P O L I C Y F O R A C C R E D I T A T I O N C L I N I C A L D E P A R T M E N T S F O R T H E

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1 P O L I C Y F O R A C C R E D I T A T I O N OF C L I N I C A L D E P A R T M E N T S F O R T H E D I A G N O S T I C I M A G I N G M E D I C A L P H Y S I C S T R A I N I N G P R O G R A M Author : S Howlett Changed by: M Irvine Reviewed by: DICP Authorized by: PSB Issue date: 1/07/2016 Version No: 2.0 File Location : s:\accreditation, certification and registration\accreditation\dimp dept accreditations

2 Acknowledgements: This policy was adapted from the equivalent ROMP policy (version 5.0) by Mike Irvine. The major contributors to the original document were Anne Perkins, Steve Howlett and John Drew. Accreditation Clinical Departments for DIMP TEAP V2.0 Page 2

3 CONTENTS Contents Introduction Relation to Other Documents Training Objectives and Coverage Granting and Withdrawal of Accreditation Accreditation Categories Accreditation Specialties Accreditation Conditions Withdrawal of Accreditation Renewal of Accreditation Department Accreditation Panel Guidelines to be Considered During Accreditation Evidence of Commitment To TEAP Diagnostic Imaging Services and Equipment Human Resources Physical Resources Educational Activities Applying for Accreditation Accreditation Process Accreditation Site Visits Teleconference Interviews Roles and Responsibilities for Accreditation Chief Physicist DAP PSB Chair Medical Physics Training Coordinator Appeals Accreditation Clinical Departments for DIMP TEAP V2.0 Page 3

4 11 Fees and Charges Glossary Appendix A Support for Diagnostic Radiology Only Accreditation Appendix B Support for Nuclear Medicine Only Accreditation Accreditation Clinical Departments for DIMP TEAP V2.0 Page 4

5 1 INTRODUCTION DIMP TEAP is the Training, Education and Assessment Program in Diagnostic Imaging Medical Physics administered by the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM), through the Professional Standards Board (PSB) and the Diagnostic Imaging Certification Panel (DICP) 1. Trainees are called registrars by the ACPSEM. Completion of TEAP enables a registrar to achieve Certification from the ACPSEM as a Medical Physicist in diagnostic imaging, with specialisation in radiology, nuclear medicine or both. A key component of TEAP is a period of competency based training at an ACPSEM accredited clinical department. The ACPSEM accredits clinical departments to ensure that they are capable of and committed to delivering the required training in the full range of competencies. This document outlines the policy used by the ACPSEM in accrediting clinical departments for DIMP TEAP. For the purposes of this document, the term department is used to denote any hospital, department, centre, service or practice which employs diagnostic imaging medical physicists, including networks of these. 2 RELATION TO OTHER DOCUMENTS This revised policy supersedes the following documents: Accreditation of Clinical Departments for the Diagnostic Imaging Medical Physics Training Program v1.5 (2012) Templates to assist in the management of accreditation applications are included in: Templates for Accreditation of Clinical Departments for the Diagnostic Imaging Medical Physics Training Program (2016) The application form to be used by departments when applying for accreditation or reaccreditation is: Application form for Accreditation of a Clinical Department for the Diagnostic Imaging Medical Physics Training Education and Assessment Program (2016) The DIMP clinical training guide (CTG) is a necessary reference for the development of the departmental training plan and to map out what assistance is required from other DIMP departments to provide the training: Diagnostic Imaging Medical Physics Clinical Training Guide V4.0 (2016) 1 Refer to the ACPSEM policy Training Education and Assessment Program for Medical Physics and Radiopharmaceutical Science for full details of TEAP. Accreditation Clinical Departments for DIMP TEAP V2.0 Page 5

