when a prevocational trainee have not been in the term for two years or when the facility decides it no longer needs the post. The facility is to notify HETI in writing of these situations. Accreditation of new or revised terms requires the following information to be submitted to the Prevocational Accreditation Committee for consideration;

• A term description which adheres to HETI’s guide • DPET, General Clinical Training Committee and DMS approval

6. Change of Facility Role Facilities that alter their role (with associated changes to prevocational trainee education and supervision) during a period of accreditation must notify HETI in writing. 8. The Appeal Process A facility may appeal against an accreditation decision. An Appeals Committee will consider any such appeal and make recommendations to HETI. Please see Appeals Policy and Procedure. (Appendix I) 9. Between Accreditation Surveys Facilities should comply with HETI’s standards throughout the period for which they are accredited. HETI reserves the right to review accreditation status, at any time where there is substantial evidence to suggest that HETI’s standards are not being met. 10. The Responsibility of Prevocational Trainees HETI acknowledges that prevocational trainees have a responsibility for practising safely and for furthering their own education. They should be encouraged to participate actively in their education, to identify their own limitations and practise safely at all times.


Appendix B: Position Description: Director of Prevocational Education and Training

Position Description: Director of Prevocational Education and Training

DOC07/3840

Name of hospital: To be completed by employing hospital

Responsible To: Hospital executive through the General Clinical Training Committee (GCTC)

Version: January 2011 Mission of hospital (2-3 sentences to be completed by employing hospital) Role of DPET in achieving the mission of the hospital (2-3 sentences to be completed by employing hospital) Key relationships Regular liaison with Prevocational Trainees and Term Supervisors Liaison with Attending Medical Officers, the General Manager and

administrative staff as required. Key roles and responsibilities The role of the Director of Prevocational Education and Training is to direct the education and training of prevocational medical trainees in the hospital. In performing this role, the fundamental responsibility of the Director of Prevocational Education and Training is to ensure patient safety at all times. Specific responsibilities of the role: 1. Ensuring that the principles of prevocational education and training are attained by: supporting a culture of professional development providing a structured education program and evaluating its effectiveness developing, coordinating and promoting the clinical training of prevocational

trainees in association with JMO staff management and the General Clinical Training Committee

providing fair and transparent term allocations and workload providing effective term and hospital orientation overseeing ongoing and constructive assessment and feedback processes identifying and supporting trainees with special needs providing for adequate and appropriate supervision providing adequate education and information resources


assisting the hospital in maintaining its accreditation status with HETI participating in the education of prevocational trainees promoting professional responsibility and ethics among prevocational trainees being a resource for clinical teachers.

2. Looking after the personal and professional welfare of prevocational trainees,

particularly those experiencing difficulties.

3. Being an advocate for the professional development of trainees by: ensuring procedural fairness maintaining independence from line management addressing system-wide issues.

4. Liaising and attending meetings with relevant groups and individuals in the training

and education of trainees including: Term Supervisors Network Committee for Prevocational Training (NCPT) General Clinical Training Council Directors of Medical Services Visiting Medical Officers JMO Managers and administrative staff Hospital Executive Other DPETs within the Network HETI.

5. Managing the DPET funding through the Director of Prevocational Education and

Training cost centre.

6. Developing a DPET succession plan.

Skills, knowledge and experience – selection criteria 1. Medical graduate with clinical postgraduate qualifications 2. A clinical appointment to practice at the hospital 3. Qualifications, appointment and experience at a level sufficient for communicating

on authoritative terms with senior consultants acting as term supervisors 4. A commitment to and confidence in improving the quality of education and training

offered by the hospital 5. An understanding of the principles of adult education and professional development 6. A genuine interest in postgraduate medical education, a willingness to develop

expertise in this area, and a demonstrated understanding of the importance of the continuum of medical education as a lifelong professional commitment

7. Established collaborative links with administration and for medical staff council 8. A commitment to the mission of HETI and the ability to present and explain HETI’s

goals.


Evaluation The General Clinical Training Committee (GCTC) will undertake an annual performance review of the Director of Prevocational Education and Training. The performance review will be based on: Feedback from prevocational trainees, term supervisors and medical

administration Evaluation of activities undertaken by the Director of Prevocational Education and

Training Performance indicators (to be developed in consultation with the Director of

Prevocational Education and Training). Appointment process A formal letter is to be sent to the Chair of the Prevocational Training Council at HETI from the Executive of the hospital with specific input from the General Clinical Training Committee (GCTC) with a recommendation for a new DPET (including his or her curriculum vitae). The Prevocational Training Council reviews the hospital’s recommendation, advises the hospital of their consideration and sends a letter of welcome to the new DPET. Verification This section verifies that the position holder and supervisor have read the above position description and are satisfied that it accurately describes the position.

Position Holder Signature..................................................................... Date.......................................

Supervisor Signature..................................................................... Date........................................


