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Application for accreditation as an approved practice setting

Name of service that is applying for accreditation as an approved practice setting:
Vocational scope of practice that the service is applying for accreditation:
Contact person for this application:
Postal address:
Street address:
Phone:
Fax:
Email address:
Date submitted:
We wish to apply for accreditation as an approved practice setting, for the purposes of employing or contracting the services of IMGs and providing supervision to them.If approved by the Medical Council, the accreditation period will be determined by Council and may be for a period of up to
3 years from the date of approval.
Name / Signature
Chief Medical Officer:
Clinical Director or
Head of Department:
By the signing the above, I confirm that I have reviewed all of the information provided in this application, and I confirm that it is correct from both a clinical and an organisational perspective.
Names of doctors registered in a vocational scope working in service:
Name / Area of Medicine / Location / Hours working per week / Reg #
IMGs currently under supervision in the service:
Name / Area of Medicine / Location / Hours working per week / Reg #
Interns currently under supervision in the service:
Name / Area of Medicine / Location / Hours working per week / Reg #
Doctors registered in a general scope of practice in the service:
Name / Area of Medicine / Location / Hours working per week / Reg #

Assessment for accreditation as an Approved Practice Setting (APS)

Instructions for applicants completing an APS application

This document is designed to assist a service to become accredited by the Medical Council of
New Zealand (Council) as an Approved Practice Setting (APS). If a service meets the requirements of an APS, this will satisfy Council that appropriate support and supervision is available and provided to international medical graduates (IMG) to ensure their safe integration into medical practice in
New Zealand, and ongoing assessment.

The assessment checklist is designed for both primary and secondary care. The following three publications are of direct relevance to this checklist and are available at

  • Orientation, induction and supervision for international medical graduates.
  • Continuing professional development and recertification.
  • Good Medical Practice.

This application is a tool for the purposes of gathering information and Council will assess each application in its entirety, rather than on whether individual questions provide a satisfactory or unsatisfactory outcome to the application. There are no absolute correct or incorrect answers to questions in this application. The answers to questions will vary between services.

Completing the application form

Please complete the following application form and submit to Adeline Cumings at . All questions must be completed in full paragraphs and key information from supporting documents need to be integrated into the application. Supportingdocuments should beappendixed clearly in the top right hand corner as to which question numberthey relate to.

Whilst all aspects of this application are of importance when considering accreditation as an APS, increased weighting is given to Section 2: Clinical management of doctors – in particular the framework your service has established for the orientation, induction, credentailling and supervision of IMGs. To assist in preparing your response, Council’s publication Orientation, induction and supervision for international medical graduates will help to identify what is required for supervision of an IMG.

In particular, Council would like to see evidence (such as policy or protocol documents) of the existing or proposed framework for the orientation, induction, credentailling or supervision processes and how you ensure all staff in the service are familiar with them. This helps both the service and the IMG (and all staff) to understand the roles and responsibilities from appointment.

If you have questions about this application please contact Joan Crawford or Adeline Cumingsby calling0800 286 801or email: .
Contents

Please complete once you have finished your application

Section 1 Clinical Governance

1.1 Structures p.?

1.2 Quality and public safety p.?

1.3 Risk Management p.?

1.4 Complaints System p.?

1.5 Identifying and acting on concerns p.?

Section 2 Clinical Management of doctors

2.1 Annual Appraisal process p.?

2.2 Credentialling p.?

2.3 Induction p.?

2.4 Supervision and assessment p.?

Section 3: Adherence to regulatory requirements

3.1 Practising Certificate (PC) p.?

Section 4: List of Appendices p.?

Section 1: Clinical governance

Notes: It is expected that all doctors, both senior and junior, have meaningful, appropriate input to the systems by which health care is delivered and the quality of that health care can be continually improved. There should be a formal system of clinical governance or a quality assurance system that includes clear lines of responsibility and accountability for the overall quality of medical practice.

1.1

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Structures

1.1.1. / Describe the structure that is used for both service and hospital-wide decision making on key clinical issues.
Please provide evidence such as charts demonstrating the organisation structure and the service’s clinical structure, including names of key staff members and lines of responsibility.
1.1.2 / What meetings take placein your service that involves clinical discussion?
Please provide evidence of the following:
  • Specifically mention peer review meetings
  • meetings schedules
  • description of meetingscontent
  • a sample of agendas and minutes
  • evidence of attendance
  • a sample of activities that have been reviewed at the meetings and outcome of discussion
  • opportunities for learning in the meetings.

1.2

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Quality and public safety

Note: if your service iscornerstone accredited or accredited under the EQuIP4 framework, please skip to section 1.4
1.2.1 / Both quality of care and public safety are key priorities for health care organisations and services. Demonstrate how your organisation/service states this concept and ensures that quality and patient safety is a priority.
For example: policy documents.
1.2.2 / Describe how employees of your service are informed and involved in quality and public safety.
Please provide evidence such as:
  • agenda items at meetings
  • orientation and induction policies
  • other policy documents

1.3

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Risk management

Note: if your service is cornerstone accredited or accredited under the EQuIP4 framework, please skip to section 1.4

1.3.1 / Describe the risk framework used by the organisation.
Please provide a policy on risk management or other documentation.
1.3.2 / Describe the incident management system and the tools used in it. Do you undertake a root cause analysis? What methods are used to ensure that learning occurs in the organisation from incidents that happen?
Please provide evidence such as a tool or document demonstrating how incidents are recorded and followed up, with corrective actions undertaken.
1.3.3 / Describe the support systems available for staff who are involved in adverse incidents or near misses. Is there a senior doctor nominated who will provide initial support and advice? Is there any external agency support available?

