Accreditation Policy

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. 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 Accreditation standards for Training Sites and Supervisors: guide to implementation, Codes and principles for training sites and supervisors and the RACGP Accreditation application handbook and the FSP Accreditation Handbook for Training Sites and Supervisors.

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. providing a safe environment for the Registrar and the patient,

    2. providing quality training suitable for the Registrar’s training needs, and

    3. ensuring supervision is matched to the training needs and competence of the Registrar.

3.2 RACGP systems for accrediting training sites and supervisors:

    1. ensure transparent processes,

    2. include processes for accreditation of different training environments, including general practices, Specialty Practices, Special Training Environments, Extended Skills Training posts, Additional Rural Skills Training (ARST) posts and sites requiring remote supervision,

    3. minimise administrative burden,

    4. accredit Training Sites in line with areas of workforce need,

    5. provide robust monitoring of Training Sites and Supervisors throughout the three-yearly accreditation cycle,

    6. elicit adequate details of the Training Site’s scope for training to allow matching of suitable Registrars,

    7. clarify expectations of Training Sites and Supervisors,

    8. focus on continuous quality improvement of learning environments,

    9. incorporate mechanisms to ensure nationally consistent application of the Standards, and

    10. incorporate opportunities for appeals and reconsiderations.

4. Training site accreditation requirements

4.1 The RACGP requires Training Sites to hold current practice accreditation against the RACGP Standards for general practice (5th edition), or against equivalent standards of the medical specialisation relevant to the Training Site.

    1. Training Sites must adhere to the Accreditation Standards for Training Sites and Supervisors: Guide to implementation.

4.2 Training Sites must be:

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

    2. fully or interim accredited for training an FSP Registrar at the site.

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

    1. providing all documentation requested, and

    2. the RACGP completing a site visit and interview.

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 conductive to teaching and learning.

4.6 If the Training Site is unable to fulfil its contractual obligations, the RACGP may:

    1. direct the Training Site to undertake remedial activities,

    2. remove the Registrar from the Training Site until such activities are satisfactorily completed, and/or

    3. de-accredit the Training Site.

5. Supervisor accreditation requirements

5.1 Supervisors must adhere to the Accreditation Standards for Training Sites and Supervisors: Guide to implementation.

5.2 Supervisors must hold full and unrestricted 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 as either:

    1. Primary Supervisor, or

    2. Secondary Supervisor.

5.4 Supervisors must satisfactorily complete the supervisor accreditation process, including:

    1. completing an 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. 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. direct the Supervisor to undertake remedial activities and

    2. remove the Registrar from the Supervisor’s supervision until such activities are satisfactorily completed, and/or

    3. de-accredit the Supervisor.

6. Reconsideration and appeal of accreditation decisions

6.1 Reconsideration of an accreditation decision:

    1. Training Sites and Supervisors (Applicants) who are not satisfied with decisions related to their accreditation status may apply for reconsideration through the following reconsideration and appeals process.

      1. The Applicant may apply to the National Accreditation Unit to have a decision regarding their accreditation (the Original Decision) reconsidered using the Accreditation Decision Reconsideration Request Form.

      2. Reconsideration of a decision takes into account all 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 not consider any other 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 reconsider the Original Decision.

        1. The responsible officer is someone who:

          1. did not make the Original Decision, and

          2. is of at least equivalent seniority to the Original Decision maker.

      5. The responsible officer may uphold, amend or overturn the Original Decision.

      6. The responsible officer will provide a decision on the matter within 40 Business Days of the receipt of the complete application for reconsideration unless the RACGP advises otherwise.

6.2 Appeal to the Appeals Committee:

    1. The Applicant may apply to the RACGP in writing to appeal the outcome of a reconsideration, using the Accreditation decision application for appeal form.

    2. An application for appeal must be submitted to the RACGP within 20 Business Days of Receiving the Notification of the outcome of a reconsideration.

    3. The Appeals Committee:

      1. will be convened by the Appeals Officer and the chair of the Appeals Committee once a complete application is received and will provide an outcome to the Applicant within 30 Business Days unless advised otherwise,

      2. decides each appeal on its merits, is subject to the rules of natural justice and procedural fairness, and may inform itself of any matter and in such a manner as it considers fit, and

      3. may give the Applicant the opportunity to make a verbal submission.

    4. 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.

7.  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.