6 3 TRAINING OBJECTIVES AND COVERAGE The purpose of the competency-based clinical training is for registrars to develop the skills, knowledge and attitudes to practice professionally as a DIMP. Registrars must achieve the required competencies specified in the ACPSEM s DIMP Clinical Training Guide (CTG). Competency based training helps registrars to build on the theoretical knowledge gained during their postgraduate degree, and learn how to apply it in practice. The day to day work of DIMPs includes a substantial component of practical hands-on work which cannot be adequately taught outside the hospital. In addition, the practical training period enables registrars to learn the professional aspects of DIMP work, operating as part of the multidisciplinary imaging team. At the conclusion of the clinical training the registrar will be expected to have achieved: The required competencies specified in the ACPSEM DIMP Clinical Training Guide An ability to work under minimal supervision within their specialty area(s) of diagnostic imaging medical physics. An ability to supervise the practice of standard diagnostic imaging medical physics tasks. An ability to establish new work programs. A capacity for judgement, innovation, investigation and creativity. A capacity for interpreting the state of the art to non-specialists, students, professionals in related disciplines, regulatory authorities or administrators. 4 GRANTING AND WITHDRAWAL OF ACCREDITATION 4.1 ACCREDITATION CATEGORIES The ACPSEM issues accreditation to clinical departments in one of three categories: Full accreditation -The clinical training program meets or exceeds the standards for accreditation. Full accreditation extends for period of five years Provisional Accreditation (A) The ACPSEM has identified deficiencies which require correction before full accreditation can be granted. Provisional Accreditation (A) is granted for fixed periods of time after which accreditation may be withdrawn if the deficiencies remain uncorrected. The period for Provisional Accreditation (A) is variable up to a maximum period of two years, at the discretion of the PSB. Provisional Accreditation (B) A new clinical training department at its initial accreditation will receive Provisional Accreditation (B) for a maximum period of two years. Accreditation Clinical Departments for DIMP TEAP V2.0 Page 6

7 4.2 ACCREDITATION SPECIALTIES The ACPSEM issues accreditation to DIMP clinical departments in one of three specialty configurations, depending on access to diagnostic imaging equipment and qualified staff: Diagnostic Radiology and Nuclear Medicine -The department may train registrars in both specialties. Diagnostic Radiology Only The department may only train registrars in diagnostic radiology. Evidence of assistance from other departments to achieve the core nuclear medicine competencies may still be required (see Appendix A). Nuclear Medicine Only The department may only train registrars in nuclear medicine. Evidence of assistance from other departments to achieve the core diagnostic radiology competencies may still be required (see Appendix B). 4.3 ACCREDITATION CONDITIONS The following standard conditions apply to all categories of accreditation: There is an upper limit to the number of registrars which may be employed at the department. The department must supply an annual status report to the ACPSEM. The department must inform the ACPSEM of any significant changes which may affect the department s ability to provide training to TEAP registrars. In addition, for departments with Provisional Accreditation (A) or (B), the PSB may, at its discretion, impose additional conditions. A department may seek to vary the conditions of accreditation by applying to the PSB Chair. Any application to vary conditions of accreditation must explain why the variation is sought and should provide evidence that the proposed variation will not compromise the training of registrars in the department. 4.4 WITHDRAWAL OF ACCREDITATION Failure to comply with any of the conditions of accreditation may lead to withdrawal of accreditation. Accreditation may also be withdrawn by the PSB in the event of serious deficiencies in the delivery of training by a department. Before the PSB withdraws accreditation, the department will be notified that it is at risk of having accreditation withdrawn and given the opportunity to make a submission as to why accreditation should not be withdrawn. 4.5 RENEWAL OF ACCREDITATION At the expiration of a period of full or provisional accreditation, the ACPSEM will arrange for the department to be re-accredited according to the procedures described in Section 8 of this policy and in the related process document. In the case of delays in organizing reaccreditation for a department by the ACPSEM, the current accreditation will continue until re-accreditation can be arranged. Accreditation Clinical Departments for DIMP TEAP V2.0 Page 7

