An accreditation team member guide has been developed for accreditation team leaders and members providing a clear outline of their role along with necessary information and tools to conduct a comprehensive accreditation review.
The composition of an accreditation visit team will depend on the size of the Local Health Network (LHNs), and the training program it provides. The accreditation visit team will usually comprise three to six visitors, who may represent the following groups: Directors of Clinical Training (DCTs), Clinicians, Trainee Medical Officers (TMOs), Medical Education Officers (MEOs) or Medical administrators. Special expertise may be sought if particular issues have been identified prior to the accreditation visit.
It is the responsibility of the accreditation team to:
- Conduct a comprehensive review of the supervision, training and support received by TMOs at the LHN under consideration.
- Report in a relevant, timely and accurate manner, enough information for the Accreditation Committee to make a well informed recommendation on the accreditation status of the facility.
- Act in a courteous, professional and non-judgemental manner as a representative of the SA MET Health Advisory Council (the Advisory Council).
The accreditation team leader is appointed by the Accreditation Committee on the basis of their accreditation experience and leadership qualities. Accreditation team leaders are responsible for:
- Leadership and direction of each accreditation visit, the finalisation of each report and the assessment of team members; and
- Offering advice to the Accreditation Committee and if required, an Internal Review Committee regarding the accreditation status of a facility, unit or department.
Accreditation team members are individuals who act on behalf of the Advisory Council to visit a LHN or unit and assess its compliance with the Accreditation Standards. Accreditation team members will:
- Actively participate in visits, providing analysis of a unit or LHN’s submission, contributing to meetings while on a site visit, and contributing to the production of a visit report;
- Provide feedback and advice to LHNs on how to improve the education and training of TMOs;
- Provide advice to the Advisory Council on broader issues which might emerge from the visit and which are relevant to the education and training of TMOs;
- Declare any actual or potential conflict of interest in accordance with the accreditation conflict of interest policy and procedure;
- Notify the SA MET Unit of any real, potential or perceived conflicts of interest between themselves and the unit, facility or network being accredited; and
- Have their performance assessed by an approved accreditation team leader.
The SA MET Unit may include observers on accreditation visits from time to time who may be undertaking accreditation team training or may be from an unrelated LHN preparing for an accreditation visit.
An observer guide has been developed that outlines the roles and responsibilities of an accreditation team observer.
Information gathered in relation to an accreditation visit must be treated by accreditation team members in confidence. Accreditation team members and members of the Accreditation Committee are required to complete and sign a confidentiality agreement prior to undertaking any accreditation functions on behalf of the Advisory Council.
Visitors undertaking accreditation visits on behalf of the SA MET Health Advisory Council may, in their investigations, encounter issues which pose risks to patient and/or TMO safety. The process for managing patient / TMO safety concerns document sets out how the accreditation team should manage such concerns.
An accreditation team member may be recruited in one of the following ways:
- Nomination by their professional body or organisation,
- Invitation from the SA MET Unit,
- Attendance at the accreditation team training program,
- Membership of the Accreditation Committee, and
- Registration of interest made via email to HealthSAMETAccreditation@sa.gov.au
An accreditation team member training program has been developed for new and existing team members to equip them with the necessary skills and knowledge to undertake effective accreditation visits. The training program comprises an online individual training module, complemented by practical group sessions.