Medical Board of Australia - Supervised practice for international medical graduates guidelines

1. Scope

These guidelines apply to international medical graduates (IMGs) who are granted limited registration or provisional registration under the Health Practitioner Regulation National Law as in force in each state and territory (the National Law).

All IMGs who are granted limited registration or provisional registration must be supervised. Supervision remains a requirement of registration for the duration of the IMG’s limited or provisional registration.

These guidelines do not apply to Australian and New Zealand graduates with provisional registration (interns) who undertake a period of supervised practice in an accredited intern position. The supervision requirements for interns are specified in the National Internship Framework.

2. Purpose of supervision

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Supervision provides assurance to the Medical Board of Australia (the Board) and the community that the practice of the medical practitioner with limited or provisional registration is safe and is not putting the public at risk.

Supervision also monitors and supports the IMG throughout the period of limited or provisional registration. The supervision introduces and promotes a culture of continuous learning and professional development.

Formal supervision processes monitor and assess the IMG’s performance, within a structured framework. Performance review and feedback are important components of supervision. Feedback should describe the strengths of the IMG, areas that need development, and strategies that the IMG might employ to improve performance. Good supervision should enable the IMG to review and develop their practice in a constructive and supportive environment, and to develop and enhance their knowledge, skills and professionalism.

In deciding the level of supervision that is necessary, the Board will take into consideration a range of factors that include the:

specific position that the IMG has been offered, including the level of risk of the position
context of the practice
supports available, and
qualifications, training and experience of the IMG.

During the period of limited or provisional registration, the Board will approve a principal supervisor as well as co-supervisor(s) depending on the employment arrangements.

At the end of the period of limited or provisional registration granted, and after considering the work performance reports provided by the supervisors, the Board will determine whether the IMG is suitable for ongoing registration.

Except where otherwise stated, the word ‘supervisor’, as used throughout these guidelines, refers to all types of supervisors including principal supervisor, co-supervisor, term co-supervisor and temporary co-supervisor.

