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Accreditation Guidelines

These guidelines have been developed in consultation with the Accreditation Working Group comprising representatives of the Australasian Faculty of Rehabilitation Medicine (AFRM), the Australian Orthotic & Prosthetic Association (AOPA), Prosthetists, Prescribing Medical Specialists and EnableNSW. The guidelines are reviewed every three years.

Process

The accreditation cycle for Amputee Units, Prescribing Medical Specialists, Prosthetists and Prosthetic Service Providers is five years. An applicant can apply for provisional accreditation at any time within the cycle. Provisional accreditation is for a period of 12 months at which time the applicant must apply for full accreditation status. After obtaining full accreditation status the applicant will be included in the normal accreditation cycle.

It is the responsibility of the accredited Prescriber, the Director of the Amputee Unit, accredited Prosthetist or Prosthetic Service Provider to inform EnableNSW of any changes that may affect their accreditation status with EnableNSW.

Review and Appeals

It is expected that applications for accreditation will be managed within the Guidelines. If an application is received, and a determination cannot be made, further information and clarification will be sought from the applicant. Advice may also be sought from the appropriate professional body in regard to qualifications and experience.

Where an application is declined, the applicant may appeal the decision in writing to the EnableNSW Manager. Input from external bodies or clinical experts may be sought when reviewing the appeal.

Quality Improvement and Review

EnableNSW routinely reviews compliance with the Guidelines to ensure the provision of quality services. Reviews occur through the use of audits or as the result of a specific investigation into an area of non-compliance. EnableNSW will contact an accredited individual and/or facility to address any areas of non-compliance and will work with services to ensure that they are able to meet the standards for accreditation.

EnableNSW can withdraw accreditation status if there is repeated failure to comply with the Guidelines by an individual and/or facility.

Contents

Amputee Units

An Amputee Unit is a unit run under the auspice of a Local Health District incorporating a number of associated amputee clinics at different facilities throughout the District.

These clinics have similar personnel across different facilities.

EnableNSW is not currently accrediting new clinics, and the guidelines listed here are used for re-accreditation of existing clinics.

Provisional Accreditation

  1. Function within a public or private Hospital that has Australian Council of Health Care Standards (ACHS) Accreditation.
  2. Function within a multidisciplinary rehabilitation service classified as level 5 or 6 under the NSW Role Delineation Guidelines according to current best practice.
  3. Be able to provide service on both an inpatient and outpatient basis.
  4. Nominate the site(s) of each individual Clinic run by the Unit.
  5. Have appointed to the Amputee Unit “core members” ie:
    1. A prescribing doctor(s) who meets the EnableNSW Prescribing Medical Specialist accreditation criteria
    2. A visiting prosthetist(s) who is an employee of an EnableNSW accredited Prosthetic Service Provider
    3. A physiotherapist(s)
  6. Nominate all of the Amputee Unit’s prescribing doctors individually to EnableNSW.
  7. Have one of the Amputee Unit’s prescribing doctors nominated to EnableNSW as Director of the Unit.
  8. Have access to an occupational therapist and social worker as required.
  9. Provide documentation supporting an ongoing commitment to adhere to and obtain the relevant sections of the NSW Agency for Clinical Innovation (ACI) document: Care of the Person following Amputation- Minimum Standards of Care.

Re-Accreditation

  1. Maintain all the requirements of Provisional Accreditation, plus:
  2. Hold a minimum of 6 amputee * “Prescribing Clinic Sessions” per clinic per year.
  3. Have >80% of “Prescribing Clinic Sessions” attended by the full core membership of the Unit.
  4. Show formal, documented evidence of ongoing commitment to Continuous Quality Improvement / Clinical Audit and Best Practice in the form of multidisciplinary quality and benchmarking activities.
  5. Show that each of the core members of the Amputee Unit have, within their own discipline, an ongoing commitment to Continuous Quality Improvement, Best Practice and Continuing Medical Education specifically related to Amputee management.
  6. Have submitted to EnableNSW relevant Amputee Unit related data as requested.

* By definition a “Prescribing Clinic Session” is one where a patient(s) is assessed by the core multidisciplinary amputee team, ie the prescribing doctor, prosthetist, and physiotherapist for the purpose of having an EnableNSW PLS script raised if necessary, among other things. It is understood that for reasons of leave, sickness etc the three core members will not all always be in attendance and that at times other team members may attend eg OT, Social worker etc. In order to be classed as a prescribing clinic session a prescribing specialist must be in attendance along with at least one other of the three core team members.

Prescribing Medical Specialists

Provisional Accreditation

  1. Have Specialist Registration with the Australian Health Practitioner Regulation Agency.
  2. Be a practicing Rehabilitation Medicine Physician with Fellowship of the Australasian Faculty of Rehabilitation Medicine or be able to show an equivalent level of training and experience in the rehabilitation management of limb amputees and limb prosthetics prescription.
  3. Have completed Australasian Faculty of Rehabilitation Medicine accredited courses in Lower Limb and Upper Limb Prosthetics. Where a prescriber has completed the lower-limb course, and is waiting to complete the upper-limb course, provisional accreditation may be granted provided the upper-limb course is completed within 12 months and appropriate supervision is provided for upper-limb prescriptions until full accreditation is obtained.
  4. Participate in the “MyCPD” continuing professional development program of the Royal Australasian College of Physicians or equivalent.

