ANZBP Local Training Accreditation Form

ANZBP Local Training Unit Accreditation Application Form

Prior to completion, ensure you have read the requirements of the ANZBP Training Accreditation Policy .

Use this form to apply for ANZBP accreditation of a local Australian or New Zealand traininng unit. This application supports ANZBP approval, renewal, request for variation of an existing accreditation arrangement, or application for a approval of a shared trainee arrangement. Applications must include sufficient information and supporting documentation to demonstrate that the institution can provide an appropriate, safe and sustainable training environment for ANZBP registered local Trainee Perfusionists progressing towards CCP (ANZ). Lead Supervisor and Clinical Supervisor Applications must be submitted concurrently.

Application Type(Required)

New training unit accreditation

Renewal of existing accreditation

Variation to existing accreditation

Shared trainee arrangement

Resubmission of documentation for accreditation

Name of training unit / hospital / service provider(Required)

Hospital Address(Required)

Main Contact for Application

Name(Required)

First Last

Email(Required)

Head of the Perfusion Department (add own name if head of department)(Required)

Institution Requirements as per the Policy

For an application to be considered for approval, the institution much satisfy the requirements of the ANZBP Training Accreditation Policy.

Has the institution provided cardiac surgery services for at least 24 months? Yes/No(Required)

Describe the perfusion service and its maturity, including years, service and capacity.(Required)

Unit Type(Required)

Adults

Paediatrics

Mixed

Brief description of Case Mix

Total CPB Cases performed in the last 12 months.(Required)

The policy sets a guide of 200 CPB cases/year per trainee position for adult units and 150 CPB cases/year per trainee position for paediatric units, unless otherwise approved. It also requires consideration of trainee staging and whether case access and supervision are diluted when multiple trainees are present

Number of trainees being employed under this unit's accreditation application(Required)

Are any other trainees currently employed? If yes, describe how trainees are staged in progression and how the unit will ensure adequate access, evaluation and supervision for all trainees?(Required)

The policy requires sufficient staffing, resources, and rostering capacity to support training without compromising patient safety or service delivery

Will the unit have sufficient staffing resources and capacity to support training without compromising patient safety or service delivery. Yes/No?(Required)

The policy requires maintained equipment, current perfusion protocols, emergency procedures, and systems for maintenance, incident reporting, escalation, orientation, and equipment competency.

Are emergency procedures and incident reporting systems documented and available? Yes/No?(Required)

Does the unit use maintained and in-service perfusion equipment consistent with the ANZCP Standards and Guidelines? Yes/No?(Required)

Are current CPB protocols documented and available? Yes/No?(Required)

The policy requires evidence that the trainee has secured employment and access to a work-integrated learning environment for the duration of training, with a recommended minimum of 3 days/week. It also requires support for examinations, workshops, and academic participation.

Describe how the institution will support employment for the entire training program, acknowledging that if the trainee loses employment at any time, they will be placed on intermission or withdrawn from the academic program, as per the University requirements.(Required)

Describe how the institution will support attendance for academic requirements (tutorials/workshops) and board examinations.(Required)

Will the unit provide financial support for education? If not, please ensure the student is aware at time of employment.(Required)

Clinical Supervision Requirements

The policy requires access to ANZBP-approved supervisors, a named Lead Supervisor, sufficient Clinical Supervisor capacity, and an uploaded supervision plan identifying supervision level, nominated supervisors, review points, escalation arrangements, and any conditions.

Proposed Lead Supervisor Name(Required)

First Last

Proposed Lead Supervisor Email(Required)

Proposed Clinical Supervisor/s and Email Address/es(Required)

Describe how direct and indirect supervision will be managed safely.(Required)

Supervision Plan

Please upload the documented supervision plan for each Local Trainee Perfusionist covered by this application. The supervision plan must be approved by the Lead Supervisor and supported by the employing unit. It must identify: the plan for training exposure, complexity progression, supervision plan, review points, escalation arrangements or any conditions or limitations relevant to practice.

File(Required)

Max. file size: 32 MB.

Required Letters

The ANZBP Clinical Supervision Policy requires a number of letters of support to fulfill the course work integrated learning component.

Head of Perfusion Name(Required)

First Last

Head of Perfusion Email(Required)

Head of Perfusion Supporting Letter(Required)

Max. file size: 32 MB.

Please upload a supporting letter from the Head of Perfusion addressing the requirements of the Policy.

Authorised Representative of Hospital Executive Name(Required)

First Last

Authorised Representative of Hospital Executive Email

Authorised Representative of Hospital Executive Supporting Letter(Required)

Max. file size: 32 MB.

Upload a letter from an authorised representative or hospital executive that confirms and acknowledges the requirements in the Policy.

Head of Cardiothoracic Surgery Name(Required)

First Last

Head of Cardiothoracic Surgery Email

Head of Cardiothoracic Surgery Supporting Letter(Required)

Max. file size: 32 MB.

