Section A: Local Health Network Details

Insert name of Local Health Network here

Date of submission _ _ / _ _ / _ _ _ _

This form should be returned to the SA MET Unit no later than 60 days prior to the date of the Accreditation Visit. If you need to provide additional information please attach a separate sheet to this submission.

The Chief Executive Officer is ultimately responsible for ensuring health services meet the SA MET Accreditation Standards within the Local Health Network (LHN) and should be informed of the process through appropriate reporting lines.

For Official Use Only (When Completed)-I2-A2

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Section A: Local Health Network Details

Contents

Section A: Local Health Network Details

1.Contact Details

2.Number of accredited posts

3.Provisos and recommendations from previous accreditation visits

4.Chief Executive Officer’s Statement

5.Director of Clinical Training Report

6.Term Supervisor Reports

Section B: Self-Assessment Against Accreditation Standards

Governance and Program Management

Monitoring, Evaluation and Continuous Improvement

Education, Training and Clinical Experience

Supervision

Assessment

TMO Welfare

Section A: Local Health Network Details

1.Contact Details

Local Health Network:

Facilities within Network, including all Secondary Sites:

Local Health Network Accreditation Representative:

Name:
Position:
Contact No:
Email:

Chief Executive Officer of Local Health Network:

Name:
Contact No:
Email:

Director/s of Medical Services:

Name:
Position:
Contact No:
Email: / Name:
Position:
Contact No:
Email: / Name:
Position:
Contact No:
Email:

Director/s of Clinical Training

Name:
Contact No:
Email: / Name:
Contact No:
Email: / Name:
Contact No:
Email:

Chair of Education and Training Program Committee/s:

Name:
Position:
Contact No:
Email: / Name:
Position:
Contact No:
Email: / Name:
Position:
Contact No:
Email:

Medical Education Officer/s:

Name:
Contact No:
Email: / Name:
Contact No:
Email: / Name:
Contact No:
Email:

Please create additional boxes for additional individuals if necessary.

2.Number of accredited posts

Review the below table which outlines the number of interns and PGY2+s within the Local Health Network.Data has beenextracted from SA MET Unit records.

Review and make amendments where necessary and indicate:

new terms to be accredited; and
anyincrease in number of requiredposts within existing accredited terms

Please attach term descriptions for every listed term.

TERM NAME / PRIMARY SITE / CORE / NON-CORE / NO. OF INTERNS / NO. OF PGY2+S / NO. OF ADDITIONAL INTERNS REQUIRED / NO. OF ADDITIONAL PGY2+S REQUIRED

3.Outstanding provisos from previous accreditation visits

Data has been extracted from SA MET Unit records.

Primary Site / Proviso / Recommendation / Actions Undertaken / Closed
( Y / N)
Incl. date

4.Chief Executive Officer’s Statement

The Local Health Network (LHN) Chief Executive Officer (CEO) is responsible for ensuring prevocational medical training is managed effectively and is adequately resourced.

The CEO statement must address:

How prevocational medical teaching and training fits into the strategic plan for the LHN.
How the LHN gives a high priority to education and training.
How the LHN organisational structure supports medical education and training.
The budget and resource allocation for medical education and training.

5.Director of Clinical Training Report

The Director of Clinical Training (DCT) is to provide an overview of prevocational medical education and training at the Local Health Network. This should include:

A summary of the work of the Medical Education Unit and what staff movements have occurred since the last accreditation visit.
The strengths of the medical education and training program (ETP).
Challenges in providing an ETP.
How the ACF is mapped to the ETP.
A summary of TMO evaluations and rate of return.
A summary of the TMO assessment process and rate of return.
An outline of the orientation program evaluation process and changes made as a result.
Whether there are training agreements with secondment sites and how assessment and welfare are managed across sites.

6.Term Supervisor Reports

Provide an overview of each term, outlining the following:

Strengths
Areas of concern
Planned initiatives
Recent changes
Any issues the unitfeels could be improved by accreditation.
DCT comment

Term Name / Term Overview
Term Name
Term Name
Term Name
Term Name
Term Name
Term Name

For Official Use Only (When Completed)-I2-A2

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Section B: Self-Assessment AgainstAccreditation Standards

Section B: Self-Assessment Against Accreditation Standards

Assess if the facility has met, partially met or not met the Accreditation Standards.

Rating Scale
Met / There is good evidence to show compliance with the Accreditation Standards. There is evidence that systems and processes to support trainee medical officer (TMO) education and training are integrated and observed uniformly across the LHN.
Partially Met / There is evidence of systems and processes in place to support TMO education and training, but they are either not yet fully integrated or not observed uniformly across the LHN.
Not Met / There is little evidence of systems and processes in place to support TMO education and training.

Governance and Program Management

Executive Accountability

Standard 1.1 - Facilities have an organisational structure, ultimately accountable to the Local Health Network Chief Executive Officer.

a)Assess if the LHNhas:

Met;
Partially Met; or
Not Met the criteria of Standard 1.1

Information should be provided in the comments box on areas partially met or not met in meeting criteria and plans for improvement. Where possible, attachments should be provided to demonstrate plans in place to meet these criteria.