3. Principles of supervision

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3.1	The supervision arrangements that have been approved by the Board must be in place at all times when the IMG is practising. An IMG must not practise if the approved supervision arrangements cannot be met.
3.2	These guidelines prescribe requirements for supervision of IMGs but also aim to be flexible where this is safe. They allow individuals to make a case to the Board if they are proposing arrangements that do not fit with the guidelines. The Board will consider each proposal on its individual merits and will only approve arrangements that it considers to be safe. The guidelines also acknowledge that different settings have different structures in place. For example, supervision in a tertiary public hospital is different to that in rural general practice.
3.3	Principal supervisor All IMGs will have a principal supervisor. The principal supervisor: is approved by the Board oversees the supervision of the IMG should nominate one or more co-supervisors when applying to the Board to be the principal supervisor If a co-supervisor cannot be appointed in advance, the principal supervisor must inform the Board of the arrangements that will be made when the principal supervisor is absent. For example, to cover sick leave or annual leave. is responsible for ensuring that the IMG is adequately supervised (regardless of whether co-supervisors have been appointed or nominated to supervise the day-to-day practice of the IMG) who delegates supervision is responsible for ensuring that any co-supervisor(s) (including term co-supervisors and temporary co-supervisors) meet the requirements of these guidelines and have the necessary skills and experience to provide supervision must agree in writing to provide supervision as prescribed by the Board for the duration of the period of registration or until changed by the Board, and provides reports to the Board about the IMG’s work performance.
3.4	Co-supervisors Co-supervisors supervise the IMG when the principal supervisor is not available. It is usual for one or more co-supervisors to be appointed. Co-supervisors: are approved by the Board (see below for exceptions) must meet the requirements set in these guidelines who regularly share supervision of the IMG with the principal supervisor should be included in the Supervised practice plan and supervisor’s agreement must agree in writing to provide supervision as prescribed by the Board for the duration of the period of registration or until changed by the Board, and together with the principal supervisor, provide reports to the Board about the IMG’s work performance. Term co-supervisors In the hospital setting, a Director of Medical Services (DMS) or Director of Clinical Training (DCT) (or equivalent) may be appointed as a principal supervisor. The DMS or DCT (or equivalent) may appoint term co-supervisor(s) without Board approval. The term co-supervisors are delegated the day-to-day supervision of the IMG.
3.5	Requirements for supervisors All supervisors, including principal supervisors, co-supervisors, term co-supervisors and temporary co-supervisors: must not have conditions imposed on their registration or undertakings accepted by the Board as a result of health, performance or conduct issues must not be a relative or domestic partner of the IMG, and must not be an employee of the IMG. The Board may take into consideration the past notification history of proposed supervisors when deciding whether or not to approve them. The Board may not grant approval or may revoke approval for a supervisor, if it receives a notification of a serious allegation about the supervisor’s health, performance or conduct. Requirements for principal supervisors, co-supervisors and term co-supervisors All principal supervisors, co-supervisors and term co-supervisors: should have specialist registration If the proposed supervisor has general registration, not specialist registration, they must provide an explanation for the Board’s consideration about their training and experience and why they are suitable to be a supervisor. A medical practitioner with limited or provisional registration cannot be appointed as an IMG’s supervisor. must be appropriately qualified, preferably in the same field of medicine as the position proposed for the IMG If the proposed supervisor is not qualified in the same field of medicine as the proposed position for the IMG, they must provide an explanation for the Board’s consideration as to why supervision will not be undertaken by a person qualified in the same field of practice and how it is proposed that effective supervision will be provided. should have a minimum of three years full time equivalent practice with general and/or specialist registration in Australia prior to being appointed as a supervisor If the proposed supervisor does not have three years full time equivalent experience with general and/or specialist registration in Australia, they must provide an explanation for the Board’s consideration as to why they are suitable to be a supervisor. must satisfactorily complete the Board’s online education and assessment module on these guidelines, to ensure that they understand their roles and responsibilities as a supervisor. New supervisors must satisfactorily complete the module within one month of commencing as a supervisor. All supervisors must repeat the module each time the guidelines are re-issued by the Board.
3.6	Number of IMGs permitted per supervisor The Board will not normally allow any practitioner (principal supervisor, co-supervisor, term co-supervisor or temporary co-supervisor) to have direct supervisory responsibility for more than four IMGs. A supervisor who concurrently consults with (their own) patients while supervising IMGs may supervise up to one IMG on level 1 supervision and up to three IMGs on other levels (i.e. levels 2, 3, 4 supervision), up to a maximum of four IMGs. A supervisor who does not consult with (their own) patients while supervising IMGs may supervise up to a maximum of four IMGs (including more than one IMG on level 1 supervision). Prospective supervisors who are applying to supervise more than four doctors must provide a proposal for the Board’s consideration about how they will provide supervision to each registrant. DMSs and DCTs are exempt from the restrictions on number of IMGs (see below).
3.7	Arrangements for Directors of Medical Services and Directors of Clinical Training Recognising the supervisory structures that exist in hospitals, DMSs and DCTs (or equivalent) can be appointed as the principal supervisor and can delegate day-to-day supervision to term co-supervisors. A DMS or DCT who appoints term co-supervisors for the day-to-day supervision of IMGs: can be the principal supervisor for more than four IMGs is responsible for ensuring that term co-supervisors meet the requirements in these guidelines is exempt from providing a proposal to the Board about how they will provide supervision to more than four doctors is exempt from providing an explanation as to why they are not qualified in the same field of medicine as the proposed position for the IMG, and is required to satisfactorily complete the Board’s online education and assessment module.
3.8	Arrangements for temporary co-supervisors In the case of a temporary unplanned absence, for example, due to the supervisor’s illness, a principal supervisor may delegate supervision temporarily (less than four weeks) to a temporary co-supervisor. The following exemptions apply to the appointment of temporary co-supervisors: Board approval of the temporary supervisor is not required the temporary co-supervisor does not have to have specialist registration, does not have to be in the same field of medicine as the proposed position for the IMG and does not have to have three years full time equivalent practice with general and/or specialist registration in Australia, and the temporary co-supervisor does not have to complete the Board’s online education and assessment module. A temporary co-supervisor may supervise an individual IMG for a maximum three, non-consecutive four week periods, per calendar year. If the principal supervisor is to be absent for four or more consecutive weeks, or more than three periods of four consecutive weeks in a calendar year, a co-supervisor must be approved by the Board.

4. Supervision – formal and informal

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All IMGs should have both formal and informal supervision, tailored to their level of supervision and individual needs.

4.1

Formal supervision

This is regular protected time that is specifically scheduled and enables in-depth discussion and reflection on clinical practice. It may include:

review and feedback on performance identifying strengths and weaknesses and performance issues
observation of practical skills including procedural skills and patient interactions
discussion of difficult or unusual cases
discussion of cultural and management issues, and
medical record reviews.

The supervisor needs to be satisfied that the IMG is developing the following clinical competencies and if they have not yet achieved them fully, that the IMG’s practice is being supervised sufficiently closely to ensure that they are providing safe care. The competencies include:

how to assess a patient accurately
how to recognise the sick patient
how and when to refer a patient
safe prescribing
appropriate ordering of investigations and interpreting results of investigations
current screening protocols
treatment and management protocols
effective communication with patients, families and other staff, and
an understanding of relevant legislation.

