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RACGP Standards for general practice training (4th edition)

Standard 5. Governance

Last revised: 10 Apr 2024

Standard 5 | The training program is supported by robust governance

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Governance as it relates to the control and operation of the training program is important to ensure transparency, fairness and accountability in program delivery. It impacts on the ethics, administration, compliance and risk management of the program1 and provides direction to respond to community health and training needs. Good governance promotes effective program delivery, quality improvement and quality assurance.  

The governance structure can vary depending on context but does need to be such that there are appropriate levels of responsibility, capability and decision-making authority to enable planning, implementation and evaluation of the program and to set relevant policy and procedures.  

A training program model that provides strategic direction for program planning and delivery should be aligned to the goals of the organisation delivering the training. The educational guiding principles of the RACGP educational framework provide a statement of the best practice medical education of GPs and are directed by the RACGP operational plan. These guiding principles provide a framework for training models.  

Stakeholders need to be involved to ensure a presence and voice in the governance structure. Involving stakeholder groups improves understanding and engagement of such groups in the program. It improves communication and provides feedback about the effect of decisions on those most impacted. It also provides stakeholder groups with an opportunity to identify issues and express concerns to decision making bodies. Appropriate stakeholders who could be involved in GP training are included under guidance for Outcome 5.2. 

Effective communication occurs when ideas and messages between those involved are understood clearly and lead to better cooperation and collaboration.  This is especially important where multiple stakeholders are involved. This may include communication within and between teams in a program as well as communication between the RACGP and others who deliver training, including other specialist and international colleges.   

The identification and management of risk is an important component of governance. Not only is it important to manage individual risks as they arise, but evaluation of risk profiles affords a means to identify aspects of the program that require improvement. Policies and procedures are part of risk management, for example those that deal with conflicts of interest or critical incidents. 

A program of evaluation needs to be embedded across the whole program. This provides the opportunity for quality improvement of the program at all levels. It also facilitates development of best practice in training delivery.2 Systematic collection and analysis of data is fundamental to evaluation. Effective evaluation enables the program to respond to evolving needs and external demands, and to respond to changing best practice recommendations for both clinical and educational activities. 

Outcome 5.1 The governance structure is effective, transparent and accessible 

Criteria 

5.1.1 There is a documented model of training that provides direction for the program  

5.1.2 The training model is reviewed and updated in relation to evolving needs and best practice  

5.1.3 The governance structure ensures there are mechanisms in place for managing program authority, accountability and responsibility for decision making

Guidance

The training program must provide:

  • A training model that includes a mission statement aligning with sound educational principles and organisational goals
  • A governance structure that ensures there is accountability, authority and decision-making capacity in delivery of the training program. This could include reporting to an overseeing body, for example RACGP delivered training programs that are overseen by the RACGP Board.
  • Evidence of who is responsible for ensuring the program is developed and delivered and how that occurs through appropriate policies and the provision of resourcing and staffing. There must be adequate participation of medical staff including medical educators in key areas and appropriate and sufficient administrative and technological support.
  • A description of how ongoing planning processes and revision ensure that the program remains fit for purpose and aligns with best practice.

Outcome 5.2 Stakeholders are engaged in the development and delivery of the training program 

Criteria 

5.2.1 Stakeholders participate in the planning process  

5.2.2 Stakeholders contribute to the delivery of the training program  

5.2.3 Effective communication occurs to facilitate effective program delivery

Guidance

The involvement of stakeholders in all steps of program design, delivery and evaluation and how constructive working relationships are developed must be defined.  

Stakeholders who may be involved can include (but not limited to): 

  • Registrars and their representative organisations  
  • Supervisors and their representative organisations 
  • Other members of the practice such as practice managers 
  • Aboriginal and Torres Strait Islander peoples and organisations 
  • Rural practitioners and organisations 
  • International Medical Graduates or representatives 
  • Patients and their communities  
  • Workforce agencies  
  • Primary Health Networks (PHNs; or their equivalent) 
  • Other specialist colleges 
  • Health services 
  • Post-graduate medical councils 
  • University medical schools 
  • Local, state, territory and federal governments including relevant regulators 

A clear plan for communication between teams internally and with external stakeholders should also be provided. 