Upload a letter from the Surgical Head of Department (or senior surgeon at contracted site, if a company). This letter is to offer support to the perfusion department and willingness to nuture the development of the trainee during this period, and also that confirms and acknowledges the requirements in the Policy

Do the submitted letters collectively confirm the requirements of letters in the Policy?(Required)

Yes

i) the institution’s support for accreditation as an ANZBP local training unit; ii) that the institution intends to employ and train Local Trainee Perfusionists under the ANZBP local training pathway; iii) that the institution supports the provision of appropriate clinical exposure, case volume, case mix, supervision, governance and patient safety arrangements; iv) that the institution has, or will have, access to ANZBP-approved supervisors able to support the trainee; v) that the institution supports the trainee’s participation in the relevant academic program, examinations, workshops and required educational activities; vi) The employing unit retains responsibility for ensuring that supervision arrangements are adequately resourced, appropriately structured, and sustainable. vii) that the institution will notify the ANZBP of material changes relevant to accreditation, including changes to supervision, staffing, case volume, governance, equipment, institutional support or patient safety viii) that accreditation is limited to the scope approved by the ANZBP and remains subject to ANZBP audit, review and renewal requirements. ix) The ANZBP may request clarification, further documents, interviews or independent verification before making a decision. x) Acknowledgement, and permission to share with the University as required

Shared Trainee Arrangement

Where a shared trainee arrangement is sought, the policy requires a joint application, support from both institutions, a defined primary unit, a Lead Supervisor across both sites, clear governance, and a cross-institutional training plan.

Primary Training Unit

Secondary Training Unit

Proposed Lead Supervisors at both sites

Proposed Clinical Supervisors at both sites

Shared Trainee Arrangement Plan and required letters that addresses the requirements of the Policy.

Drop files here or

Max. file size: 32 MB.

Training Site Declarations

Please read each statement carefully and tick each box to confirm that the Hospital or Service Provider meets, accepts, acknowledges, or accepts responsibility for the relevant requirement. These declarations form part of the ANZBP Training Unit Accreditation application, and ANZBP may rely on them when assessing suitability for accreditation. The applicant;

Declares that the hospital training unit fulfils the requirements of the ANZBP Training Accreditation Policy in relation to case volume, case mix, departmental capacity, staffing, supervision capacity, equipment, protocols, governance, training support, and patient safety, as applicable to the accreditation sought.(Required)

Yes

Acknowledges and understands that admission to the Monash University Master of Cardiovascular Perfusion is determined by Monash University in accordance with its published admission requirements, as amended from time to time.(Required)

Yes

Acknowledges that accreditation of a local training unit by the ANZBP does not, of itself, guarantee admission of any individual applicant to Monash University, and that individual applicants must independently satisfy all Monash University admission and enrolment requirements.(Required)

Yes

Agrees that supervision of trainees will occur in accordance with the ANZBP Clinical Supervision Policy and acknowledges that Lead Supervisor and Clinical Supervisor applications must be submitted concurrently with this application.(Required)

Yes

Confirms that a documented supervision plan has been prepared for each trainee included in this application, approved by the Lead Supervisor, supported by the employing unit, and uploaded as part of this application(Required)

Yes

Has sufficient staffing, rostering, resources and organisational capacity to maintain safe clinical service delivery and support education and supervision without compromising patient safety.(Required)

Yes

Will provide a suitable environment and appropriately allocate time for course examinations and associated academic requirements(Required)

Yes

Will provide reasonable support for the trainee’s participation in study and learning activities associated with the ANZBP-recognised training pathway(Required)

Yes

Confirms that the trainee has secured, or will secure, employment and access to an appropriate work-integrated learning environment for the duration required to support the academic and clinical components of the pathway(Required)

Yes

Acknowledge that if the trainee loses employment, they will be required to take intermission or forced to withdraw from the academic program and training program, and will notify the ANZBP as soon as possible if this occurs.(Required)

Yes

Acknowledges that trainees must be employed a minimum of three days per week for appropriate training(Required)

Yes

Agrees to provide all required documentation as per the training program, including uploads of case reviews and logbooks at every 20 case milestone.(Required)

Yes

Agrees to provide supporting documents, records and other information requested by the ANZBP in connection with monitoring, audit, review, renewal, governance, training quality or patient safety;(Required)

Yes

Acknowledges that training unit accreditation is not automatic, is not indefinite, and must be renewed every three years(Required)

Yes

Will notify the ANZBP as soon as practicable of any material change relevant to accreditation, including changes to supervision arrangements, staffing, case volume, trainee numbers, service capability, equipment, governance, institutional support, or significant patient safety concerns(Required)

Yes

Accepts responsibility for ensuring that trainees are appropriately supervised at all times, including during on-call periods, and are never required to practise without an available supervisor in accordance with ANZBP policy.(Required)

Yes

Acknowledges that direct supervision requires the supervising perfusionist to be physically present in the same room as the trainee whilst the trainee is performing clinical cases for a minimum of 125 cases.(Required)

Yes

Acknowledges that after 125 cases, indirect supervision can occur, and indirect supervision requires the supervising perfusionist to be on-site, immediately contactable, able to attend within minutes, and not simultaneously responsible for another procedure, in accordance with ANZBP policy.(Required)

Yes

Has read and understands all requirements of the ANZBP Training Accreditation Policy(Required)

Yes

Final Declaration

Final Declaration – (enter your full name)(Required)

By entering my full name, I confirm that: the information provided in this application is true and correct to the best of my knowledge; I understand the responsibilities of the role for which I am applying; I understand that ANZBP may request further information, clarification, updated documentation, or institutional endorsement; I understand that approval may be not granted, reviewed, not renewed, suspended, or withdrawn where ANZBP is no longer satisfied that the requirements of the Policy are being met; I am authorised to submit this application and accept these declarations on behalf of the Hospital or Service Provider.

Additional Supporting Documentation (where relevant)

Any additional supporting documentation.

Max. file size: 32 MB.

ANZBP Local Training Accreditation Form

ANZBP Local Training Unit Accreditation Application Form

Main Contact for Application

Institution Requirements as per the Policy

Clinical Supervision Requirements

Supervision Plan

Required Letters

Shared Trainee Arrangement

Training Site Declarations

Final Declaration

Additional Supporting Documentation (where relevant)

Contact Details

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