Accreditation Policy

1. Purpose

The purpose of this policy is to outline the principles and requirements for accreditation of Training Sites and Supervisors.

2. Scope

2.1 This policy applies to:

1. 1. all prospective and current Training Sites and Supervisors of:
      1. Core Vocational Training terms for the Australian General Practice Training (AGPT) program, and
      2. the Fellowship Support Program (FSP), and
   2. RACGP Staff.

2.2 For the purposes of this policy, we refer to the AGPT program and FSP as ‘Training Program’.

2.3 This policy should be read in conjunction with the Standards for general practice training (3^rd edition), Accreditation Standards for Training Sites and Supervisors: Guide to implementation, Codes and principles for training sites and supervisors, the AGPT Accreditation application handbook, the FSP Accreditation Handbook for Training Sites and Supervisors and the Placement Policy.

2.4 This policy replaces any previous regional training organisation policies and will come into effect on the start date of the first term of the Training Program in 2023. For the avoidance of doubt, to the extent that there is any inconsistency between the previous policy (or policies) and this policy, the terms of this policy apply. 

3. General principles

3.1 The principles underlying the accreditation of Training Sites and Supervisors are:

1. 1. the process is transparent, accountable, fair, evidence based, responsive and people focussed.

3.2 RACGP systems for accrediting training sites and supervisors:

1. 1. include processes for accreditation of different training environments, including general practices, non-GP Speciality Practices, Special Training Environments, Extended Skills Training sites, Additional Rural Skills Training (ARST) posts and sites requiring remote supervision,
   2. focus on continuous quality improvement of learning environments,
   3. incorporate mechanisms to ensure nationally consistent application of the Standards for general practice training (3^rd edition),
   4. elicit adequate details of the Training Site’s scope for training to allow matching of suitable Registrars,
   5. clarify expectations of Training Sites and Supervisors,
   6. minimise administrative burden,
   7. accredit Training Sites in line with areas of workforce need,
   8. provide robust monitoring of Training Sites and Supervisors throughout the three-yearly accreditation cycle,
   9. incorporate mechanisms for investigating and managing concerns about the performance of Training Sites and Supervisors, and
   10. incorporate opportunities for reconsiderations and appeals.

4. Training Site accreditation requirements

4.1 Training Sites are required to hold current practice accreditation against the Standards for general practices (5^th edition), or against equivalent standards of the medical specialisation relevant to the Training Site. Training Sites must adhere to the Accreditation Standards for Training Sites and Supervisors: guide to implementation.

4.2 Training Sites must be:

1. 1. fully or provisionally accredited for training before an AGPT Registrar can train at the site, or
   2. fully or provisionally accredited for training a FSP Registrar at the site.

4.3 Accreditation requires satisfactory completion of the RACGP accreditation process which includes:

1. 1. providing all documentation requested, and
   2. the RACGP completing a site visit and interview (where required).

4.4 Training Sites must comply with the monitoring and reporting requirements of the accreditation review cycle to maintain accreditation status.

4.5 Training Sites must provide the Registrar with an environment conducive to teaching and learning.

4.6 Training sites must identify and appropriately manage Conflicts of Interest (actual, potential or perceived). In some circumstances, this may require a declaration via the Conflict of Interest form.

1. 1. The RACGP will manage each declaration on a case-by-case basis.

4.7 If the Training Site is unable to fulfill its contractual obligations, the RACGP may:

1. 1. direct the Training Site to undertake remedial activities,
   2. impose conditions on accreditation,
   3. remove the Registrar from the Training site or limit further placements until remedial activities are satisfactorily completed, or
   4. de-accredit the Training Site.

5. Supervisor accreditation requirements

5.1 Supervisors must meet the Accreditation Standards for Training Sites and Supervisors: guide to implementation.

5.2 Supervisors must hold full and unrestricted medical registration with the Australian Health Practitioner Regulation Agency (AHPRA) as a practising specialist medical practitioner and hold appropriate qualifications specific to their Supervisor role.