Appendix C: General Clinical Training Committee Terms of Reference

Terms of Reference

General Clinical Training Committee

Purpose of Committee: To support the mission of the Health Education and Training Institute’s (HETI), by ensuring that trainees are clinically competent for safe practice and provide quality patient care

Role and responsibilities:

Advisory functions:

Advise on education and information resources needed to support education programs

Provide appropriate advice on other matters relating to the delivery of medical education and training, as required by the hospital

Operational Functions:

The Committee will conduct its activities in accord with the rules of the hospital and its terms of reference

Develop, implement, monitor and evaluate all orientation, training and educational programs for doctors in training

Ensure that each trainee rotation, including secondments, is consistent with HETI guidelines

Regularly review and evaluate the training, education, experience and working conditions of each trainee

Review hospital performance according to the HETI standards

Determine the specific orientation, training and educational needs of prevocational trainees

Review and evaluate the performance of Term Supervisors and the Director of Prevocational Education and Training and

Ensure there is a Director of Prevocational Education and Training succession plan

Membership:

The membership is to include a broad range of expertise and backgrounds. The wide membership and effective functioning of the committee will ensure that all relevant departments of the hospital develop a sense of responsibility for the education, training and development of their trainees.

Chair: Position: To be nominated. This is not to be the Director of Prevocational Training

Responsibilities: The Chair provides leadership to the GCTC and promotes a cohesive and effective environment. Key roles and responsibilities of the Chair include:

• assisting staff and the Committee to understand their role, responsibilities and accountability


• assessing the performance of Term Supervisors and the Director of Prevocational Education and Training on a regular basis

• ensure rotations, including secondments are consistent with HETI guidelines

• providing recommendations and advice to HETI in respect to medical education, training, standards, accreditation and workforce

• disclosing interests, which may impinge upon the exercise of his or her duties as Chair of the Committee.

Committee Support Officer:

Position: To be nominated

Responsibilities: This person is held accountable for the preparation of

agendas, minutes, the distribution of minutes and committee papers and follow-up on matters raised.

Minutes of meetings are to be kept and circulated to members of the Committee and the senior management of each hospital in the network after each meeting.

Other members: The committee will include representatives of:

Hospital Management

Trainees (prevocational and vocational)

Junior Medical Officer Management

The Medical Staff Council

Term Supervisors

Director of Prevocational Education and Training

Representatives from associated universities, colleges and other training programs (as appropriate)

Ex Officio & Co-opted or non-voting members:

The Committee may co-opt members to the Committee and/or establish working parties as may be necessary

Conduct of meetings: Quorum 50% + 1

Voting As necessary

Frequency The Committee will meet at least quarterly

Duration:

Time:


Location:

Standing agenda items:

Formal reporting to: The Committee is responsible to senior hospital management. The senior hospital management will ensure that the committee has authority for a range of relevant activities and that it is provided with adequate secretarial and administrative support.

Endorsed by: Committee or organisation:

Date:


Appendix D: Position Description, Term Supervisors

Position description Position title: Term Supervisor Name of hospital: To be completed by employing hospital Reports to: Director of Prevocational Education and Training Version: DOC09/970

Mission of hospital (2-3 sentences to be completed by employing hospital)

Role of Term Supervisor in achieving the hospital mission (2-3 sentences to be completed by employing hospital) The Term Supervisor is responsible for the welfare of prevocational trainees allocated to their team or unit. Their key roles are ensuring appropriate supervision for patient safety, providing training to meet the learning objectives of the term, monitoring trainee progress and assessing trainee performance.

Key relationships

• Prevocational trainees and attending medical officers • Director of Prevocational Education and Training • Chair of the Network Committee for Prevocational Training • Chair of the General Clinical Training Committee • General Manager • Administrative staff as required

Key roles and responsibilities

Patient safety • Employs strategies to ensure the safety of care, including combinations

of graded supervision, training and personal support for the prevocational trainees assigned to the term.

Trainee welfare • Coordinates trainee activities across the term. • Determines the level and proximity of supervision required for each

prevocational trainee in each work situation. • Ensures that the systems of work and training minimise risks and

support the safety of prevocational trainees. • Discusses issues such as grievances and career guidance with

prevocational trainees.


• Encourages prevocational trainees to develop progressively increasing independence.

Education and training • Prepares and reviews a term description in consultation with other

attending medical officers in the team, the Director of Prevocational Education and Training, Junior Medical Officer Management and prevocational trainees. The term description describes the responsibilities and accountabilities of the prevocational trainee, specifies the skills required by the prevocational trainee to function safely and defines the specific knowledge and skills to be gained or enhanced during the term.

• Discusses training goals and expectations with the trainee at the beginning of term and ensures that a clinical orientation to the term is provided.

• Develops the educational program available to trainees during the term, supports attendance by prevocational trainees at educational events and provides effective practice-based teaching.

• Monitors the progress of prevocational trainees and provides continuous constructive feedback to guide their professional development.

• Encourages attending medical officers to provide continuous teaching, supervision and constructive feedback to prevocational trainees.

