Accreditation Proviso Reporting
Process
Canberra Region Medical Education Council
(CRMEC)
Purpose
To define accreditation provisos and recommendations and outline the required followup and sign off process.
1. Accreditation Provisos
Accreditation is awarded for a period of time, subject to the resolution of provisos. A proviso is a
conditional stipulation which must be met within a specified period of time in order for accreditation to be
maintained. Provisos are based on evidence gathered and indicate areas where the Accreditation
Standards are not being met. Provisos are listed in the final accreditation report and units/facilities are
required to report on the progress of their implementation to the Canberra Region Medical Education
Council (CRMEC) within a stipulated timeframe. The CRMEC is required to report to the Australian
Capital Territory Board of the Medical Board of Australia for the accreditation of intern posts.
2. Accreditation Recommendations
Accreditation recommendations refer to areas where training in a facility or unit could be improved, but
action is not required to achieve accreditation for this cycle. Recommendations have no mandatory
reporting requirement prior to the next facility accreditation.
3. Developing an Action Plan
The facility will be required to complete an action plan outlining how provisos and recommendations will
be met within the agreed timeframes. This action plan will provide details of how the unit / facility plans to
meet the provisos and recommendations, timelines for resolution, staff members responsible for each
action point, and the risk of timelines not being met. The RAG (red, amber, green) risk indicator is
intended for facilities to use to determine the risk of a proviso not being met within the specified
timescale. The CRMEC Secretariat (“the Secretariat”) will provide a template action plan to be completed
by the unit / facility.
4. Reporting on Progress
The facility is required to report to the CRMEC Accreditation Committee regarding their progress in
meeting provisos and are encouraged to report on their progress regarding recommendations.
The facility is expected to outline planned and completed actions within the action plan, detailing how the
provisos are being resolved. It is anticipated that when a facility reports how it has resolved a proviso
with a short timescale, progress against those with longer timescales will also be reported. The action
plan should be kept up to date for all provisos. The document is also intended to be an aid for facilities
and units to keep up to date with their progress towards recommendations.
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Accreditation Proviso Reporting
Process
Canberra Region Medical Education Council
(CRMEC)
5. Reporting Timeframes
Each proviso and recommendation in the accreditation report will have a reporting timeline. Unless
otherwise stated, the timeline commences when the final report is issued to the facility. Deadlines for
reporting on provisos and recommendations may be a specified number of months, for example after six
months, or may fall in line with the training year terms or a full accreditation cycle.
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Accreditation Proviso Reporting
Process
Canberra Region Medical Education Council
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6. Proviso Follow-up Process
Once the report has been signed off by Council, it will be sent to the unit / facility with the action
plan. The action plan will include timelines for resolution of the provisos.
The Secretariat will contact the unit / facility to discuss support opportunities to assist the unit /
facility to meet the timelines in the action plan.
Reports are produced by units / facilities and sent to the Secretariat to show progress against the
provisos and recommendations in line with timelines agreed in the action plan.
These reports will be reviewed for satisfactory compliance with provisos by the Accreditation
Committee.
Satisfied
Not Satisfied
Provisos and/or recommendations will
be signed off as complete.
This outcome will be communicated
to CRMEC.
Provisos that are not signed off by the
Accreditation Committee will be
communicated to CRMEC
Further actions and provisos may be
required.
The Secretariat will work closely with the unit / facility to ensure outstanding provisos are met.
Progress against provisos will be monitored closely in a repeat of the above process.
Continued non-compliance will be communicated to the ACT Board of the MBA.
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Accreditation Proviso Reporting
Process
Canberra Region Medical Education Council
(CRMEC)
For more information:
Ms Jodie Skriveris
CRMEC
123 Carruthers St
CURTIN ACT
P: (02) 6205 9852
E: jodie.skriveris@act.gov.au
Acknowledgement:
The CRPMC gratefully acknowledges the assistance of the South Australian Medical Education and Training Unit. This
document is modeled on their documents of the same name.
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