8 5 DEPARTMENT ACCREDITATION PANEL The accreditation and re-accreditation of departments shall be undertaken by a Department Accreditation Panel (DAP), which consists of the following: The Chair of the Diagnostic Imaging Certification Panel (or nominee) The Vice-Chair of the Diagnostic Imaging Certification Panel (or nominee) The ACPSEM Medical Physics Training Coordinator (MPTC) for the DIMP program A nominee from the Radiology Specialty Group, usually from the same state as the department being accredited (if radiology accreditation sought). A nominee from the Nuclear Medicine Specialty Group, usually from the same state as the department being accredited (if nuclear medicine accreditation sought). A chairperson for the panel should be selected from within the DAP. 6 GUIDELINES TO BE CONSIDERED DURING ACCREDITATION The purpose of department accreditation is to assess the ability of a department to provide comprehensive training to registrars, and their commitment to doing so 2. Departments will be required to provide information about their commitment to TEAP, facilities and equipment, human resources, physical resources and educational activities. Items to be considered by the DAP are summarized in Sections 6.1 to 6.5 of this document. While all the items will be taken into account, it is not expected that every department will be able to provide evidence related to every item. It is recognized that there are many possible ways in which departments can facilitate registrar training, and that training is a cooperative effort between departments, the universities, the ACPSEM and the jurisdictions. The DAP will form an overview of the department s overall commitment to TEAP and ability to deliver training. Any relevant additional information which contributes to a department s ability to provide training, outside that specified in Sections will also be taken into account during the departmental accreditation process. In the case of a department seeking re-accreditation, it is expected that the department will be able to supply information based on their current implementation of TEAP. In the case of a department seeking accreditation for the first time, some information will necessarily be in the form of planned action rather than current action. 2 Accreditation is not a direct assessment of the professional competence of the department or its staff. An accredited status does not imply that the department is qualified to provide any particular diagnostic imaging medical physics services, and conversely a provisionally accredited or nonaccredited status does not imply that the diagnostic imaging medical physics services provided by the department are in any way sub-standard. Accreditation Clinical Departments for DIMP TEAP V2.0 Page 8

9 6.1 EVIDENCE OF COMMITMENT TO TEAP Evidence of support for DIMP training from the director of the department, including a commitment to providing the necessary resources for TEAP. A detailed and comprehensive departmental training plan designed to ensure that registrars can achieve all the required elements of TEAP within the expected timeframe. Appointment of designated clinical supervisors responsible for overseeing the training programs of registrars in the department. The clinical supervisors must be qualified DIMPs 3 or be explicitly approved by the Diagnostic Imaging Certification Panel. The designated supervisors must demonstrate an awareness of what is expected of a TEAP supervisor and a commitment to the role. Appointment of designated trainers for competencies and/or modules (where relevant). The designated trainers need not necessarily be qualified DIMPs but must be appropriately qualified in the areas for which they are providing training. They must demonstrate an awareness of the requirements for TEAP training and competency assessment, and a commitment to undertaking them. Where trainers are from non-dimp disciplines, they must have the support of their manager for their role in DIMP training. In cases where the department does not have the equipment or resources to provide training in all competencies, evidence of arrangements with other departments to provide the required training. This should include full details of the number and timing of visits to the other department(s), the training that will be provided and how the competencies will be assessed. The agreement to provide training and/or assessment must be in writing and agreed to by the chief medical physicists of both departments. Regular meetings between registrars, the clinical supervisor and any designated trainers. Evidence that registrar progress is regularly reviewed and documented in accordance with ACPSEM requirements. Established relations with the local clinical preceptor or clinical coordinator (whether locally appointed within the department or state-based), including details of the preceptor/coordinator role at the department, site visit schedule etc. Evidence that the department is committed to giving registrars adequate time to complete TEAP, which may include allocation of protected time. Information about the registrars employment status (supernumerary or permanent) and their expected contribution to clinical workload should be provided. Provision of six monthly registrar progress reports to the ACPSEM. These may be provided by either the designated clinical supervisor(s) or the local coordinator/preceptor. The performance of current and previous registrars, as documented in annual progress reviews, examination results and certifications. 3 For the purposes of departmental accreditation, a qualified medical physicist is a person who holds one or more of the following: ACPSEM Certification in Radiology Medical Physics ACPSEM Certification in Nuclear Medicine Medical Physics On the ACPSEM Register of Qualified Medical Physicists for Radiology and/or Nuclear Medicine Accreditation Clinical Departments for DIMP TEAP V2.0 Page 9