• Provides formal documented assessment at mid-term and the end of term. These two formal assessments begin with the trainee’s self-assessment and are developed in consultation with attending medical officers, registrars, nurses and other professional staff. Assessment includes planning and documenting actions to improve trainee performance.

• Intervenes when necessary to correct gaps or weaknesses in the knowledge or skills of prevocational trainees.

• Informs the Director of Prevocational Training if a prevocational trainee appears to be experiencing difficulty with work or the training program.

Skills, knowledge, experience competencies and behaviours

The Term Supervisor must be an attending medical officer (AMO) at the hospital with AMO responsibility for providing patient care within the scope of the term. Term Supervisors must have:

• an understanding of the concepts of adult education, performance monitoring and quality improvement

• superior interpersonal skills • a commitment to the mission of the Health Education and Training

Institute (HETI) and the ability to present and explain HETI goals.


Performance evaluation The performance of the Term Supervisor will be evaluated annually by the General Clinical Training Committee (GCTC) with reference to:

• DPET feedback • Prevocational trainee feedback • Efficiency of activities • Performance indicators (to be developed by the GCTC)

Verification This section verifies that the position holder and supervisor have read the above position description and are satisfied that it accurately describes the position.

Position Holder Signature..................................................................... Date.......................................

Supervisor Signature..................................................................... Date........................................


Appendix E: Network Committee Terms of Reference

Terms of Reference

Network Committee for Prevocational Training NCPT

Purpose of Committee:

The purpose of the Network Committee for Prevocational Training (NCPT) is to ensure safe, high quality training in Prevocational Trainees through good governance and management of the Prevocational Training Program based in the Network and associated training activities for other trainees.

Each network will establish a NCPT that supports the efficient running of training in a fair and transparent manner.

Role and responsibilities:

Role

The role of the NCPT is to provide:

1. An opportunity for all stakeholders (trainees, Hospital Supervisors of Prevocational Training, Departmental Directors and health service administrators) to participate actively in the governance of the training network

2. A forum for discussion of ideas and strategies to improve training within the Network or remedy identified deficiencies at a local level

3. A locus of accountability for Prevocational training based in the network

4. Support for the hospital-based Directors of Prevocational Education & Training

5. Transparent and equitable network governance and management; to include reporting on its operations and expenditure to NSW Health through the NSW Prevocational Training Council

6. Distribute prevocational trainees across the network taking into account home base hospital preferences and information obtained through the workforce distribution formula.

Functions

The NCPT will ensure the provision of:

Training Networks

The NCPT will oversee a training network and ensure equal partnership between hospitals in that network.

The NCPT will ensure the delivery of high quality teaching at all network sites that provides trainees with opportunities to acquire the skills and knowledge required for the Australian Curriculum Framework for Junior Doctors. This will include provision of term allocations in the November before the start of the clinical year and feedback on all terms in the Network.

Appropriate Quality of Training & Supervision

The NCPT will act to ensure appropriate quality of training provided at all training sites within the network. This will include ensuring that training is in accordance with the


training standards of Health Education and Training Institute (HETI).

In particular the NCPT will ensure that all trainees are supervised and supported by more senior staff at a level consistent with their skill and experience

Opportunities to Learn

The NCPT will ensure that all trainees in the Network are afforded equitable access to learning opportunities. This includes the provision of

• Safe working hours which facilitate learning

• Access to educational sessions

• Opportunities for professional development

Workforce Distribution

Each NCPT will provide the full range of experience required for prevocational trainees.

NETWORK PRINCIPLES The NCPT will be guided by the following principles in undertaking these functions; Principles for workforce distribution - The number of PGY1s at individual hospitals now (2007) is the baseline i.e. no further

reduction at any hospital

- The priority for additional staff is distribution to rural and outer metropolitan sites first

- All terms must be accredited with HETI for supervision and training - The availability of terms, quality of supervision and the provision of education and training is

taken into account by the network in distributing the workforce - That confirmed funding is provided for all new positions - That HETI will be notified on the agreed distribution by a certain date - In cases of conflict involving distribution the matter is to be referred to HETI

Principles for home base hospitals - The establishment of a fair and transparent process for allocating home base hospitals which

takes into account network needs and home base hospital preferences

- PGY1’s will rotate to no more than three hospitals in each year of training

- Notification to the PvTC on which accredited hospitals in their network can be considered home base – this should take into account the availability of terms, quality of supervision and the provision of education and training,

- Prevocational trainees to be informed of their home base hospital by November before the start of the clinical year.

Notes:

- HETI will track the distributions against those suggested by the allocation distribution formula

- The accreditation process will include review nominated home hospitals which have previously been considered secondment hospitals as part of the accreditation cycle. If a hospital wishes additional terms to be accredited then these should follow the standard process.

- A summary of home base hospitals and the number of prevocational trainees should be


copied to the PvTC for information.

Delegated Authority: The governance arrangement will provide an understanding between all stakeholders in the training network, including trainers, trainees, hospital administration, and area health services, and will include representation from each Prevocational-accredited hospital within the network.