Outcome 5.3 Systems and processes support the training program and the registrar 

Criteria 

5.3.1 The systems and processes used to keep records, deliver training and monitor the progress of the registrar are up-to-date and secure  

5.3.2 There are policies and procedures for the identification, mitigation and management of risks   

5.3.3 The quality management system enhances stakeholder satisfaction and is regularly reviewed 

5.3.4 Reporting requirements are complied with 

Guidance

As a component of adequate resourcing of the program, there must be training data and learning management systems that are up- to-date, secure and fit for purpose. The systems support those who participate in or deliver training, including those working in rural or remote areas and are supported by a suitably qualified team who regularly review the systems to ensure they maintain currency, security and usability.  

Policies and procedures for risk management must be developed and implemented. This includes the use of a risk register and ongoing evaluation to identify systematic issues. 

Reporting requirements may exist in relation to reporting to the RACGP from external bodies delivering training or by the RACGP to other organisations such as the Australian Medical Council or the relevant Commonwealth department. 

Outcome 5.4 A program of evaluation is embedded and informs program improvement. 

Criteria 

5.4.1 There is a formal review and quality improvement process to which stakeholders contribute 

5.4.2 Data is collected and used to improve education program quality  

5.4.3 A culture of feedback is established  

5.4.4 Quality improvements are identified and implemented as a result of the review process  

5.4.5 Outcomes of evaluation are communicated to those involved in the program 

Guidance

A program of evaluation that involves relevant stakeholders must be provided. This applies to all aspects of the training program and includes a consideration of the needs and expectations of stakeholders in the evaluation process and community expectations. 

Data may be collected from a variety of sources including (but not limited to): 

  • Registrar, supervisor, practice and other stakeholder feedback, for example that related to the educational program, training sites or other aspects of the program 
  • Review of processes, for example those related to reconsiderations and appeals, assessment results, conflicts of interest or adverse event and critical incident reporting.   
  • Data related to training for example registrar, practice and supervisor numbers, practice distribution, assessment results, graduate outcomes, etc.  

This data may also be used to target longer term outcomes such as workforce maldistribution and meeting of community need. 

Feedback is an essential component of evaluation and is part of the data that is collected. A culture of feedback is one in which feedback is actively sought and in which individuals are encouraged to provide honest constructive feedback in the knowledge that it will be treated with respect and will be used to promote improvement.3  

The program should demonstrate how a feedback culture has been established. This could include encouraging feedback by providing clear avenues and opportunities for all involved in the program to provide it. It can also be by embedding evaluation and feedback opportunities in all activities and ensuring there are opportunities for confidential feedback to be provided where necessary.   

The training program must also provide evidence of: 

  • how feedback and data is collected 
  • how those providing feedback are informed of its purpose and confidentiality  
  • the use of data to inform and improve the quality of the program  
  • how results of data analysis are shared with stakeholders and how any changes that result are clearly communicated. 
  • Strategic plan  
  • Annual report   
  • Business/Operational plan  
  • Organisational chart  
  • Terms of reference for all stakeholder individuals and groups that have input into governance and decision-making  
  • Examples of interactions with relevant stakeholders  
  • Meeting dates, agendas where stakeholders have been involved in governance  
  • Registrar training records  
  • Communications to stakeholders about the training program 
  • Information Management, Information Technology (IMIT) policies, processes and procedures 
  • Administration and records management policies, processes and procedures   
  • Version control for all materials related to education and training delivery   
  • Risk management frameworks  
  • Evaluation/quality plan   
  • Copies of questionnaires, feedback forms or other evaluation methods  
  • Results of analyses of data  
  • Examples of how data has led to quality improvement  
  • Registrar and supervisor satisfaction surveys 

This information is currently under development and will be made available for each training program ahead of implementation in 2025. 

  1. Governance Institute of Australia. What is governance? 2023. Available at;
  2. Bedoll D, van Zanten M, McKinley D. Global trends in medical education accreditation. Hum Resour Health 2021; 19(70);
  3. Ramani S, Könings KD, Ginsburg S, van der Vleuten CPM. Twelve tips to promote a feedback culture with a growth mind-set: Swinging the feedback pendulum from recipes to relationships. Med Teach 2019; Jun;41(6):625-631. doi: 10.1080/0142159X.2018.1432850.
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