Re-Accreditation

  1. Maintain all the requirements of Provisional Accreditation, plus:
  2. Formal, documented evidence of ongoing commitment to Continuous Quality Improvement and Continuing Professional Development in the area of Amputee management since the last accreditation assessment. It is expected that this would take the form of quality activities, conference attendances, research activities, membership of “Special Interest Groups” etc.
  3. An average of six (6) prosthetic prescriptions per year for the Prosthetic Limb Service to maintain prescribing skills.

Prosthetists

AOPA Membership or Grandfather Accreditation

Provisional Accreditation

  1. Show evidence of eligibility for full AOPA membership or previous Grandfather Accreditation.
  2. Be employed/contracted or have an agreement with an EnableNSW accredited Prosthetic Service Provider.
  3. Participate in the AOPA Continuing Professional Development program, including supervision by an identified EnableNSW accredited prosthetist and ongoing education, commensurate with clinical skills and experience.

Re-Accreditation

  1. Maintain all the requirements of Provisional Accreditation, plus:
  2. Show formal, documented evidence of ongoing commitment to Continuous Quality Improvement and Continuing Education in the area of prosthetic manufacturing and clinical prosthetic practice since the last accreditation assessment. It is expected that this would take the form of quality activities, conference attendances, research activities, membership of “Special Interest Groups” etc. The minimum acceptable level of Continuing Education is to be equivalent to the minimum level required by the AOPA Continuing Professional Development Program. (Details of this program are available at the Australian Orthotic Prosthetic Association website).
  3. An average of six (6) full prosthetic treatments (assess, cast, manufacture, and fit) per year for PLS consumers, evidenced by a reference from employer.
  4. Remain employed/contracted or have an agreement with an EnableNSW accredited Prosthetic Service Provider.

Prosthetists

International tertiary qualification

Provisional Accreditation

  1. Provide evidence of international tertiary qualification in prosthetics.
  2. Present references from two prosthetic prescribers (EnableNSW accredited or equivalent) dealing with the prosthetist’s clinical and manufacturing skills.
  3. Be employed/contracted or have an agreement with an EnableNSW accredited Prosthetic Service Provider.
  4. Participate in a professional development program, including supervision by an identified EnableNSW accredited prosthetist and ongoing education, commensurate with clinical skills and experience. This program should be documented and be aligned with the formal health accreditation system of the facility e.g.: Australian Council of Healthcare Standards, or AOPA Continuing Professional Development program.

Re-Accreditation

  1. Maintain all the requirements of Provisional Accreditation, plus:
  2. Show formal, documented evidence of ongoing commitment to Continuous Quality Improvement and Continuing Education in the area of prosthetic manufacturing and clinical prosthetic practice since the last accreditation assessment. It is expected that this would take the form of quality activities, conference attendances, research activities, membership of “Special Interest Groups” etc. The minimum acceptable level of Continuing Education is to be equivalent to the minimum level required by the AOPA Continuing Professional Development Program. (Details of this program are available at the Australian Orthotic Prosthetic Association website).
  3. An average of six (6) full prosthetic treatments (assess, cast, manufacture, and fit) per year for PLS consumers, evidenced by a reference from employer.
  4. Remain employed/contracted or have an agreement with an EnableNSW accredited Prosthetic Service Provider.
  5. Present references from at least one prosthetic prescriber (EnableNSW accredited or equivalent) dealing with the prosthetist’s clinical and manufacturing skills.

Prosthetic Service Providers

Accreditation will be required for Prosthetic Service Providers to receive payment from EnableNSW in return for prostheses manufactured or repaired for EnableNSW consumers.

Accreditation will be a pre-requisite for any formal contracts related to prosthetic limb services with HealthShare NSW.

Note: NSW Health does not conduct the WWCCs on workers not employed by NSW Health or otherwise employed by a third party organisation. In these circumstances, it is the responsibility of the individual or the third party organisation.

Provisional Accreditation

  1. Company details:
    1. Name of Company
    2. Company contacts including their addresses, telephone, fax and E-mail contacts
    3. Australian Business Number
  2. Expertise:
    1. All persons directly involved in the provision of Prosthetic services for the manufacturer who attend amputee clinics or have contact with EnableNSW consumers must be Prosthetists accredited by EnableNSW or must be under supervision of an EnableNSW accredited Prosthetist.
    2. The standard of craftsmanship of the Prosthetists referred to in point 2.1
    3. The qualifications, experience, role in the organisation and proportion of time to be spent in work related to EnableNSW of the administrative, professional, and manufacturing staff (other than those people referred to in point 2.1).
  3. Service Delivery:
    1. The existence of suitable and readily accessible premises for the provision of ongoing services to amputees.
    2. Details of amputee clinics to be serviced.
    3. Evidence of customer service features eg. trading hours and courier services.
    4. Evidence of links to clinical support services.
  4. Compliance with NSW Commission for Children and Young People Act 1998
    1. Lodgement of Working with Children Check with the Office of the Children’s Guardian (OCG)
    2. Employer verification of current Working with Children Check clearance (WCC) for all clinical employees via the OCG.

Re-Accreditation

  1. Maintain all the requirements of Provisional Accreditation, plus:
  2. Show formal, documented evidence of ongoing commitment to Continuous Quality Improvement and Continuing Education in the area of prosthetic manufacturing and clinical prosthetic practice since the last accreditation assessment. It is expected that this would take the form of quality activities, conference attendances, research activities, membership of “Special Interest Groups” etc.
  3. Show a level of clinical prosthetic practice and / or prosthetic manufacture for EnableNSW that would enable maintenance of clinical and manufacturing skills.
  4. Show compliance with the NSW Commission for Children and Young People Act 1998 by verifying currency of WWC for clinical employees. Form to list currency of checks available in Appendix 3.