Constitution The Network Governance Committee will have:

1. Elected Director of Prevocational Education & Training from one of the hospitals in the network as Chair

2. Directors of Prevocational Education & Training

3. Senior representatives of JMO Management

4. Senior representatives of Directors of Medical Services

5. Prevocational trainees from the Network

6. Representatives from the Network Surgical Training program

NOTE: Each training site within the network should have a representative on the Network CPT

Membership: Term of appointment: The elected Director of Prevocational Education & Training will Chair for the term of their appointment.

All other members appointed by the Chair for a period of 2 years with the possibility of extension for another 12 months.

Chair: How appointed: The elected Director of Prevocational Education & Training will Chair for the term of their appointment. They will be appointed through a merit based recruitment process.

Name & Position

Appointed: (Date)

Responsibilities:

• Leadership of the Network CPT; promotion of a cohesive and effective environment

• Development and maintain good relationships with key stakeholders

• Provision of advice and recommendations to the PVTC

Committee Support (to be appointed by network)

Position: Nominated from network

Responsibilities

• Prepare documentation in conjunction with the Chair for each meeting

• Distribute documentation for each meeting


• Liaise with members as required

• Document minutes of the meeting

Other members

Directors of Prevocational Education & Training

Senior representatives of JMO Management

Senior representatives of Directors of Medical Services

Prevocational trainees from the Network

Representatives from the Network Surgical Training program (Network Director of Training and / or surgical education support officer

Conduct of meetings:

Quorum 50%

Voting As required

Frequency At least once per training term (minimum five meetings per annum)

Formal reporting to: The Area Committee on Postgraduate Medical Education and the PVTC

Evaluation of committee and terms of reference:

Frequency of evaluation:

Date last evaluation:

Date next evaluation:

Evaluation performed by:

Endorsed by: Committee or organisation:

Date:


Appendix F: Term Description Template

Term Description

File name:

Revised and by whom:

Hospital Term Based at

Term Name

Term Supervisor

Signature Term Identifier Number (HETI Assigned) Hospital no (optional)

Term Duration (Weeks)

Date

Clinical Team Please include contact details

Is the term a PGY1 or a PGY2 term? Please note that a PGY2 ONLY accredited term may not be staffed by a PGY1. Specific accreditation must be sought for a PGY1 term

PGY1 PGY2

Term Capacity Please indicate the term capacity – total number of PGY1s and PGY2s

PGY1 PGY2 TOTAL

Term Category

Medicine Surgery Emergency Other

A: Overview of unit or service Please provide details of the role of the unit, the range of care service, etc


B: Term Objectives By the completion of this term the prevocational trainee may expect to acquire the following knowledge:

By the completion of this term the prevocational trainee may expect to gain competency in the following skills:

C: Requirements for commencing the term Please identify the knowledge or skills required by the prevocational trainee before undertaking the term and how they will be assessed. (E.g.: Paediatric resuscitation, assessed by demonstration).

Please attach a term/unit timetable

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

D: Prevocational trainee responsibilities and daily tasks Please list

Patient load (average)

Overtime


Rostered (average hours/wk) Unrostered

(average hours/wk)

E: Education and Supervision Education sessions Please outline content and timing of unit based sessions and the arrangements for prevocational trainees to attend hospital wide education sessions throughout the term

Educational resources Please outline the information resources available to prevocational trainees during this term and how to access them

AMO Teaching Please list the AMOs who will provide workface/bedside teaching to prevocational trainees

Registrar Teaching Please list the Registrars who will provide workface/bedside teaching to prevocational trainees

Supervision Please identify staff members with responsibility for prevocational trainee supervision and the mechanisms for contacting them, particularly after hours

Supervision Does this term include participation in an after hours roster and if so please advise of supervision available after hours

Rounds / Surgery No of AMO Rounds per week

No of AMO Rounds attended by JMOs

No of Out of Hours Rounds attended by prevocational trainees


No of operating sessions per week

No of operating sessions attended by prevocational trainees

Assessment and Feedback The Term Supervisor will provide formal assessment and feedback using the HETI Progress Review Form at mid-term and at the end of term. In completing the Progress Review Form, the Term Supervisor may consult with other members of the team (AMOs, registrars, nurses and other professional staff).

Additional Information (Optional)


Appendix G: Recommended Prevocational Trainee Handbook Contents A wide range of information must be provided about the hospital and its activities at the time of transition orientation. The hospital must prioritise the issues to be presented during the formal orientation program. This information and information considered important for effective transition but is unable to be included in the program, must be documented and provided to the prevocational trainee to support understanding by the prevocational trainee. The most effective way to provide the documentation is in a comprehensive handbook. The following lists of topics are provided as a guide for the contents of a prevocational trainee handbook. The list is not comprehensive and should be used by the hospital to develop a handbook to meet the needs of prevocational trainees and the hospital. Suggested contents: • Hospital organisation including:

Role of hospital and its relationships with other health services Key hospital personnel

• Prevocational trainee management / conditions of service including: Prevocational trainee management unit (or similar) Role of Director of Prevocational Education and Training, General Clinical