5.3 Supervisors must be accredited by the RACGP to undertake supervision of the Registrar.

5.4 Supervisors must satisfactorily complete the supervisor accreditation process including:

1. 1. Completing the application process, and
   2. Completing the required components of the supervisor professional development program as per their Supervisor role.

5.5 Supervisors must maintain Supervisor accreditation status by:

1. 1. completing professional development activities relevant to the Supervisor role,
   2. maintaining full and unrestricted AHPRA medical registration, and
   3. complying with all accreditation review processes.

5.6 If the Supervisor fails to perform at the required level, the RACGP may:

1. 1. direct the supervisor to undertake remedial activities,
   2. impose conditions on accreditation,
   3. remove the Registrar from the Supervisor’s supervision or limit further placements until such activities are satisfactorily completed, or
   4. de-accredit the Supervisor.

5.7 Supervisors must identify and appropriately manage Conflicts of Interest. In some circumstances, this may include a declaration via the Conflict of Interest form.

1. 1. The RACGP will manage each declaration on a case-by-case basis.

6. Management of performance concerns

6.1 If a Training Site is unable to fulfil its contractual obligations, or if a supervisor fails to perform at the required level, the RACGP will provide reasonable support to address the issue.

6.2 The RACGP will investigate all issues raised with procedural fairness.

6.3 If the RACGP considers the Training Site or Supervisor should undertake remediation the Regional Accreditation Panel (AGPT Program) or the FSP Accreditation Panel (FSP) will guide the remediation activities.

6.4 Remediation may include conditions being placed on accreditation and the development of an action plan with agreed goals. The Training Site will be advised in writing that failure to meet the agreed goals within the specified timeframes may result in de-accreditation.

6.5 If the remediation is not successful or the Training Site cannot demonstrate progress against agreed goals, the Training Site may be referred to the relevant Accreditation Panel with the recommendation for de-accreditation.

7. Deaccreditation

7.1 Where a recommendation for deaccreditation is made to an Accreditation Panel, the panel will meet and make a determination.

1. 1. 1. If a determination is required prior to the next scheduled meeting, a quorum of the relevant Accreditation Panel will be convened to make a determination out of session.

7.2 Where the RACGP determines the Supervisor should be deaccredited per clause 5.6.iv, the RACGP may deaccredit a supervisor without remediation being offered where immediate action is required in circumstances including but not limited to:

7. 1. 1. conditions are placed on AHPRA medical registration,
      2. lapsed accreditation and non-compliance with a reaccreditation request, or
      3. failure to uphold professionalism requirements.

7.3 A Supervisor or Training Site may volunteer to be deaccredited. Where this occurs, this will be noted at the next relevant Accreditation Panel meeting.

7.4 A decision in relation to deaccreditation will be provided in writing, including reasons for the decision.

8. Reconsideration and appeal

8.1 Training Sites or Supervisors (Applicant) who are not satisfied with decisions related to their accreditation status may apply for reconsideration using the Accreditation decision reconsideration request form.

1. 1. The grounds on which a decision may be reconsidered are:
      1. the original decision was inconsistent with RACGP policies, or
      2. the information provided wasn’t appropriately considered when the original decision was made.
   2. Reconsideration of a decision takes into account all relevant information available at the time of the Original Decision.
      1. The Applicant may submit additional evidence only if this evidence supports the information available to the Original Decision maker at the time of the Original Decision.
      2. The RACGP will consider relevant evidence when reconsidering a decision.
   3. The Applicant must submit an application for reconsideration to the National Accreditation Unit within 10 Business Days of Receiving the Notification of the Original Decision.
   4. Upon receipt of a complete application for reconsideration, an Accreditation Coordinator (Responsible Officer) will notify the Chair of the Accreditation Reconsideration Panel.
   5. The Accreditation Reconsideration Panel may uphold, amend or overturn the Original Decision.
   6. The Accreditation Reconsideration Panel will provide a decision on the matter within 15 business days of the receipt of the complete application, unless the RACGP advises otherwise.

