Why do we accredit training sites?

RANZCOG is accredited by the Australian Medical Council (AMC) and the Medical Council of New Zealand (MCNZ) to deliver education and training programs to doctors throughout Australia and Aotearoa New Zealand in the specialty of obstetrics and gynaecology. Under the AMC standards, the College must in turn have clear processes and criteria to assess, accredit and monitor training sites.

Accreditation activities allow the College to get a view of training exposure and opportunities available at an accredited site, as well as a sense of the working environment and culture. This ensures that the key requirements for clinical and education experience are being met. A/Prof Deryck Charters, the College’s Specialist Advisor: Accreditation, suggests that ‘accreditation also has an important role in ensuring that the consumer can be confident that trainees are getting the training and experience necessary to best service the communities in which they work’.

Accreditation also performs a vital function as a support mechanism for training sites across Australia and Aotearoa New Zealand. By ensuring training sites are driven to meet the accreditation standards, opportunities arise for the College to support O&G units in raising concerns with their hospital executive, in areas including availability of theatre lists, staffing needs, engagement with multidisciplinary teams, and workplace culture, thus providing a platform to improve training and advocate for improved services simultaneously.

Accreditation standards and processes

Accreditation standards provide an agreed-upon template to ensure there are overarching rules and guidelines that are applicable to all sites, while taking into account differences in size, patient acuity, and available education and training experiences. For example, the FRANZCOG Training Program considers the following standards necessary for the provision of effective training and support for trainees in the program:

• Support for RANZCOG Officers and engagement with hospital accreditation processes.
• Appointment and support of Training Supervisors.
• Consultant involvement with and support for FRANZCOG trainees.
• Provision of clinical supervision and experience.
• Provision of structured education programs, teaching sessions and learning opportunities.
• Workplace culture, registrar staffing, safe working hours, leave arrangements and assistance for rural rotations.

Each subspecialty program requires that an accredited unit (which can be made up of several sites in different locations) is able to provide training consistent with the expectations outlined in the handbook for each individual program. Development of a revised set of subspecialty accreditation standards is planned in 2022.

FRANZCOG accreditation is based around a site visit, with follow-up progress reports and further visits as required. Oversight of FRANZCOG accreditation activities is the responsibility of the College’s Accreditation Steering Group (ASG), with matters arising handled by the Chair of the Training Accreditation Committee and the Specialist Advisor: Accreditation. Reaccreditation of subspecialty training units utilises a hybrid paper-based and accreditation visit model to ensure ongoing monitoring across each program, and is carried out in conjunction with the Accreditation Advisors appointed by each Subspecialty Committee.

Each accreditation visit is conducted by an Accreditation Panel, usually comprising:

• A RANZCOG Fellow/subspecialist as the Panel Chair, plus an additional Fellow/subspecialist as required.
• A trainee representative (FRANZCOG site visits).
• One or more senior members of RANZCOG staff, responsible for the administration of the accreditation process.

In order to determine an outcome and appropriate period of accreditation, confidential interviews with all available trainees, Fellows, Training Supervisors, consultants, Heads of Service, and any other relevant health professionals are carried out. This supplements situational analysis information gathered prior to the reaccreditation visit in the form of a hospital questionnaire, anonymous surveys (for current/recent trainees, Training Supervisors, and consultants), information from the State/Territory/New Zealand Training Accreditation Committee or subspecialty committee, and procedure number data. Accreditation therefore acts as a snapshot of a site at the time of a reaccreditation visit.

Key focus: bullying, harassment and discrimination

The results of AHPRA’s 2021 Medical Training Survey (and those from previous years) highlight how critical the role of accreditation is in addressing the prevalence of bullying, harassment, and discrimination (BHD). Dr Hashim Adbeen (Chair, AMA council of doctors in training) recognises college accreditation of training sites as ‘ultimately a patient safety issue’ and advocates for strengthening accreditation standards.¹ Following an independent, confidential, and anonymous survey of all members and trainees conducted in the second half of 2021, the College’s BHD Advisory Working Group delivered a report to the RANZCOG Board in February 2022 with 24 recommendations. Of these, Recommendations 11 and 12 are specific to the accreditation process while Recommendation 20 centred around additional provisions in the accreditation standards with regards to complaint handling.²(Figure 1)

Figure 1. Excerpt from Bullying, Harassment and Discrimination Advisory Working Group Report to the RANZCOG Board ‘From Advocacy to Action’.²

Accreditation is recognised within the report as one of the most powerful ‘hard levers’ available, and represents an action that the College can take directly to respond to unprofessional behaviours in O&G. Actions and activities addressing these recommendations will form core tasks for the ASG and others involved in accreditation improvements throughout 2022.