Training Committee and Council Term Supervisors and term descriptions Personal conduct Grievance procedures Awards and conditions of employment Performance review and assessments Duty and shift rosters Leave and holidays Employee assistance programs and staff health Dress code and uniforms

• Prevocational trainee and staff facilities including: Library and other educational resources Quarters, lounge and dining facilities Car parking Mail and communication Child care Professional associations

• Prevocational trainee education including:

Outline of the clinical training program Educational resources


• General prevocational trainee information including:

Accessing specialist services Clinical records Clinical review and quality assurance Medico-legal issues and medical indemnity

• Patient care issues:

Contacting supervisors Admission, transfer and discharge policies Consent Confidentiality Special unit protocols (eg ICU, OR, etc) Management of aggressive patients Procedures following death of patient Infection control procedures OH&S issues Allied health services

• Disaster and emergency procedures including:

Management of cardiac arrest and other clinical emergencies Disaster plans Bomb threats Fire emergencies

The handbook (or a separate document) may also contain information to give prevocational trainees assistance in the management of common acute conditions encountered in the hospital setting.


Appendix H: Progress Review Form









Appendix I: The Appeals Process GROUNDS OF THE APPEAL Any facility that is the subject of an Accreditation decision may, within 30 days from receipt of written advice of the accreditation decision, apply to the Chair of the Prevocational Accreditation Committee to have the decision reviewed by the Appeals Committee. A further 30 days will be allowed for the facility to provide written documents to support the appeal. An appeal to the Appeals Committee shall be based on the hospital’s belief that:

1. An error in fact or due process occurred in the formulation of the earlier decision; and/or

2. Relevant and significant information which was available to the surveyors was not considered in the making of the decision; and/or

3. The decision of the Prevocational Accreditation Committee was inconsistent with the information put before that Committee

RECONSIDERATION OF DECISIONS Where the Chair of the Prevocational Accreditation Committee has a conflict of interest in regard to the facility making the appeal then the Chair will appoint another member of the Committee to stand in their place and perform all functions outlined below deemed to be performed by the Chair of the Prevocational Accreditation Committee. A conflict of interest could include but is not limited to:

1. Where the Chair was a member of the survey team. 2. Where the Chair is a member of the network that the facility belongs to.

Before convening an appeals committee, the Chair of the Prevocational Accreditation Committee may advise an applicant to seek a reconsideration and review of the original decision, in accordance with the process approved by HETI. Such reconsideration and review shall not, and does not, constitute an appeal under these rules. The Appeals Committee shall only be convened if the Chair of the Prevocational Accreditation Committee is satisfied that the applicant has exhausted all other avenues of reconsideration and review of the relevant decision. LODGING THE APPEAL When lodging an appeal, facilities are requested to provide detailed information and comments on the reason for the appeal, and specific items raised in the accreditation report that the facility may wish to dispute. A $500 lodgement fee is required to be paid at this time. In any appeal, the applicant will have the onus of proof to establish the grounds of the appeal. The applicant should state on which grounds they are making the appeal in the terms outlined above. The Appeals Committee The appeals committee will not comprise any individual who was party to the decision of HETI to which the appeal relates. The Appeal Committee will comprise nominees of the:


Medical Director Chair of the Prevocational Accreditation Committee Medical Board of Australia or Medical Council Of NSW NSW Ministry of Health or ACT Health

and An independent arbitrator who shall ensure that the rules of natural justice are

observed. The Network Coordinators shall be secretary to the appeals committee but shall not form part of the Appeals Committee. "Nominee" shall mean a person who is: • not a current member of or any of its committees; • not employed by, nor appointed to the appellant facility. All members of the Appeals Committee, including the Chair shall be entitled to vote on decision of the committee. The Appeals Committee decisions shall be carried on the basis of a majority vote. The decisions of the committee require the input of each member. If a member is unable to attend a meeting in person they should attend by telephone. The Role of the Appeals Committee The Appeals Committee will examine all relevant documentation that will include:

1. The last survey of the facility 2. Responses from surveyors 3. Relevant committee minutes 4. Documentation from the appellant facility

The Appeals Committee must act according to the laws of natural justice and decide each appeal on its merits. The Appeals Committee is not bound by the rules of evidence and, subject to the rules of natural justice, may inform itself on any matter and in such a manner as it thinks fit. The Appeals Committee shall be entitled to consider all relevant information that it thinks fit. Minutes of hearings of the Appeals Committee shall be confined to a report of the decision made by the Appeals Committee. The Chair of the Appeals committee will write a letter to HETI with the Committee’s decision. The applicant shall be liable for the costs associated with the convening of the Appeals Committee (including travel, accommodation, honoraria, recording costs etc.) minus the $500 lodgement fee Decisions of the Appeal Committee An appeals committee may decide, upon considering all submissions: • that the previous decision made by HETI is upheld • revoke the decision and refer the decision to the Prevocational Accreditation

Committee for further consideration (upon such terms or conditions that the Appeals Committee may determine)


