Some frequently asked questions about Prevocational Medical Education and Training Accreditation
What is Accreditation?
‘Accreditation is a formal process by which a recognised body, usually a non-governmental organisation, assesses and recognises that a health care organisation meets applicable pre-determined and published Standards. Accreditation Standards are usually regarded as optimal and achievable, and are designed to encourage continuous improvement efforts within accredited organisations. An accreditation decision about a specific health care organisation is made following a periodic on-site evaluation by a team of peer Surveyors, typically conducted every two to three years.’
Both a process and a product, Accreditation relies on integrity, thoughtful and principled judgment, rigorous application of requirements, and a context of trust. It provides an assessment of an institution’s effectiveness in the fulfilment of its mission, its compliance with the requirements of its accrediting association, and its continuing efforts to enhance the quality of learning and its programs and services. Based upon reasoned judgment, the process stimulates evaluation and improvement, while providing a means of continuing accountability to constituents and the public. The product of Accreditation is a statement of an institution’s continuing capacity to provide effective programs and services based on agreed-upon requirements.
Why does a Facility need to be Accredited?
A Facility needs to be accredited to:
Assist Interns (PGY1) to achieve full registration as a Medical Officer. Interns cannot be placed in a Facility term where Prevocational Medical Education and Training Accreditation status is not currently achieved and maintained
This Accreditation will
- Ensure support and development of education and training for Interns which enables them to meet high standards of safe practice with respect to patient and practitioner, clinical skills and professional confidence, and become eligible for full registration with the Medical Board of Australia (MBA)
- Ensure that the best possible environment exists to develop, evaluate and maintain the organisational processes that ensure excellence in the training of prevocational doctors
- Provide the community with a process of external validation of prevocational education programs
When is a Facility Accredited?
A Facility is accredited for prevocational medical education and training for Interns when they meet the requirements of the NT Accreditation Standards sufficiently to be awarded a period of Accreditation status by the Medical Board of Australia. The Facility needs to maintain this status throughout the period allocated via periodic assessments conducted by the NTPMC.
How is a Facility Accredited?
The Facility is accredited by applying for Prevocational Medical Education and Training accreditation status to the NTPMC. The application and following assessments must meet the requirements of the NT Accreditation System. The accreditation system is a framework of principles, policies, processes, procedures and standards undertaken and administered by NTPMC. That occurs over time, with the specific aim of establishing a healthcare facility’s ability to adequately and within a quality framework, implements the training of prevocational (Intern) doctors. Further information regarding the NT Accreditation System can be found on the NTPMC website. See the Accreditation Forms on our website for more information.
What is an Accreditation survey?
There are various types of accreditation surveys (events) used within the NT Accreditation Cycle.
The types of accreditation surveys used are:
A Full Survey requires Surveyors to undertake a visit to the Facility under review. Surveyors will be provided with the Facility’s Self Assessment Forms (completed as part of the facilities evidence) prior to the Accreditation Visit. A number of meetings/interviews with Facility staff take place during the Accreditation Visit.
New Unit Survey
This Survey is required when a Facility requests Accreditation of a Unit/Term that has not previously been accredited for Intern Education and Training. A smaller team of Surveyors will review the Units via a Paper Based Survey or Visit according to the New Unit Survey Process.
Modified Unit Survey
This Survey is required when a Unit previously accredited for Interns needs to undergo some modification since its last Accreditation Survey. Examples of modifications which would require review include but are not limited to:
- A link with another Unit which impacts on the type and amount of clinical experience available to the Intern
- Change in supervision (refer Supervision Policy)
- Alteration to rostering and clinical duties
- Change in caseload not seasonal variations in caseload e.g. additional Visiting Medical Officer (VMO) appointed
- Change to number of Interns in the Unit
- A currently accredited Unit now wanting to split into two separate Units
- Relocation of a Unit to another campus of the Facility
This Survey will be undertaken as a Paper Based Survey according to the Modified Unit Process.