Met / Partially Met / Not Met
Criterion 1.1.1: Facilities have a strategic plan for TMO education and training, endorsed by the LHN CEO. The LHN CEO is responsible for providing adequate resources to meet this plan.
Criterion 1.1.2: Facilities are funded as teaching and training organisations, and therefore give high priority to medical education and training.
Criterion 1.1.3: An organisational structure is in place to support TMO education and training, including a delegated manager with executive accountability for meeting postgraduate education and training standards, for example a DMS.
Criterion 1.1.4: Facilities have patient safety policies to ensure TMOs work within their scope of practice. TMOs are made aware of these policies.
Criterion 1.1.5: Facilities provide clear and easily accessible information about the education and training program to TMOs.
Criterion 1.1.6: Facilities allocate TMOs within the program through a transparent, rigorous and fair process which is based on published criteria and the principles of the program.
Comments
(for example) 1.1.5 The LHN intranet is currently being upgraded and until that is complete the education and training program information is emailed to each TMO.

b)Provide the following as attachments:

Document / Provided (Y/N)
Education and Training Strategic plan
Organisational Structure chart

c)Does the LHN have the following policies/strategic documents in place?

Document / Yes / No
Education and Training Strategic plan
Organisational Structure chart
Patient safety policies, which include TMO scope of practice
Guideline / process for the allocation of TMOs to terms

d)Outline how the LHN monitors whether TMOs are undertaking duties beyond their scope of practice and working beyond their competence. Provide a practical example of resolving such an issue, if available.

Resources

Standard 1.2 - Facilities provide appropriate financial, physical and staffing resources to support and promote high-quality education and training.

a)Assess if the LHNhas:

Met;
Partially Met; or
Not Met the criteria of Standard 1.2

Met / Partially Met / Not Met
Criterion 1.2.1: Facilities provide the physical, ICT, library and educational resources necessary for supporting TMO education and training.
Criterion 1.2.2: Facilities provide dedicated office space for a Medical Education Unit (MEU) or equivalent.
Criterion 1.2.3: Appropriate full time equivalent levels of qualified staff, including a DCT, MEO and administrative staff, are employed to manage, organise and support education and training. This is underpinned by regular appraisal of the unit and its personnel by the facility.
Criterion 1.2.4: Facilities have a dedicated budget to support and develop TMO education and training.
Criterion 1.2.5: TMOs are provided with a safe, secure and comfortable area away from clinical work spaces.
Comments
(for example) It is not possible to have private conversations with TMOs in the MEU office. The DMS is investigating what other available space there is in the hospital.

b)Outline the physical, ICT, library and educational resources provided for supporting TMO education and training.

Education and Training Program Committee

Standard 1.3 - The Education and Training Program Committee is the body that oversees the work of the Medical Education Unit.

a)Assess if the LHNhas:

Met;
Partially Met; or
Not Met the criteria of Standard 1.3

Information should be provided in the comments box on areas partially met or not met in meeting criteria and plans for improvement. Where possible, attachments should be provided to demonstrate plans in place to meet these criteria.

Met / Partially Met / Not Met
Criterion 1.3.1: Facilities have an ETP Committee which is adequately resourced, empowered and supported to advocate for TMO education and training.
Criterion 1.3.2: The ETP Committee oversees and evaluates all aspects of TMO education and training and is responsible for determining and monitoring changes to education and training.
Criterion 1.3.3: The ETP Committee has Terms of Reference that outline its functions, reporting lines, powers and membership, which includes TMOs.
Criterion 1.3.4: ETP Committee outcomes are regularly communicated to TMOs.
Criterion 1.3.5: Facilities report changes to the program, units or terms, that may affect the delivery of the program, to SA MET in line with the Process for Accrediting a Change of Circumstance.
Comments
(for example) 1.3.3 The Terms of Reference for the ETP Committee are currently under review to better reflect the function and membership.

b)Provide the following as attachments:

Document / Provided (Y/N)
ETP Committee terms of reference
ETP Committee annual report for the last two years

Monitoring, Evaluation and Continuous Improvement

Standard 2.1 - Facilities monitor and evaluate TMO education and training and base a program of continuous improvement on the data gained from this.

a)Assess if the LHNhas:

Met;
Partially Met; or
Not Met the criteria of Standard 2.1

Met / Partially Met / Not Met
Criterion 2.1.1: Facilities have processes to monitor and evaluate the quality of TMO education and training.
Criterion 2.1.2: TMOs have the opportunity and are encouraged to provide feedback in confidence on all aspects of their education and training.
Criterion 2.1.3: Facilities use TMO evaluations of orientation, education sessions, supervision, terms and assessments to develop the education and training program.
Criterion 2.1.4: Mechanisms are in place to access feedback from supervisors to inform program monitoring and continuous improvement.
Criterion 2.1.5: Facilities act on feedback and modify the education and training program as necessary to improve the TMO experience, using innovative approaches as appropriate.
Criterion 2.1.6: Facilities form constructive working relationships with other agencies and facilities to support education and training.
Comments
(for example) 2.1.3 TMOs have the opportunity to provide feedback on their rotations but do not often take up the opportunity. The MEU is investigating ways of improving the response rate in order that feedback can be used to improve education and training.