• revoke the decision which is the subject of the appeal and advise HETI of an alternative accreditation decision

• reject the decision, which is the subject of the appeal, and advise that the facility is to be resurveyed. The establishment of reasonable doubt as to the accreditation status awarded, will result in a survey that will focus on the specific areas in which the uncertainty exists

Resurvey Should a resurvey be conducted, a new and independent survey team will be appointed and there will be no appeal process available. Findings HETI will be bound to accept the advice of the Appeals Committee and will uphold or set aside the accreditation decision accordingly. The facility will retain its earlier accreditation status, during the review and appeal process. Representation No personal representation to the committee is permitted. Only written submissions will be considered. Cost When an appeal is lodged, an amount of $500 is to be forwarded as a lodgement fee. Facilities will be liable for any additional costs incurred during the appeal, which will be billed to the facility at the conclusion of the appeal. As a guide, the total costs may be between $3000 - $5000. PROCEDURES FOR THE APPEALS PROCESS Background

1. The Appeals committee will not, except in exceptional circumstances, consider a matter de novo

2. The Appeals Committee will comprise Prevocational Accreditation Chair, Medical Director of HETI, a nominee of the Australian Medical Board or Medical Council of NSW, a nominee of the NSW or ACT Ministry of Health and an independent arbitrator who shall ensure that the rules of natural justice are observed.

3. The Network Coordinator attends as secretary to the Appeals Committee and shall provide advice on the relevant aspects of HETI policy, practice and procedures; however he or she is not a member of the Appeals Committee.

4. The applicant may be given an opportunity to make any further written submissions necessary within a short period following the completion of the Appeal.

5. The Appeals Committee will reach a determination and the final decision will be conveyed to the appellant facility subsequently in writing.

Process An applicant will have 30 days from the date upon which it is advised in writing of the decision concerning its accreditation status in which to file for a review of the accreditation decision. Upon receiving both the written acknowledgment of the lodgement of an appeal and the appeal lodgement fee receipt, the applicant has a further 30 days in which to lodge supporting documentation


The relevant surveyors are advised by letter that the hospital has lodged an appeal against the accreditation decision. When the appeal documents are received, copies are forwarded to the relevant surveyors with a letter requesting their comments. When the appeal documents and surveyors comments have been received, the nominees as previously listed are convened. The meeting receives the applicants supporting documents, the surveyor’s comments and relevant sections of the Survey Report pertaining to the grounds of the appeal. At least 21 days prior to the convening of the Appeals Committee, the Network Coordinator will advise the applicant of:

1. The date of the Appeal Committee meeting; 2. An estimate of the costs of the Appeal, which may be incurred by the applicant.

The decision determined by the Appeal Committee shall be conveyed to the applicant, to HETI and the surveyors involved, in writing. If the decision, which is the subject of the appeal, has been revoked, then HETI’s database is amended and a new Accreditation Certificate is prepared. The review decision determined by the Appeal Committee shall be final.


Appendix J: Intern Policy New South Wales Medical Board

TITLE Internship and AMC Supervised Training FILE REF 96/125

96/129

NUMBER R7.6 MPA REF Sections 4& 5

DATE CREATED 11 December 2006 Related Policies

REVISIONS 10 April 2007, 18 September 2007, 18 December 2007, 17 June 2008

INDEX: Legislation Policy 1. Interns 1.1 Graduates of accredited Australian and New Zealand Medical Schools 1.2 Placement & Term Allocations

1.2.1 Emergency Department Terms 1.2.2 Relief Terms 1.2.3 Rotation Terms

1.3 Completion of internship 2. Supervised Training 2.1 Australian Medical Council Certificate holders 2.2 Placement and term allocations 2.3 Upgrading supervised trainees 2.4 Waiver of supervised training period 3. Part time Internship or Supervised Training 4. Deferral of Internship or Supervised Training 5. Unsatisfactory Progress 5.1 Registration for Internship or Supervised Training is Limited 5.2 Extension of Registration for Internship or Supervised Training 5.3 Withdrawal of Registration 6. Pathway


LEGISLATION

4. ENTITLEMENT TO GENERAL REGISTRATION BASED ON QUALIFICATIONS AND TRAINING

(1) A person is entitled to be registered as a medical practitioner if the person has recognised medical qualifications and has successfully completed a period of internship or supervised training as required by the Board.

(2) A person has recognised medical qualifications if the person is a graduate of a Medical School (whether within or outside Australia) accredited by the Australian Medical Council or has successfully completed examinations held by that Council for the purposes of registration as a medical practitioner.

(3) The entitlement under this section is an entitlement to general registration (that is, registration not subject to any condition).