Accreditation interventions: how accreditation can address issues arising

The normal processes and mechanisms used for accreditation (such as hospital questionnaires, trainee surveys, site visits reports necessarily identify and address training site issues at the time these processes are used. However, at other times, the accreditation team may be alerted to potential issues in a range of other ways; for example, formal complaints, trainee feedback via six-monthly assessment surveys, the Training Support Unit or regional offices, Fellow feedback through committees or direct conversations with the President. Recognising the need for support mechanisms outside of a standard accreditation cycle, the Accreditation Interventions Framework was developed and introduced in 2020 to more immediately support both trainees and training sites in addressing specific or urgent issues as they arise.

Where an accreditation visit is not already scheduled, the Interventions Framework provides a number of options in order to address the area(s) of concern, from a simple letter to the training site requesting a response to the stated issue(s), to a Situational Analysis Report comprising the information requested prior to conducting an accreditation visit. An actual visit may then be required after reviewing responses.

This framework allows for an array of training-related issues to be addressed promptly rather than being left to fester for the remainder of an accreditation cycle, and has been used to great effect alongside standard accreditation processes as a driver for positive change and increased support.

Gynaecological surgical training: putting the ‘G’ back in O&G

There is an imbalance in access to gynaecological surgical training, depending on training site and location, affecting both FRANZCOG and subspecialty trainees. The effects of the COVID-19 pandemic, with lockdowns, elective surgery cancelled in some jurisdictions, and ongoing strain on hospital staff dealing with the Omicron variant, have exacerbated the existing issue of how trainees can receive adequate gynaecological surgical training and meet their training requirements.

A significant amount of work has been undertaken in the accreditation space over the last two years to address this issue. Guidelines for gynaecological surgical training have been developed, which re-emphasise the number of opportunities that must be offered by different types of training hospital, together with accreditation mechanisms to address underperforming sites. Perhaps more important is the accompanying document Strategies for Training Hospitals to Improve Trainee Gynaecological Surgery Procedure Numbers, supporting O&G units to achieve better outcomes for trainees.

Accreditation and COVID-19

Accreditation was not unaffected by COVID-19, with the pandemic necessitating the development and implementation of virtual reaccreditation visits. The use of Zoom and other videoconferencing technology has allowed reaccreditation visits to continue, with 31 virtual visits conducted since July 2020. While some aspects of a virtual reaccreditation visit differ from their physical counterpart by necessity (the opportunity to conduct interviews in person, tour training sites, and share a meal with colleagues remain sorely missed), robust information gathering and clear standards ensure the continued integrity of the process.

How can you help?

The accreditation process is made possible by the Fellows and trainee representatives who volunteer their time to contribute to training. Not only do they attend visits and conduct interviews, but they also review and contribute to reaccreditation and progress reports and share their wealth of medical education and training knowledge throughout Australia and Aotearoa New Zealand. Panel members report finding the experience valuable as an opportunity for reflection and providing insight into best practice across other training sites. Fellows have the ability to claim CPD points under the Educational Activities (EA) domain for any RANZCOG Accreditation Visit where they form part of the Accreditation Panel.

For further information about accreditation, or to be included in the mailing list for future visits, please email [email protected].

1. John W. Bullying in medicine: the biggest losers. AU: Medical Republic; 2022. Available from: medicalrepublic.com.au/bullying-in-medicine-the-biggest-losers/62475
2. RANZCOG BHD Advisory Working Group. Report to the RANZCOG Board: From Advocacy to Action. Melbourne, VIC: RANZCOG; 2022. Available from: https://ranzcog.edu.au/news/fostering-respect/