4.2

Informal supervision

This is the day- to-day observation, communication and interaction providing advice, guidance and support as and when necessary.

5. Supervision responsibilities

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All IMGs with provisional or limited registration must be supervised. The Board imposes specific obligations on the IMG, their supervisors and the IMG’s employer.

5.1	Responsibilities of the IMG include to: schedule regular meetings with their supervisor(s) and make all reasonable efforts to ensure that these meetings take place set supervision and development goals, together with the supervisor contact their supervisor early if they have a problem recognise the limits of their professional competence and seek guidance and assistance from their supervisor obtain approval of the Board for any proposed changes to supervision arrangements, registration conditions or requirements before they are implemented, and inform the Board if the conditions or requirements of their supervision are not being met. For example, if the supervisor is unable to provide the necessary level of supervision.
5.2	Responsibilities of the supervisor include to: ensure as far as is possible, that the IMG is practising safely and is not placing the public at risk observe the IMG’s work, conduct case reviews, periodically conduct performance reviews and provide constructive feedback address any problems that are identified notify the Board immediately if they have concerns that the IMG’s performance, conduct or health is placing the public at risk notify the Board immediately if the IMG is not complying with conditions imposed or undertakings accepted by the Board or is in breach of any requirements on registration verify that the IMG is practising in accordance with work arrangements approved by the Board and report to the Board if the IMG is not doing so ensure that approval of the Board has been obtained for any proposed changes to supervision arrangements, registration conditions or requirements before they are implemented inform the Board if they are no longer able or willing to provide supervision provide an orientation for the IMG and provide an orientation report to the Board three months after initial registration provide work performance reports to the Board in the approved form at intervals determined by the Board agree to provide supervision at a level determined by the Board, and be clear about how they can be contacted by the IMG when the IMG is practising, during working hours and after hours.
5.3	Responsibilities of the employer include to: ensure supervision is provided according to the Supervised practice plan and supervisor’s agreement facilitate the provision of protected time for the IMG and supervisor to enable the formal supervision requirements to be met ensure the IMG is adequately oriented to organisational policies and procedures, and advise the Board of any concerns about the IMG if they form the opinion that there is a risk to the public that they cannot adequately address by implementing local measures.

6. Supervision levels

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The levels of supervision are designed to ensure that the practice of the IMG is safe.

6.1	The level of supervision that is required will depend upon a number of factors including: the IMG’s qualifications the IMG’s previous experience, especially in the type of position for which the IMG has applied whether the IMG has practised recently and the scope of their recent practice the requirements of the position including the type of skills required for the position the position itself, including the level of risk, the location of practice and the availability of supports (other practitioners, local hospital) the seniority of the position for hospital positions recommendations from a pre-employment structured clinical interview (PESCI) (noting that the Board may require a different level of supervision than recommended in the PESCI), and recommendations from a specialist medical college which has assessed the IMG (noting that the Board may require a different level of supervision than recommended by the college).
6.2	Supervision in general practice positions It is preferred that IMGs with limited or provisional registration work in general practices that are currently accredited to the RACGP Standards for general practices (latest edition). If the practice is not accredited, the supervisor must satisfy the Board that they have structures in place to support safe practice by the IMG.¹The Board will decide on one of the following supervision levels for IMGs working in general practice. Level 1 supervision The supervisor takes direct and principal responsibility for each individual patient. The supervisor must be physically present at the workplace at all times when the IMG is providing clinical care. The IMG must consult their supervisor about the management of all patients at the time of the consultation and before the patient leaves the practice. Supervision via telephone contact or other telecommunications is not permitted. Level 2 supervision The supervisor shares with the IMG, responsibility for each individual patient. The supervisor must ensure that the level of responsibility that the IMG is allowed to take for patient management is based on the supervisor’s assessment of the IMG’s knowledge and competence. Supervision must be primarily in person - the supervisor must be physically present at the workplace a minimum of 80% of the time that the IMG is practising. Where the supervisor is not physically present, they must always be accessible by telephone or video link. The IMG must inform their supervisor on a daily basis about the management of individual patients. Level 3 supervision The IMG takes primary responsibility for each individual patient. The supervisor must ensure that there are mechanisms in place for monitoring whether the IMG is practising safely. The IMG is permitted to work alone provided that the supervisor is contactable by telephone or video link. Level 4 supervision The IMG takes full responsibility for each individual patient. The supervisor must oversee the IMG’s practice. The supervisor must be available for consultation if the IMG requires assistance. The supervisor must periodically conduct a review of the IMG’s practice
6.3	Supervision in hospital-based positions The supervision levels described above are suited to the general practice environment. However, it may be more appropriate to use the existing hospital supervision structures and protocols for hospital-based positions. If the levels above do not correspond to the proposed level of supervision for a hospital-based position, the Board will consider other supervision structures. The proposal for the supervision should outline supervision arrangements for all practice contexts, for example procedures, surgery or hospital clinics.
6.4	Supervision for after-hours, on-call, offsite (home) visits and locum services An IMG may provide after-hours services at their approved workplace if supervision is provided by an approved principal supervisor, co-supervisor, term co-supervisor or temporary co-supervisor and they comply with the supervision requirements approved by the Board. For example, an IMG in a hospital-based position on level one supervision may be rostered for after-hours services in the hospital if their supervisor (principal supervisor or co-supervisor) is also physically present at the workplace and is available to consult about the management of all patients at all times when the IMG is providing clinical care. An IMG may work overtime or additional shifts at their approved workplace provided they comply with their supervision arrangements approved by the Board. An IMG may provide on-call or offsite (for example home) visits as an adjunct to their approved hospital or general practice position provided they comply with their supervision arrangements approved by the Board. For example, an IMG on level one supervision may make a home visit, if they are accompanied by their supervisor. An IMG on level one or two supervision cannot be approved for a position which consists solely of on-call or home visits. An IMG on level one or two supervision is not permitted to provide locum services. An IMG on level three or four supervision is permitted to do on-call, offsite (home) visits and locum services provided they comply with their supervision arrangements approved by the Board.
6.5	Changing supervision levels The Board may change the level of supervision that applies to an IMG’s practice at any time during the period of limited or provisional registration. The Board will review the work performance report which is submitted after the three month initial registration period. Based on the supervisor’s report, the Board may direct that supervision continues at the specified level or may change the supervision level. The level of supervision that applies may also be reviewed at any time during the period of supervised practice, at the request of the IMG. To request a change of supervision level, the IMG must make a request to the Board in writing and provide reasons why the change is appropriate.