10 6.2 DIAGNOSTIC IMAGING SERVICES AND EQUIPMENT The access to diagnostic radiology and nuclear medicine systems. The range of diagnostic imaging services offered in the department. The range of physics equipment available in the department. Physics work practices. Where a department isn t routinely involved in areas for which CTG competencies exist, the department must show how registrars will achieve those competencies. 6.3 HUMAN RESOURCES The number of clinical medical physics staff in the department, their professional qualifications and experience. The number of qualified staff must be adequate to meet the clinical workload (based on a justifiable workforce model). A department seeking accreditation to train registrars in both specialties must have at least one dual-qualified MP or one qualified MP in each specialty. A department seeking accreditation to train registrars in only one specialty must have a qualified MP in that specialty and an arrangement with a qualified MP of the other specialty to cover the needed areas in the CTG (see Appendices A & B). The ratio of registrars to qualified DIMPs in the department. Full accreditation will normally only be issued if the ratio of qualified staff to registrars is at least 1:1 4. Provisional accreditation may be issued at a slightly lower ratio, subject to the DAP being confident that the department can still meet its training commitments. In calculating this ratio, the ACPSEM will only consider qualified staff in filled positions at the time of accreditation. 6.4 PHYSICAL RESOURCES Access to text books and journals Adequate office space Access to lecture theatres, tutorial rooms, audio-visual facilities, teleconferencing, webconferencing etc. Access to laboratories and workshops Number of campuses, and (if applicable) arrangements for registrar rotation between campuses, including supervision arrangements at each campus. 4 Except in exceptional circumstances where a case can be made based on past good record. Accreditation Clinical Departments for DIMP TEAP V2.0 Page 10

11 6.5 EDUCATIONAL ACTIVITIES Links to universities, including conjoint appointments, joint research projects, supervision of student research projects etc. Whether the department is situated in a teaching hospital, or in a unit with formal links to a teaching hospital. Accreditation of the associated diagnostic imaging department by RANZCR for the training of radiology and/or nuclear medicine registrars. Departmental, educational and professional development activities such as journal clubs, seminars, multi-disciplinary meetings, grand rounds, etc. Commitment from the department for registrars to attend external professional development opportunities such as workshops, seminars, conferences, summer schools and TEAP training days. Commitment from the department for supervisors and trainers to attend external professional development opportunities. This includes attendance at courses, workshops and seminars aimed at developing skills in education and clinical supervision, as well as skills in diagnostic imaging medical physics. Involvement of DIMPs from the department in providing training for others, such as training staff from other disciplines, training registrars from other centres and participating in teaching at TEAP training days, tutorials, workshops or summer schools. Contributions by DIMPs from the department to the development and running of TEAP, such as acting as Examiners or APR Assessors or participating in ACPSEM committees and working groups. 7 APPLYING FOR ACCREDITATION Applications for accreditation or re-accreditation should be completed on the standard form entitled Application form for Accreditation of a Clinical Department for the Diagnostic imaging Medical Physics Training Education and Assessment Program and submitted to the ACPSEM office. 8 ACCREDITATION PROCESS 1. Application for accreditation is received by the ACPSEM. a. For departments with current accreditation, the MPTC advises departments when their current accreditation is due to expire and invites them to submit an application for re-accreditation. b. For departments seeking new accreditation, applications may be submitted at any time 2. On receipt of the application, the MPTC conducts a preliminary review of the application form to ensure that all the required information is present, and requests the department to provide any missing information. 3. The ACPSEM invoices the department for a lodgement fee. Accreditation Clinical Departments for DIMP TEAP V2.0 Page 11