8.2 Training Sites or Supervisors may apply to the RACGP to appeal the outcome of a reconsideration using the Accreditation decision appeal form.

1. 1. An application for appeal must be submitted to the RACGP within 20 Business Days of Receiving the Notification of the reconsideration.
   2. The Appeals Committee:
      1. will be convened by the Appeals Officer, and the Appeals Committee Chair will provide an outcome to the Applicant within 30 Business Days of receiving a complete application for appeal, unless the RACGP advises otherwise,
      2. decides each appeal based on its merits, is subject to the rules of natural justice and procedural fairness, and may inform itself of any matter in such a manner as it thinks fit, and
      3. must give the Applicant the opportunity to make a verbal submission.
   3. Decisions of the Appeals Committee:
      1. may uphold, amend, or overturn the Original Decision,
      2. will be provided to the Applicant within 10 Business Days of the decision being made, and
      3. will be final, and the Applicant is unable to further appeal the outcome.

9. Amendment of this policy

The Censor-in-Chief (CiC) may, without the consent of the RACGP Board, make Minor, Moderate and Consequential Amendments to this policy at any time.

If the CiC makes amendments, they must advise the RACGP Board of those amendments as soon as practicable.

The RACGP Board may make amendments to this policy at any time.

10. Responsibilities

10.1 Censor-in-Chief	Approving Minor Amendments Approving Moderate Amendments Approving Consequential Amendments
10.2 RACGP Board	Approving Major Amendments
10.3 Regional Accreditation Panel	Guiding remediation activities for Training Sites or Supervisors on the AGPT Program  Making deaccreditation decisions for Training Sites and Supervisors in the AGPT program.
10.4 FSP Accreditation Panel	Guiding remediation activities for Training Sites and Supervisors in the FSP. Making deaccreditation decisions for Training Sites and Supervisors in the FSP.
10.5 National Reconsideration Panel	Deciding on the outcome of a Reconsideration application Providing the outcome of the reconsideration to the Applicant within 10 Business Days.
10.6 RACGP	Providing reasonable support to Training Sites and Supervisors where there are performance concerns. Receiving Appeal applications and referring them to the Appeals Officer per the Dispute, Reconsideration and Appeal Policy.
10.7 Supervisors	Ensuring they meet the requirements of accreditation Ensuring they maintain Supervisor accreditation. Applying for reconsideration of a decision with 10 business days of Receiving the Notification of the original accreditation decision Applying for an appeal with 20 Business Days of Receiving the Notification of the outcome of a reconsideration Identifying and appropriately managing Conflicts of Interest.
10.8 Training Sites	Ensuring they meet the requirements of accreditation Ensuring they maintain Training Site accreditation Applying for reconsideration of a decision with 10 Business Days of Receiving the Notification of the original accreditation decision Applying for an appeal with 20 Business Days of Receiving the Notification of the outcome of a reconsideration Identifying and appropriately managing Conflicts of Interest.