¹Note that this is accreditation of the practice by an independent accreditation agency (Australian General Practice Accreditation Limited (AGPAL) or GPA ACCREDITATIONplus). This is separate to accreditation of the training post against RACGP and/or ACRRM standards for general practice education and training.

7. Reporting requirements

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The Board requires supervisors to provide regular work performance reports regarding the IMGs that they are supervising.

The work performance reports should be completed and signed jointly by the principal supervisor and any co-supervisors responsible for direct supervision during the period of supervised practice.

If there is a change of supervisor during the period of supervision, where possible, the new supervisor should consult with the exiting supervisor to inform the work performance report.

7.1	Initial three month report At three months after initial registration supervisors must provide a report to the Board that includes: an orientation report confirming that the IMG has completed an orientation to the Australian healthcare system that addresses the requirements as detailed in the Board's Orientation report ORIG-30, and a work performance report confirming that the IMG is safe to practise in the supervised practice position that was approved by the Board in the initial application.
7.2	At renewal of registration After the first report at three months, a work performance report must be provided at the time that an application is made for renewal of, or application for registration and then annually thereafter unless otherwise directed by the Board. The Board may require more frequent reports when there are concerns about the IMG’s performance that may potentially result in risk to the safety of the public.
7.3	Reporting requirements for IMGs with provisional registration IMGs with provisional registration may be eligible for general registration at the end of 12 months supervised practice. The work performance report at the end of 12 months supervised practice for these practitioners should include: the rotations that the IMG has been practising in, or the scope of their clinical practice, and whether or not the IMG has met the standard expected for general registration and whether they are practising at least at the level of an Australian qualified intern at the end of their intern year.
7.4	Format of reports Reports for IMGs who are not in the specialist pathway must be in the format specified by the Board which includes an IMG self assessment for comparison with the supervisor’s assessment. Templates for the orientation report and the work performance report are provided. IMGs with limited or provisional registration who are on the specialist pathway should follow the supervision and feedback requirements that are defined by the specialist college. The Board will accept work performance reports in the format specified by the relevant specialist college provided that the report includes the required information.

8. Audit of supervision requirements

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IMGs and their supervisors may be audited to check compliance with the Board’s supervision requirements. The IMG, their supervisors and the IMG’s employer may be required to provide evidence that the IMG is practising in accordance with their level of supervision and the supervision arrangements approved by the Board.

9. Review

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These guidelines take effect on 4 January 2016.

The Board will review these guidelines from time to time.

Supervised practice for international medical graduates guidelines

Codes, Guidelines and Policies

1. Scope

2. Purpose of supervision

3. Principles of supervision

4. Supervision – formal and informal

5. Supervision responsibilities

6. Supervision levels

7. Reporting requirements

8. Audit of supervision requirements

9. Review