12 4. On receipt of the lodgement fee by the ACPSEM, the MPTC convenes a DAP. 5. The DAP meets (usually via teleconference) to review all documentation submitted as part of the application and decide: a. Whether additional documentation needs to be requested from the department. b. Whether a site visit is required. If so, a person to conduct the site visit should be identified. This is normally a member of the DAP. The DAP should identify who needs to be interviewed and the key issues that need to be resolved should be noted. c. Whether teleconference interviews are required. If so, the person(s) to conduct the interviews should be identified. This is normally a member or members of the DAP. The DAP should identify who needs to be interviewed and the key issues that need to be resolved should be noted. 6. The MPTC liaises with the department to arrange site visits, teleconferences and additional documentation as identified at the previous step. 7. The DAP delegate conducts site visits and/or teleconferences if needed and prepares a report for the DAP. 8. DAP meets (usually via teleconference) to discuss the application, reports from site visit and teleconference interviews, and any additional documentation. If there are issues of concern, the Chairman of the DAP shall attempt, as far as possible, to resolve the issues with the department. When the DAP is satisfied or no further progress is possible proceed to Step DAP makes a recommendation to the PSB Chair: a. To award accreditation or not b. Which specialties are included in the accreditation c. Which category of accreditation should be awarded d. If the accreditation is provisional, any additional accreditation conditions 10. PSB Chair considers the DAP recommendation and makes a final decision. 11. MPTC communicates PSB Chair decision to department, coordinator/preceptor, issues an accreditation certificate and updates ACPSEM records. 8.1 ACCREDITATION SITE VISITS Site visits, to be undertaken by a selected member of DAP, are required for new accreditations. For all re-accreditations, the DAP will decide whether a site visit is required. Site visits are recommended for departments: o o o with provisional accreditation where there have been registrars with unsatisfactory registrar APRs in the period since the last accreditation where there is evidence of a failure to comply with departmental accreditation conditions or of serious deficiencies in TEAP training Accreditation Clinical Departments for DIMP TEAP V2.0 Page 12

13 At the site visit, the DAP representative will have the opportunity to inspect the facilities and have discussions with staff and registrars. The DAP representative will usually meet with: The departmental head of diagnostic imaging medical physics or nominee to discuss: o Any queries related to the accreditation application o Performance of current and previous registrars (if applicable) o Research and educational activities in the department. o Any changes from the previous accreditation (if applicable) o Any changes to the clinical training program expected during the next five years. Clinical supervisors, designated trainers and prospective trainers, to elicit feedback on their experiences of TEAP and to discuss details of the clinical training program. Registrars, to elicit feedback on their experiences of TEAP. The DAP representative will pay particular attention to understanding the opportunities for adequate training across both specialties. The representative will review samples of registrar records and training portfolios (if applicable), and will tour the facilities available to the registrars including office space, laboratories, computing facilities, libraries, technical workshops etc. At the conclusion of the visit the DAP representative shall hold a debriefing discussion with the departmental head of diagnostic imaging medical physics or nominee. The DAP representative will prepare a report on the site visit for the DAP. 8.2 TELECONFERENCE INTERVIEWS The DAP may wish to meet with staff via teleconference to discuss some or all of the topics listed in Section 8.1 instead of or as well as the conducting a site visit. A DAP representative will prepare a report on the teleconference interviews for the DAP. 9 ROLES AND RESPONSIBILITIES FOR ACCREDITATION 9.1 CHIEF PHYSICIST The chief physicist of the department or nominee is responsible for: Submitting applications for accreditation / re-accreditation Liaising with the DAP to arrange site visits (if required) Providing additional information as requested by the DAP (if required) Complying with the conditions of departmental accreditation Applying to the PSB Chair to vary accreditation conditions as required (for example, to increase the number of registrars). Completing Annual Status Reports on request from the ACPSEM Accreditation Clinical Departments for DIMP TEAP V2.0 Page 13

14 Informing the PSB of any significant changes at the department which may affect the ability to provide TEAP training (such as a decrease in the number of qualified staff, or the de-commissioning of major equipment) 9.2 DAP The DAP is responsible for: Reviewing applications for accreditation / re-accreditation Deciding whether a site visit or telephone interviews are required, and if so o Identifying a DAP representative to conduct the site visit / interviews o Identifying who the DAP representative needs to meet with and what are the issues to be discussed o Reviewing the completed site visit / telephone interview report(s) Identifying issues of concern (if any) and through the DAP chairman, forwarding these to the department for comment. The Chairman of the DAP shall attempt, as far as possible, to resolve any issues with the department and to reach agreement. Preparing a recommendation about the accreditation/re-accreditation of the department for the PSB Chair, including the accreditation category and, for provisionally accredited departments, whether there should be any special conditions. Accreditation Clinical Departments for DIMP TEAP V2.0 Page 14