11. Glossary

11.1  Additional Rural Skills Training (ARST)	52 calendar weeks (FTE) in an accredited training post that provides the appropriate depth and breadth of experience necessary to meet the requirements of the particular ARST curriculum.
11.2  Applicant	The Training Site or Supervisor applying for a reconsideration under this policy.
11.3 Appeals Officer	The National Team member responsible for coordinating reconsiderations or appeals.
11.4 Business Day	A day when both the RACGP national and relevant regional offices are operating.
11.5 Conflict of Interest	A situation in which it is reasonable to conclude that an individual’s or group of individuals’ personal interests directly conflict with the best interests of the GPiT or where individuals’ actions may be influenced by their personal interests rather than education and training outcomes. A Conflict of Interest includes, but is not limited to, when: close personal friends or family members are involved, an individual or their close friends or family members may make financial gain or gain some other form of advantage, and an individual is bound by prior agreements or allegiances to other individuals or agencies that require them to act in the interests of that person or agency or to take a particular position on an issue.
11.6 Consequential Amendment	An amendment that requires urgent implementation as a necessary result of an amendment to another policy or process.
11.7 Core Vocational Training	General practice term (GPT) 1, GPT2, GPT3 and Extended Skills Training term of the AGPT program.
11.8 Extended Skills Training	A 26-calendar week (FTE) term undertaken to extend the depth and breadth of a Registrar’s skill base in an area relevant to general practice.
11.9 Full-Time Equivalence (FTE)	Where a Registrar undertakes part-time training is the number of hours worked as a proportion of the full-time training.
11.10 Major Amendment	An amendment that materially changes the operation of the policy but is not otherwise a Minor or Moderate Amendment (ie a change to one major clause or policy review).
11.1 Minor Amendment	An amendment to style, to correct grammatical mistakes, change overall formatting, make updates that do not materially change meaning, or any other amendment, which in the opinion of the Censor-in-Chief, does not materially alter the operation of the policy.
11.12 Moderate Amendment	An amendment that materially changes the operation of a policy by a limited amount (ie a change to one minor clause, or changes that have a limited impact on the outcome of the policy).
11.13 National Accreditation Unit	The team responsible for Training Site and Supervisor Accreditation processes.
11.14 National Team	The team overseeing the overall governance and coordination of the training program, that provides high-level educational leadership and resourcing, and supports generic activities to enable efficient and effective training delivery in the regions and local areas with a national consistency.
11.15 Original Decision	A decision that is the subject of a dispute, reconsideration, or appeal.
11.16 RACGP Staff	Anyone who is an employee or contractor of the RACGP.
11.17 Receiving the Notification	The RACGP deems the Applicant to have received a notification on: the date the RACGP sends the email, or the confirmed date of delivery of the registered mail.
11.18 Registrar	A medical practitioner enrolled in the: Australian General Practice Training (AGPT) Program, Remote Vocational Training Scheme (RVTS), or Fellowship Support Program (FSP).
11.19 Speciality Practices	Practices that provide specialist medical care in a defined discipline.
11.20 Special Training Environments (STEs)	A placement offering a training opportunity with a limited case mix and different operational arrangements. Therefore, STEs do not meet accreditation standards for Australian Comprehensive General Practice. Registrars can be placed at an RACGP-approved STE for a maximum of six months.
11.21 Supervisor	An accredited general practitioner who is both a clinician and role model who takes responsibility for the educational and training needs of the Registrar while in the practice.
11.22 Supervisor Role	The Supervisor’s Role varies depending on: the level of supervision they are providing, the requirements of the Training Program, and the scope of the Training Site where they are supervising.
11.23 Training Program	Either the: Australian General Practice Training (AGPT) program, or Fellowship Support Program (FSP).
11.24 Training Site	A health service accredited by the RACGP where the Registrar may undertake their general practice training. For AGPT Registrars, this excludes the mandatory hospital training time.

12. Related documents, legislation and policies

• Accreditation Decision Reconsideration Request form
• Accreditation decision appeal form
• Accreditation Standards for Training Site and Supervisors: Guide to implementation
• AGPT Accreditation Application Handbook
• Codes and principles for training sites and supervisors
• Dispute, Reconsideration and Appeals Policy
• FSP Accreditation Handbook for Training Sites and Supervisors
• Placement Policy
• RACGP Standards for general practice training (3^rd edition)
• RACGP Standards for general practice (5^th edition)
• RACGP accreditation application handbook

Policy review and currency

This policy will be reviewed every three calendar years from the last approval date, or when there is a significant change in the intent of the policy. This policy remains valid and applicable notwithstanding if it is overdue for review.