1.4

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Complaints system

1.4.1 / What methods are in place to ensure that patient complaints are appropriately acted upon and relevant staff informed? How do patients know how to raise a concern or complaint and how that will be dealt with?
Please provide evidence of any policies or protocolson dealing withpatient complaints and/or patient pamphlets.
1.4.2 / How does the organisation/service know that relevant changes have been made as a result of complaints? Are they discussed at management and clinical/staff meetings?
1.4.3 / Is there a policy on 'full disclosure' to patients and how does the organisation/service ensure that staff are aware of the policy and it is conscientiously actioned?
Please provide evidence of policies dealing with ‘full disclosure’ to patients.

1.5

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Identifying and acting on concerns

1.5.1 / What policies and procedures are in place that are aimed at early identification and remediation of concerns over fitness to practise (conduct, competence, or health)?
Please provide evidence of any policies about the mechanisms for doctors and other staff to report concerns regarding fitness to practise of doctors in the practice relating to conduct, competence or health.

Section 2: Clinical management of doctors

2.1

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Annual appraisal process

2.1.1 / Is there a method of giving and receiving performance feedback on an annual basis? Please describe. Does this include an appraisal of the supervision relationship?
Please provide evidence of a doctor’s performance appraisal (anonymised).

2.2

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Credentialling

“Credentialling is a process used by health and disability service providers to assign specific clinical responsibilities to health practitioners on the basis of their education and training, qualifications, experience and fitness to practice within a defined context. This context included the particular service provided, and the facilities and support available within the organisation”
– The Credentialling Framework for New Zealand Health Professionals, Ministry of Health
(refer to this publication for further information)
2.2.1 / Is there a process of credentialling employees on appointment, or a similar process for those entering general practice? Does it include annual review?
Please provide your credentialling framework and an example of a credentailling report (anonymised).

2.3

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Orientation & Induction

2.3.1 / Please provide the framework for orientation and induction processes of your service:
  1. Orientation is an introduction and overview to medical practice in New Zealand (including the NZ health system and cultural competence)
  2. Induction is the familiarisation of systems and processes of the workplace and the individual service of departments.
Framework should reflect what is required in MCNZ’s Orientation topic checklist:

2.4

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Supervision and assessment

Notes: For this section you may wish to provide a policy which covers a number of the following questions. If this is the case, please specify which answers it corresponds to.
2.4.1 / Each IMG is expected to maintain a portfolio that includes:
  • a logbook of procedures undertaken (if appropriate)
  • evidence of clinical audit and peer review activities
  • documentation of educational activities
Please provide evidence that portfolios are reviewed at 3-monthly meetings between the supervisor and the IMG and that any educational needs are identified.
If this is a new system for your service, please provide documentation (such as a policy or protocol document) that demonstrates how this will be implemented, and communicated to staff.
2.4.2 / Describe how records are stored of complaints or incidents that involved the IMG, including any concerns raised by colleagues, and any other information relevant to fitness to practise (conduct, competence, or health).
2.4.3 / Describe and provide evidence of a documented supervision framework.
Council’s publication Orientation, induction and supervision for international medical graduates (page 53) details requirements of framework for supervision. Please include a documented framework for how supervision takes place in your service including protected time for formal supervision meetings and frequency.
If your service covers more than one site, please explain how you ensure appropriate supervision is provided to IMGs when they work at each site, for example the framework needs to describe how many doctors registered in a vocational scope of practice work at each site and how you ensure that all staff are aware of the IMGs who require supervision.
2.4.4 / Describe the process for dealing with supervision reports. Are supervision reports completed every three months for each IMG? Are reports discussed with the IMG? Who reviews all supervision reports? Where are they stored?
Please provide evidence such as a policy or protocol document.
2.4.5 / What is the process for dealing with an IMG’s poor performance? What happens when there is a poor report?If you have identified poor performance, how do you ensure that this does not impact on patient health and safety?
2.4.6 / How many doctors registered within the relevant vocational scope work in your service? Has this number changed over the past year? How do you ensure that they are aware of which doctors require supervision.
2.4.7 / If your service spans more than one site, please describe how clinical staff are allocated to each site. Do they rotate through all sites? How many doctors registered within the relevant vocational scope at each site? How do you ensure the IMG is appropriately supervised at all times?
2.4.8 / As part of Council’s ongoing work to support supervisors of IMGs, Council has been running training workshops for supervisors of IMGs. These workshops offer supervisors with a chance to:
  • learn about different methods for dealing with difficult or poorly performing clinicians and giving feedback
  • gain an understanding of maps and models of supervision and supervision tools
  • learn how to deal with cultural differences and different approaches to practising medicine
It is expected that all vocationally registered doctors working in a service applying to be accredited as an APS will attend training within a period of 2 years of gaining approval.
Have any of your vocationally registered doctors attended one of these workshops, and if so, who? Please also indicate if any vocationally registered doctors are booked to attend, or are planning to attend a training workshop within the next 12 months?
2.4.9 / Please describe the learning resources available, such as internet access to medical web sites, library etc.

Section 3: Adherence to regulatory requirements

3.1

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Practising certificates (PC)

3.1.1 / What processes are in place that enables the organisation to ensure that all medical staff hold a current practising certificate?
3.1.2 / How do you ensure that all medical staff are working within any conditions on their practising certificate?
3.1.3 / How does the organisation/service know that the medical staff are aware of their obligations as described by Good Medical Practice and other Council publications?

List of supporting documents

For example:

Appendix 1- Service Structure Chart

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