5. ENTITLEMENT TO REGISTRATION WITH CONDITIONS FOR INTERNS

(1) A person is entitled to be registered as a medical practitioner

subject to appropriate conditions if the person would be entitled to registration under Section 4 except for the fact that he or she has not completed a period of internship or supervised training required by the Board

(2) The appropriate conditions of registration are such conditions as the Board thinks appropriate for the purpose of enabling the person to complete that internship or training

POLICY 1. INTERNS 1.1 GRADUATES OF ACCREDITED AUSTRALIAN AND NEW ZEALAND MEDICAL SCHOOLS

Graduates of medical schools accredited by the AMC are eligible to undertake an internship in NSW. These graduates are entitled to registration with conditions for interns.

Interns are only permitted to work in hospitals that meet NSW Institute of Medical Education and Training (IMET) accreditation standards and can only work in terms accredited by IMET. By agreement with the Board, IMET manages the accreditation of hospitals for internship and oversees the process of hospital certification of satisfactory performance by interns.

1.2 PLACEMENT AND TERM ALLOCATIONS

The allocation of graduates to intern positions is undertaken by IMET. Interns are allocated to a prevocational training network. One hospital in the network is nominated as the home hospital, (a hospital within the allocated network where the trainee will spend the majority of their training, i.e. three or more terms). Allocation to a prevocational training network is for two years in order to encompass internship and RMO1 (Registered Medical Officer 1) year.


The internship consists of 5 terms (usually of ten weeks duration). All interns must undertake a term in medicine, surgery and emergency medicine (known as core terms). All interns are required to complete at least three terms at their nominated hospital within the network. The other two terms may be done at any one or more of the rotation hospitals within the hospital network with the expectation that one will be a rural rotation (where one exists).

4 weeks of annual leave is permitted during the Internship but no more than one week should be taken during any core term. Periods of annual leave longer than one week should be taken during a non-core term such as the Relief term. Annual leave must be clearly recorded in the Certificate of Hospital Service or term report in which the leave was undertaken.

As per IMET standards, the terms must be supervised to a degree commensurate with the intern’s level of training and experience, and should have a general educational content suitable to the level of training and experience of the intern.

1.2.1 EMERGENCY DEPARTMENT TERMS

The Emergency Department term provides interns with the broadest range of experience and is a good discriminator of performance, but it may not be the appropriate first term placement for an intern experiencing difficulties. In allocating terms, hospitals should attempt to identify those interns who would benefit from completing other terms first and endeavour not to place them in the Emergency Department in their first term.

1.2.2 RELIEF TERMS

Relief terms are often characterised by suboptimal orientation, variable supervision arrangements and uncoordinated reporting. A relief term is not recommended as a first term placement for an AMC supervised trainee who is unfamiliar with the Australian healthcare system. Similarly, it may not be an appropriate allocation for a trainee (AMC supervised or intern) who has demonstrated performance difficulties in previous terms. In allocating terms, hospitals should attempt to identify those trainees (AMC supervised or interns) for whom a relief term is undesirable. In these circumstances, a relief term may not count towards the Board’s requirements.

1.2.3 ROTATION TERMS

A rotation term may not be the appropriate first term placement for an intern experiencing difficulties because of the likelihood that supervision may be inconsistent. In allocating terms, hospitals should attempt to identify those interns who would benefit from completing terms at the home hospital before being sent to a rotation hospital.

1.3 COMPLETION OF INTERNSHIP

The Board must be satisfied that the internship has been completed satisfactorily before it can consider entitlement for general registration. The Board requires a


Certificate of Hospital Service from the home hospital evidencing successful completion of the period of internship.

Time spent at both the home hospital and the rotation hospitals should be documented, including the disciplines in which the rotations have been served. Details of any aspect of the intern's service deemed to be unsatisfactory should be documented by the home hospital. The home hospital must ensure that it has gathered sufficient information from rotation hospitals to enable proper completion of the Certificate of Hospital Service.

The Board will also consider entitlement to general registration for graduates of AMC accredited medical schools who have satisfactorily completed a recognised internship in another State or territory in Australia or in New Zealand. If such a graduate has completed an internship other than in Australia or New Zealand, the Board may require the applicant to undertake a period of supervised training, prior to general registration being considered.

2. SUPERVISED TRAINING 2.1 AUSTRALIAN MEDICAL COUNCIL CERTIFICATE HOLDERS

Doctors who have passed the Australian Medical Council (AMC) Examinations are required to undertake a period of supervised training. These doctors are entitled to registration with conditions for the period of supervised training.

The purpose of the supervised training is to ensure that the doctor is familiar with local health care delivery systems and attains a level of clinical competence equal to that of graduates of medical schools accredited by the AMC. The period of supervised training is usually 12 months.

Supervised training is generally undertaken in hospitals that meet IMET accreditation standards, but may be undertaken in other settings where appropriate. In such circumstances the Board must be satisfied of the appropriateness of the training program and the level of supervision.

At the commencement of supervised training, the doctor should be supervised in all clinical activities as if an intern, and should not be responsible for the supervision of the clinical activities of other junior doctors.

2.2 PLACEMENT AND TERM ALLOCATIONS

The allocation of AMC graduate doctors to supervised training positions is undertaken by IMET. The Board authorises IMET to allocate AMC graduate doctors using the same criteria as apply to graduates of AMC accredited medical schools undertaking internships.