8. Responsibilities

8.1 Censor-in-Chief
  1. Approving Minor Amendments
  2. Approving Moderate Amendments
  3. Approving Consequential Amendments

8.2 RACGP
  1. Determining satisfactory completion of remedial activities
  2. Administering applications for reconsideration and appeal

8.3 RACGP Board
  1.     Approving Major Amendments

8.4 Supervisors
  1. Ensuring they meet the requirements of accreditation
  2. Applying for reconsideration of a decision with 10 business days of Receiving the Notification of the original accreditation decision
  3. Applying for an appeal with 20 Business Days of Receiving the Notification of the outcome of a reconsideration

8.5 Training Sites
  1. Ensuring they meet the requirements of accreditation
  2. Applying for reconsideration of a decision with 10 Business Days of Receiving the Notification of the original accreditation decision
  3. Applying for an appeal with 20 Business Days of Receiving the Notification of the outcome of a reconsideration

 

9. Glossary

9.1 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.

9.2 Applicant

The Training Site or Supervisor applying for a reconsideration or appeal under this policy.

9.3 Appeals Officer

The National Team member responsible for coordinating reconsiderations and appeals.

9.4 Business Day

A day when both the national and relevant regional office are operating.

9.5 Consequential Amendment

An amendment which requires urgent implementation as a necessary result of an amendment to another policy or process.

9.6 Core Vocational Training

General practice term (GPT) 1, GPT2, GPT3 and Extended Skills Training term of the AGPT program.

9.7 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.

9.8 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).

9.9 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. 

9.10 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).

9.11 National Accreditation Unit

The team responsible for Training Site and Supervisor Accreditation processes.

9.12 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.

9.13 Original Decision

A decision that is the subject of a dispute, reconsideration, or appeal.

9.14 Primary Supervisor

The medical practitioner taking ultimate responsibility for the Registrar and managing the supervision provided to that Registrar by the practice team to ensure safe patient care. A Primary Supervisor provides formal and informal teaching, feedback, and assessment. The Primary Supervisor is the RACGP’s main point of contact with the practice.

9.15 RACGP Staff

Anyone who is an employee or contractor of the RACGP.

9.16  Receiving the Notification

The RACGP deems the Applicant to have received a notification on:

  1. the date the RACGP sends the email, or
  2. the confirmed date of delivery of the registered mail.

9.17 Registrar

A medical practitioner enrolled in the:

  1. Australian General Practice Training (AGPT) Program, 
  2. Remote Vocational Training Scheme (RVTS), or
  3. Fellowship Support Program (FSP).

9.18 Secondary Supervisor

The medical practitioner contributing to supervision and education of the Registrar under the guidance of the Primary Supervisor. A Secondary Supervisor may temporarily take on Primary Supervisor duties and responsibilities when the Primary Supervisor is absent.

9.19 Specialty Practices

Practices that provide specialist medical care in a defined discipline.

9.20 Special Training Environments (STEs)

Placements offering training opportunities with a limited case mix and different operational arrangements. Therefore, STEs do not meet accreditation standards for Australian Comprehensive General Practice. The Registrar can be placed at an RACGP-approved STE for a maximum of six months.

9.21 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.

9.22 Supervisor Role

The Supervisor’s Role varies depending on:

  1. the level of supervision they are providing,
  2. the requirements of the Training Program, and
  3. the scope of the Training Site where they are supervising.

 

9.23  Training Program

Either the:

  1. Australian General Practice Training (AGPT) program, or
  2. Fellowship Support Program (FSP).

9.24 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.


10. Related documents, legislation and policies

10.1  Accreditation standards - Guide to implementation

10.2  Dispute, Reconsideration and Appeals Policy

10.3  RACGP Standards for general practice training (3rd edition)

10.4  RACGP Standards for general practice (5th edition)

10.5  RACGP accreditation application handbook

10.6  Codes and principles for training sites and supervisors

10.7  Accreditation Decision Reconsideration Request Form

10.8 Accreditation decision application for appeal form

11. 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.


Version history

Version

Date of effect

Amended by

2

The start date of the first term of the Training Program in 2023

Education Policy and Guidance Lead

Amendment details
  • Clause 4.2 i-ii has been amended to clarify the scope of accreditation required
  • Definition of Registrar has been updated to include a medical practitioner enrolled in the Fellowship Support Program (FSP)
  • Links have been updated throughout where documents have become avaliable

1

The start date of the first term of the Training Program in 2023

Education Policy and Guidance Lead

Amendment details
  • This policy is required as the RACGP is taking over accreditation of training sites and supervisors
  • It aligns with the accreditation framework and RACGP Accreditation Application Handbook
  •  It replaces all previous RTO Accreditation policies
  • It ensures there is a reconsiderations and appeals mechanism for accreditation decisions

Policy owner:

RACGP Board

Approved by:

RACGP Board

Approved on:

13/12/2022

Next review due:

07/2025

 

 

Advertising

Advertising