A Periodic Survey is undertaken halfway through the Accreditation Cycle of a Facility. This Survey will, in most circumstances, be undertaken as a Paper Based Survey according to thePeriodic Survey Process. A Self Assessment is classed as a Periodic Survey and occurs at least six months before a full survey visit.
What are we being surveyed against?
The Facility is surveyed against the NT Postgraduate Medical Councils endorsed Accreditation framework which includes principles, policies, processes, procedures and standards. The Accreditation Standards are broken into two functions –
2. Intern Education and Training Program
Under these Functions are 14 standards
- Facility Structure
- Personnel overseeing the Intern Education Program
- Intern Education and Training Program (IETP)
- Intern Term evaluation process
- Intern Education and Training Committee
- Structure of the IETP
- IETP Orientation
- Facility Education Program Content
- Facility Education Program Delivery
- Evaluation of the Facility Education Program
- Term Content
- Term Orientation and Handover
- Term Supervision
- Intern (Performance) Assessment
Each of these standards then has their own specific criteria that need addressing to meet the accreditation standard and overarching function.
A five point rating scale (based on that used by the ACHS) is used to determine the level to which the Facility meets the Accreditation Standards. The rating scale can be viewed on the NTPMC website.
Who is responsible in the Facility to oversee that the Accreditation standards are met?
The Facility Delegated Officer. The title of Delegated Officer refers to the Facility staff member who has been given responsibility for overseeing specific Accreditation Standards or all of the Accreditation Standards by the Facility Manager. The Delegated Officer is responsible for ensuring compliance with the Standard/s.
Quite often this responsibility is delegated to the Facility Director of Medical Services.
What do I need to do for an Accreditation survey?
Depending on what your role is in the Facility your participation may range from providing and preparing evidence for submission, updating or reviewing documentation, making time to meet with the accreditation survey team when they visit to discuss the IETP in your facility and/or term.
Who organises the Accreditation survey?
The Medical Education Unit will usually in a Facility organise staff and the submission of documentary evidence in preparation for an accreditation survey. This can be for a paper based survey or a full survey requiring a visit by a survey team.
Who carries out the Accreditation survey?
The NTPMC Accreditation Committee provides a survey team to attend or undertake a paper based survey. A Survey Team is a group of Surveyors (clinical and non-clinical) chosen for their individual expertise to undertake a survey visit or desk top survey of a Facility. The facility is notified prior to an accreditation visit who the survey team members are.
How can I become an Accreditation surveyor?
You can submit an expression of interest to the NTPMC regarding your interest to be trained as a surveyor. A surveyor is an individual trained in all aspects of the Accreditation program who acts on behalf of NTPMC to visit or undertake a desktop survey for a Facility and assess its compliance with the Standards.
Surveyor Training occurs on a needs basis.
Who makes the final decision regarding Accreditation status?
The final judgement regarding a Facilities accreditation status lies with the Medical Board of Australia. The Board is guided by the NTPMC Accreditation Committees Survey teams report findings and recommendations.
How long does Accreditation last?
The maximum Accreditation period awarded to a Facility is four years from the date of the visit
Periods of reduced Accreditation can be awarded by Medical Board of Australia where limited or non-compliance with Standards has been identified.
Can a Facility appeal against the Accreditation Report Recommendations?
Any Facility, individual or department subject to an Accreditation decision may, within 14 days from receipt of written advice of the Accreditation decision, apply to the Chair of the NTPMC for review of the decision by an Appeals Committee for any of the following reasons:
1. An error in due process occurred in the formulation of the earlier decision
2. Relevant and significant information which was available to the Surveyors was not considered in the making of the recommendations
3. The decision of the NTPMC Accreditation Committee was inconsistent with the information put before that Committee.
This process refers to the appeal prior to a NTPMC recommendation being forwarded to the NT Branch of Medical Board of Australia. For more information see ‘Appeal against the Accreditation Committee Recommendation Process’ on the NTPMC website
Where can I go to get more information about Prevocational Medical Education and Training Accreditation?
More information regarding the NTPMC Accreditation Framework can be found on their website