15 9.3 PSB CHAIR The PSB Chair is responsible for: Making a final decision on the accreditation / re-accreditation of the department, taking into account the recommendations of the DAP Issuing letters of accreditation through the ACPSEM office Approving variations to conditions of accreditation, in response to applications from the department. The PSB Chair may take advice from the MPTC and/or the DICP Chair in forming a decision on whether or not to approve variations. 9.4 MEDICAL PHYSICS TRAINING COORDINATOR The MPTC is responsible for: Identifying departments which are due for accreditation/re-accreditation. Convening the DAP when required. Participating on the DAP. Coordinating all administrative aspects of the accreditation/re-accreditation, including arranging meetings and visits, collating documentation and invoicing. 10 APPEALS Appeals against a decision of the PSB in relation to clinical department accreditation may be submitted according to the ACPSEM policy Appeal Process, which is available on the ACPSEM website. 11 FEES AND CHARGES Clinical Department Accreditation fees are set by the ACPSEM each year. There is a lodgement fee for submitting an application for accreditation /re-accreditation, and an annual fee to maintain accredited status. Details of the current fees can be found on the ACPSEM website or by contacting the ACPSEM office. Accreditation Clinical Departments for DIMP TEAP V2.0 Page 15

16 12 GLOSSARY ACPSEM APR CTG DAP DIMP DR FTE MP MPTC NM PSB RANZCR DICP ROMP TEAP Australasian College of Physical Scientists and Engineers in Medicine Annual Progress Review ACPSEM Diagnostic Imaging Medical Physics Clinical Training Guide Departmental Accreditation Panel Diagnostic Imaging Medical Physics (or Physicist) Diagnostic Radiology Full Time Equivalent Medical Physicist Medical Physics Training Coordinator Nuclear Medicine Professional Standards Board Royal Australian and New Zealand College of Radiology Diagnostic Imaging Certification Panel Radiation Oncology Medical Physics (or Physicist) Training, Education and Assessment Program Accreditation Clinical Departments for DIMP TEAP V2.0 Page 16

17 APPENDIX A SUPPORT FOR DIAGNOSTIC RADIOLOGY ONLY ACCREDITATION From examination of the CTG it can be seen that a number of core modules may need support from a NM MP specialist. In some cases, this support will come from the formation of a training network. Otherwise, an agreement for a NM MP from another department or institution to assume responsibility for the needed supervision is required. Documentation of the detail and authorisation of such an agreement is needed for accreditation. Examples of the core modules that might need to be considered are listed below: Module C2:Monitoring Radiation Levels, Including Personnel Monitoring Module C10: Regulatory Controls, ALARA, Radiation Safety Precautions and Other Guidance on the Safe Use of Ionising Radiation in Medical Imaging (Radiology and Nuclear Medicine) Module C11: Radiation shielding considerations in design of new facilities Module NM3.2: Exposure from Sealed and Unsealed Sources and the Risk of Contamination Module NM3.4: Risk Assessment and Advice to Staff, Patients and Others Regarding Radiation Risks in Nuclear Medicine with special attention to Radionuclide Therapy Module NM6.1: Principles of Radionuclide Therapy Module NM6.6: Radiation Safety Precautions for Therapy using Unsealed Radionuclide Sources Module NM9.1: Protocols for Routine Clinical Procedures Module NM9.4: Principles and Physiological Basis for Common Clinical Studies Accreditation Clinical Departments for DIMP TEAP V2.0 Page 17

18 APPENDIX B SUPPORT FOR NUCLEAR MEDICINE ONLY ACCREDITATION From examination of the CTG it can be seen that a number of core modules may need support from a DR MP specialist. In some cases, this support will come from the formation of a training network. Otherwise, an agreement for a DR MP from another department or institution to assume responsibility for the needed supervision is required. Documentation of the detail and authorisation of such an agreement is needed for accreditation. Examples of the core modules that might need to be considered are listed below: Module C11: Radiation shielding considerations in design of new facilities Module DR2.3: Radiation protection and safety review Module DR7.1: Ionising radiation dosimetry and principles of measurement Module DR8.2: Paediatric dosimetry Module DR8.3: Foetal dose estimation Module DR10.1: Radiation risk to the patient in diagnostic radiology Accreditation Clinical Departments for DIMP TEAP V2.0 Page 18