7. Implementation

7.1 College responsibilities for change
7.2 Changes to resource and infrastructure
7.3 Measures of success and data collection

Overall this Reference Group advocates a step-based approach to change over a defined period of three to five years so that all of the required infrastructure, resources, cultural changes, and training can be put into place without putting at risk the high standards and current gains that have been achieved. Colleges are already undergoing fundamental changes, partly led by the AMC accreditation processes. Likewise, community expectations and the settings in which training is expected to occur are also changing. During these changes there are opportunities to generate large benefits by undertaking relatively small changes or resources towards the proposed expanded network training model.

To ensure effective implementation of the Expanded Specialty Network Model there are a number of activities that need to be carried out simultaneously. The colleges will be responsible to ensure some of these processes are in place, whilst others are either shared responsibilities or outside the province of the colleges. In some instances the changes which have infrastructure and/or resource implications will require cooperation between many stakeholders (jurisdictions, governments, hospitals) and therefore, may need some level of oversight or coordination. The activities include:

7.1 College responsibilities for change:

• Defining accreditation principles for non-traditional training settings including the clarification of the required educational infrastructure in private sector environments and other non-traditional settings
  
  
• Identification of both opportunities and limitations for clinical experiences in non-traditional settings and the identification of mechanisms to overcome any limitations. When colleges accredit a non-traditional training setting they will identify where there are limitations in clinical experience and identify the processes by which such limitations can be overcome. For example, the ways in which the range of experiences required will be provided within the network
  
  
• Collaboration between colleges to ensure more efficient shared accreditation processes. (see project work of the AHWOC/ACCC review). Such processes must meet the colleges' current requirements for accreditation whilst taking into account the need for natural justice (across the range of settings and specialties). In some instances this may lead to augmentation of requirements in some settings, whilst decreasing duplication in others
  
  
• Curriculum development by the specialty colleges needs to define the required competencies and to more clearly identify outcomes expected from the variety of training settings. This process will include agreement on whether rotation outcomes be defined by time in setting, or acquisition of competencies. This curriculum development needs to be supported by the AMC accreditation processes
  
  
• Defining the principles of portability of training. The work which has already begin on recognition of prior learning will contribute to this process
  
  
• Defining trainee involvement in the governance and management of training
  
  
• Clarifying the processes through which trainees can participate in multidisciplinary training, (for example, sessions on patient safety or clinical reasoning) to obtain system-wide, holistic knowledge that is relevant to their specialty
  
  
• Defining the parameters and requirements for training of supervisors, and also possibly administrators, to deal with changing roles and expectations Top of page

7.2 Changes to resource and infrastructure:

• Development of efficient service delivery models to ensure current service delivery demands in public teaching hospitals are met, ensuring that the service provided to patients in public hospitals is at least maintained
  
  
• Selection of the most appropriate model for the coordination of the ESNM and then the identification, and development, of the necessary infrastructure for that selected model to oversee training between specialisations and across settings (including the public/private divide)
  
  
• Specification of administration and accountability arrangements for training and supervision. This includes clearer definition of the roles and responsibilities for standard setting and maintenance, financial controls and performance outcomes
  
  
• A review of current entitlement and employment conditions of trainees to ensure that they are consistent between settings, and that all trainees receive appropriate reimbursement for their services and are able to maintain their employment conditions across settings. This could mean that the funding for training may need to be reassessed and/or that some settings may have to allocate more resources to achieve training standards
  
  
• Because each potential training setting and jurisdiction may have different administrative arrangements and conditions this could lead to an increase in implementation costs. Alternatively, it could lead to greater efficiencies where administration across settings is shared
  
  
• Greater identification of potential areas for resource sharing among the various training stakeholders, to ensure a decrease of the fragmentation in the training sector and improve efficiencies. For example, there is potential for efficiencies of scale through providing training across settings and across disciplines through more effective administrative coordination (e.g. a director of clinical training, shared training and supervision) whilst increasing training opportunities
  
  
• Even though accreditation will be for networks rather than individual settings, bringing some settings within the network up to the required standards of training infrastructure may incur increased costs (internet connections, online journal access, library facilities, video conferencing, meeting and training rooms, and secretarial services)
  
  
• Introduction of cultural change in the community, as well as within the specialties and the non-traditional training settings Top of page

7.3 Measures of success and data collection

Any diversification of training programs should be measured against objective competencies and performance capabilities, and should meet the current and projected health and workforce needs of the community. To monitor the effectiveness of the Expanded Specialty Network Model during its implementation and beyond, it is essential to establish mechanisms for on-going monitoring and evaluation of the training; the partnerships; the diverse training settings; and the training networks. To this end it will be important to establish effective processes to regularly gather and analyse data from the many stakeholders, particularly from trainees and patients, and to have the capacity to respond to feedback and to implement change.

Indicators of the efficacy of the ESNM need to be monitored regularly. The following could be included amongst the evaluation processes:

• The contribution of the different training settings can be measured against objective competencies and performance capabilities during and at the end of training. One clear, simple indicator of success would be that trainees are successfully completing their training in minimum time, being able to meet all of the requirements of an independent practitioner
  
  
• The quality of trainees' performances across the whole range of competencies can be monitored through patient outcomes, and competency assessments, as well as staff and patient satisfaction indicators
  
  
• The value and effectiveness of the diverse training settings can be assessed through two very different processes providing different kinds of data:
  
  
  1. trainee feedback forms collected anonymously during, and/or at the end of their rotations
  2. by assessing the actual learning outcomes against those that are defined by the specialty as expected/required outcomes for that setting
     
     
• It will also be possible to evaluate the capacity of the expanded system to meet the workforce and health care needs of the community. Linkages within the networks will provide a mechanism for government to monitor and advise on workforce supply and demand, and
  
  
• A longer term evaluation process will be to ascertain the match between the training experiences and how well they match the health needs of the community.