The same term allocation criteria that apply to graduates of AMC accredited medical schools undertaking internships apply to the AMC graduate doctor. The AMC graduate doctor must satisfactorily complete five terms including a term in medicine, surgery and emergency medicine (known as core terms) and complete terms at rotation hospitals within the allocated hospital network.


2.3 UPGRADING SUPERVISED TRAINING

The home hospital, after having reviewed the AMC graduate doctor's performance, may apply to the Board to place the doctor in a term accredited by IMET as suitable only for doctors having completed an internship.

2.4 COMPLETION OF PERIOD OF SUPERVISED TRAINING The Board must be satisfied that the period of supervised training has been completed satisfactorily before it can consider entitlement for general registration. The Board requires copies of all term reports and a letter of recommendation for General registration from the Director of Prevocational Education and Training (DPET) at the home hospital evidencing successful completion of the period of supervised training.

Time spent at both the home hospital and the rotation hospitals should be documented, including the disciplines in which the rotations have been served. Details of any aspect of the AMC graduate doctor's service deemed to be unsatisfactory should be documented by the home hospital. The home hospital must ensure that it has gathered sufficient information from rotation hospitals to enable proper completion of the certificate of hospital service.

2.5 WAIVER OF THE SUPERVISED TRAINING PERIOD

The Board may consider waiving the supervised training requirement partially or completely if the AMC graduate doctor has had appropriate clinical experience in Australia.

3. PART TIME INTERNSHIP OR SUPERVISED TRAINING

The internship and the period of supervised training can be undertaken on a part-time basis, subject to the following criteria:

- the aggregate number of hours worked is the same as that required of those

completing an internship or period of supervised training on a full-time basis; - the range of work and shifts undertaken provide an equivalent exposure to

varying clinical circumstances and patterns; - the total time taken does not exceed three years; and - there is a full-time component for at least one term of 10 weeks duration

(usually completed at the commencement of the internship or period of supervised training).

4. DEFERRAL OF INTERNSHIP OR SUPERVISED TRAINING

The internship or period of supervised training can be deferred. Anyone contemplating deferral should be aware that they will not necessarily be able to automatically resume their internship or period of supervised training at the point they deferred.

They may be required to attend an interview at the Board to determine eligibility for registration to resume practice, and in determining eligibility for registration the following issues will be considered:


• The period of time elapsed since completion of their degree or AMC examinations; and

• Subsequent study and / or employment.

They may be required to undertake formal assessment, such as the AMC Multiple Choice Question examination before being able to resume their internship or period of supervised training.

5. UNSATISFACTORY PROGRESS 5.1 REGISTRATION FOR INTERNSHIP OR SUPERVISED TRAINING IS LIMITED

Registration to undertake internship or supervised training is granted for defined periods of time. Twelve months is the usual period allocated for preparation for general registration. At the end of twelve months, the majority of interns and AMC graduate doctors will progress to general registration. This is not automatic, but depends on having demonstrated satisfactory performance and progress.

5.2 EXTENSION OF REGISTRATION FOR INTERNSHIP OR SUPERVISED TRAINING

A very small number of doctors are unable to satisfy the home hospital and the Board that they should be granted general registration after the initial 12-month period of internship or supervised training. Doctors may require more than twelve months’ supervised experience to achieve general registration.

There is no automatic entitlement to extension of registration with conditions for internship or supervised training.

The Board will consider additional periods of registration with conditions if the doctor has demonstrated progress and has a suitable job offer in an IMET accredited position. Where extension is granted, it will be for a specified period and will generally be linked to the number of additional terms required.

Terms undertaken on a “supernumerary” basis will not be counted in assessing progress to general registration unless the hospital certifies that the registrant has been required to undertake all the normal duties and workload of an Intern/Supervised Trainee, and has been assessed as satisfactory at the completion of the term.

5.3 WITHDRAWAL OF REGISTRATION

While most doctors are able to satisfactorily complete their internship or supervised training with the completion of additional terms, there cannot be an open-ended approach to the completion of an internship or supervised training, as this would encourage unrealistic expectations in the doctor and create difficulties for employers. Hospitals are encouraged to contact the Board at the earliest opportunity if progress is unsatisfactory, rather than leaving it until the end of the period of internship or supervised training.


The Board will withdraw registration at the conclusion of the extension period unless the required standard for general registration has been met, or a further extension is warranted in accordance with these principles.

6. PATHWAY 1. BASIC TRAINING - 12 months 2. SUPPLEMENTARY I - up to 3 (10 week) terms 3. SUPPLEMENTARY II - up to 2 (10 week) terms

2 YEARS

PROGRESSION TO GENERAL REGISTRATION FOR INTERNS/AMC

Satisfactory – General

Registration

Not satisfactory but progressing and suitable

employment offer

At conclusion of registration period

Not satisfactory, no job offer

Register for further time-limited period

Registration lapses

May apply for further time-limited registration

if offered suitable employment – normal

registration criteria apply.

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