Reporting of Patient Safety Concerns Arising from Trainee Assessment Policy

TA492 V3.1

The purpose of this policy is to describe a process to address matters of significant concern arising from assessments of trainees conducted during any training program (including Joint Training Programs) of the Australasian College for Emergency Medicine (ACEM; the College), and which may be sufficient to warrant those concerns being communicated to a relevant regulatory (e.g. Medical Board of Australia; MBA, Medical Council of New Zealand; MCNZ) or other statutory authority.  These matters may relate to any aspect of professional performance, including those arising from technical clinical knowledge and skills, as well as those more related to the affective domains of professional practice, such as communication, relationships and ethics.

Unless the context otherwise implies, for the purposes of this policy, ‘trainee’ means any specialist or non-specialist trainee undertaking an ACEM training program.  ‘Assessment(s)’ means any form of evaluation conducted by the College as a component of either a formally designated training program or a peer review/oversight process.  Examples include examinations, workplace-based assessments and structured references. ‘Supervisor’ means the College-appointed individual(s) responsible for oversight of a trainee’s training and refers to Directors of Emergency Medicine Training (DEMTs) or equivalent in programs other than the FACEM Specialist Training Program.

3.1 Context

The College recognises its responsibilities to trainees, including the availability of prompt, effective remediation and support processes.  It also recognises the responsibility to act in the public interest where concerns during training arise that may compromise the provision of safe, high quality patient care.  The College is also aware of the nature of its training programs as conducted in workplaces such as hospitals and other facilities in that there is a direct and necessary connection between it, as the training organisation, and the workplace as an employer.

As such, it is recognised that supervisors and others involved with trainees during the course of their training will have responsibilities under workplace policies and statutory requirements that may result in action being taken in regard to trainees who demonstrate significant performance and competence concerns during training.  These concerns may arise from assessments conducted as part of the trainee’s training program, or from observations made as part of the trainee’s day-to-day workplace responsibilities, or a combination of both.  As such, local workplace processes may be instituted to address concerns, which the College expects it will be made aware of as part of the interaction between it and the training site.

Alternatively, observations may be made specifically in relation to trainee performance on a college assessment(s) that are not conducted in a workplace setting.  In these instances, the onus is on the College to consider informing the trainee’s employer, as regular processes would not result in the transfer of concerns to any workplace supervisor, as well as possible notification to a relevant regulatory or other statutory body.

3.2 Confidentiality

The College recognises its obligations under privacy principles and associated legislation.  Matters that give rise to actions under this policy shall be dealt with, as far as possible, on a confidential basis and consistent with the protection offered by the legal principle of qualified privilege.  The College does not, however, guarantee anonymity of trainees or others involved in matters actioned under this policy.

3.3 Procedural Fairness

The College has a separate policy relating to Procedural Fairness (COR 140).  Any trainee against whom a matter is actioned under this policy is entitled to receive sufficient details of the nature and circumstances of the matter as will allow him or her to fully respond to the matter and as the rules of procedural fairness and natural justice may require.  This may necessitate the disclosure of the identity of others from whom information was obtained.

The trainee is also entitled to respond to all allegations by making written and/or oral submissions at meeting(s) or hearing(s) at which the matter is considered, pursuant to any relevant regulations, policies or other documents operating in relation to the entity or entities in question.

(a) It is recognised that matters that may give rise to action(s) under this policy may arise from a number of avenues and a range of sources.  Regardless, the College views such matters seriously and will expedite any necessary action(s) in as timely a manner as practicable.

(b) Regardless of how the College becomes aware of a matter that may be the subject of action under this policy, it is the responsibility of College staff or officers to forward relevant concerns and any associated information to the Chair of the College entity with responsibility for the trainee and the assessment(s) in question.  Relevant entities include, but are not limited to:

• Regional Trainee Progression Review Panels
• the Specialist Training and Assessment Committee and its subcommittees
• the Emergency Medicine Associateship Training Programs Committee and
• the Joint Paediatric Emergency Medicine (Joint PEM) Trainee Progression Review Panel.

The Chair of the entity with responsibility for the trainee and their assessment(s) shall be responsible for initial consideration of the information and will determine whether the matter is one that does not represent a significant patient safety risk and is best dealt with through regular processes associated with the trainee and associated assessment(s), without further escalation.  In doing so, the Chair may inform their deliberations as they see fit, within relevant considerations of confidentiality and procedural fairness.

(c) Where the Chair of the entity with responsibility for the trainee and the assessment(s) in question is of the view that the matter is of significant concern in that it warrants consideration by the College for potential further action, the Chair shall arrange for the matter to be considered by an ad-hoc panel consisting of the Chair, the College Censor-in-Chief (CIC) and the College Deputy Censor-in-Chief (DCIC) .  This panel may inform itself as considered necessary, within relevant considerations of confidentiality and procedural fairness.  The College Chief Executive Officer shall be advised of any convening of a panel, the nature of the matter and any action(s) decided by that panel. 

(d) Where the panel convened in (c) above is of the view that that the matter is such that it warrants communication to the trainee’s supervisor(s) over and above that resulting from regular college processes in relation to the assessment in question, that communication will be actioned by the Panel through the responsible College administrative unit.  Consideration will be given to specific remediation that may assist the trainee to address the matters that are the source of the concern, as well as whether the communication requires further dissemination within the trainee’s employer organisation.  In composing the correspondence, the Panel should consider the need to liaise with other College officers (e.g. President, Chief Executive Officer).  The trainee who is the subject of the report shall be provided with a copy of any communication.

(e) Where the panel convened in (c) above is of the view that that the matter is such that it warrants reporting to an authority, the Censor-in-Chief shall advise the Chief Executive Officer, who will be responsible for making the report.  The trainee who is the subject of the report shall be provided with a copy of the report and any associated communication to the authority, and their supervisor shall be advised that the matter has been referred to the authority in question for consideration.

(f) The Chief Executive Officer will be responsible for informing the Censor-in-Chief, the Deputy Censor-in-Chief and the Chair of the relevant entity under which the matter was originally actioned of further development in relation to the referral.

• Policy on Procedural Fairness (COR140)
• Complaints Policy (COR166)