Accreditation Surveyors

COMPOSITION

The composition of an accreditation surveyor team will depend on the size of the Local Health Network and the training program it provides. The accreditation surveyor team will usually comprise four to six members, who may represent the following groups:

• Directors of Clinical Training,

• Senior Clinicians,

• Prevocational doctors,

• Medical Education Officers

• 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 surveyors to:

• Conduct a comprehensive review of the supervision, training and wellbeing support received by prevocational doctor at the health facility under consideration.
• Report in a relevant, timely and accurate manner, enough information for the SA MET Health Advisory Council’s 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 surveyor lead is appointed by the Accreditation Committee on the basis of their accreditation experience and leadership qualities.

Accreditation surveyor leads 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 surveyor team members are individuals who act on behalf of the Accreditation Committee and Advisory Council to visit a health service or unit and assess its compliance against the National Standards.

Accreditation team members will:

• Actively participate in assessment visits, providing analysis of a unit or health service submission, contributing to interviews during assessment visits and contributing to the development of an accreditation report;
• Provide feedback and advice to health services on how to improve the education and training of prevocational doctors;
• Provide advice to the Accreditation Committee and 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 (PDF format) should they arise during the assessment visit;
• 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 lead.

The SA MET Unit may include observers on accreditation assessment visits from time to time who may be undertaking accreditation surveyor training or may be from an unrelated health service who are preparing for an accreditation assessment.

An observer guide has been developed that outlines the roles and responsibilities of an accreditation surveyor observer.

VIEW GUIDE

Information gathered in relation to an accreditation assessment visit must be treated by accreditation surveyor members in confidence.

Accreditation surveyor members, members of the Accreditation Committee and Advisory Council are required to complete and sign a confidentiality agreement prior to undertaking any accreditation functions on behalf of the Advisory Council.

View the confidentiality agreement and conflict of interest declaration.

VIEW GUIDE

Surveyors undertaking accreditation assessment 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 guide for managing patient and / or TMO safety concerns sets out how the accreditation team should manage such concerns.

VIEW GUIDE

An accreditation surveyor 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 surveyor training workshop,
• Membership of the Accreditation Committee, and
• Please register your interest in becoming an accreditation surveyor via email: HealthSAMETAccreditation@sa.gov.au

An accreditation surveyor training program has been developed for new and existing surveyors to equip them with the necessary skills and knowledge to undertake effective accreditation assessment visits.

The training program comprises an online individual training module, complemented by practical group sessions.

• Please register your interest to attend a training session by emailing HealthSAMETAccreditation@sa.gov.au.