b)Provide an outline of the monitoring and evaluation processes undertaken by the LHN. This overview is to include details of processes implemented to gain feedback from TMOs and supervisors, and how this feedback is used to monitor and improve the education and training program, and overall experience for TMOs(max 500 words).

c)Provide an example of how an issue or area for improvement was identified through the LHN’s monitoring processes andthe resolution. This is to include what the issue was, how it was identified, the steps taken to resolve the issue, and the final outcome. NB: No information that could identify individuals should be provided.

d)Provide details of any working relationships developed with other facilities or agencies to support TMO education and training.

e)Provide the following as attachments:

Document / Provided (Y/N)
Reports on TMO evaluation of the formal education and training program
Reports on TMO evaluations of terms
Reports developed from supervisor feedback

Education, Training and Clinical Experience

Education and Training

Standard 3.1 - Facilities provide a structured education and training program mapped to the Australian Curriculum Framework for Junior Doctors (ACF).

a)Assess if the LHNhas:

Met;
Partially Met; or
Not Met the criteria of Standard 3.1

Met / Partially Met / Not Met
Criterion 3.1.1: All TMOs can access the education and training program provided and supplementary training activities offered on all terms.
Criterion 3.1.2: Formal education and training program sessions are designated protected time.
Criterion 3.1.3: The education and training program offered is mapped to the ACF and covers topics relevant to TMO training.
Criterion 3.1.4: The education and training program is structured to reflect the requirements of the registration standard for granting general registration as a medical practitioner to Australian and New Zealand medical graduates on completion of intern training.
Criterion 3.1.5: Facilities provide guidance to TMOs to inform career choices and how to access these careers.
Criterion 3.1.6: TMOs are encouraged to participate in hospital wide educational opportunities, for example Grand Rounds.
Comments
(for example) 3.1.3 Mapping the ACF to the ETP is in progress – a draft is attached.

Clinical Experience

Standard 3.2 - TMOs have appropriate opportunities for experiential learning.

a)Assess if the LHNhas:

Met;
Partially Met; or
Not Met the criteria of Standard 3.2

Met / Partially Met / Not Met
Criterion 3.2.1:Facilities provide TMOs with a program of terms that enables the attainment of ACF competencies, including relevant skills and procedures. Intern terms should reflect the requirements of the registration standard for granting general registration as a medical practitioner to Australian and New Zealand medical graduates on completion of intern training.
Criterion 3.2.2: Facilities ensure TMOs are able to participate in learning opportunities appropriate to each term, including practical experience in each specialty undertaken with the opportunity to improve their practical skills. This includes exposure to theatre time during surgical terms. Intern terms should take into account the Australian Medical Council Guidelines for intern terms.
Criterion 3.2.3: In identifying terms for training, facilities consider the following:
• complexity and volume of the unit's workload
• the TMO’s workload
• the experience TMOs can expect to gain
• how the TMO will be supervised, and who will supervise them.
Criterion 3.2.4:All clinical settings for TMOs are able to demonstrate the education and learning opportunities available.
Criterion 3.2.5:TMOs have access to the tools and opportunities for an appropriate handover at the start and end of each shift, during shifts if required, and at the start of each term.
Criterion 3.2.6: Facilities provide information to TMOs regarding the experiences available on all terms, including those at secondary sites.
Criterion 3.2.7: All terms have an approved term description that has been developed by the term supervisor with input from TMOs who have undertaken the term. Term descriptions are monitored and updated regularly to ensure tchey reflect the current practice and experience available on each term.
Criterion 3.2.8: Facilities provide a comprehensive orientation to the facility at the beginning of their employment with that facility.
Criterion 3.2.9: TMOs receive an orientation to all secondary training sites that they rotate through.
Criterion 3.2.10: TMOs complete a Basic Life Support course as part of the facility orientation program, and every two years thereafter.
Criterion 3.2.11: All TMOs receive an appropriate orientation to each term.
Comments
(for example) Based on TMO term evaluations, there are two units which are working on improvingtheir TMO term orientation. The MEU has been working closely with the term supervisors to improve the term orientation, attached are the revised orientation handbooks and programs for the two terms.

b)Outline the guidance provided to TMOs regarding career choices.

c)Provide the following attachments

Document / Provided (Y/N)
Sample intern facility education program at each facility
Sample PGY2+ facility education program at each facility
Most recent intern facility orientation program at each facility
Most recent PGY2+ facility orientation program at each facility
Intern and PGY2+ rosters for the calendar year at each facility
TMO attendance rates at formal weekly teaching sessions for the past 12 months at each facility
Handover protocols/policies at each facility

Supervision

Standard 4.1 - Appropriate clinical supervision is provided to TMOs during all periods of duty.

a)Assess if the LHNhas:

Met;
Partially Met; or
Not Met the criteria of Standard 4.1