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Health professional accreditation lacks Aboriginal voice

(A response from the Australian Medical Council was added on 10 August, 2018).

Introduction by Croakey: A recent post reported the formation of The Aboriginal and Torres Strait Islander Health Strategy Group at the Australian Health Practitioners Regulation Agency (AHPRA).

Aboriginal and Torres Strait Islander health sector leaders have worked with representatives of the 15 national health practitioner boards, AHPRA, and accreditation authorities, to develop a Statement of Intent to achieve equity in health outcomes between Aboriginal and Torres Strait and other Australians to close the gap by 2031.

As reported in the previous post, the Statement of Intent has as its centerpiece, the concept of cultural safety.

This is an exciting initiative, and much needed if we are to have a health workforce that is competent to care for patients in a way that respects the “inextricably linked elements of clinical and cultural safety”, as defined by Aboriginal and Torres Strait Islander Peoples.

But, as with most good intentions for change, there are barriers to be overcome.

Newcastle-based Dr Mark Lock, the founder and Director of Committix Pty Ltd, researches, writes about and works in the area of cultural safety and corporate governance for Aboriginal people.

He administers a Facebook group, Cultural Safety and Security, to discuss some of these issues, on which the post below first appeared.

Lock reasoned that, to be able to accredit health services as culturally safe and secure, accreditation agencies would need a solid background in Aboriginal governance and cultural safety themselves.

Working from the list of accreditation agencies in the second edition of the National Safety and Quality Health Service Standards, he set about finding out what information was publicly available about their levels of Aboriginal representation and governance.


Mark Lock writes:

Following-on from the Australian Health Practitioner Regulation Agency (AHPRA) announcement situating ‘cultural safety’ as central to health practitioner regulation, I took a closer look at the governance of health professional accreditation in Australia.

The draft report for the Independent Review of the National Registration and Accreditation Scheme for health professionals (NRAS Review), when referring to the development of health profession competency standards, states:

Whilst the involvement of educators, practitioners and regulatory bodies in the development and review process is identified in many of the competency standards, few mention the involvement of consumers and others (e.g. employers or target population groups such as Aboriginal and Torres Strait Islander advocates) who could provide critical perspectives of community need and broader workforce reform.” (page 83)

The report further states that:

The principle of the ‘wide-ranging consultation requirements’ as outlined in the National Law (s46(2)) for accreditation standards should equally apply to the development of competency standards.” (page 83)

In the same report, the Australian Indigenous Doctors’ Association was quoted as stating, ‘In AIDA’s view, cultural safety should be considered in broad terms across the accreditation context’, and the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives stated, ‘…cultural safety and respectful practice are as important to quality care as clinical safety.’

If Aboriginal peoples’ perspectives are not included in the accreditation of health professionals, then health professionals may not be sensitised to consider Aboriginal peoples’ needs.

This is a major barrier that the AHPRA has to plan to overcome, and it aims to do so through cultural safety training (See the Reconciliation Action Plan, p.11).

One indicator of the height of the barrier to increasing cultural safety in health professional regulation and accreditation through the inclusion of cultural voice, can be seen by examining the accreditation agencies for the National Safety and Quality Health Service Standards (2ed).

Overall, there is little evidence of the representation of Aboriginal peoples’ perspectives.

At 2018, the nine accrediting agencies are:

  1. The Australian Council on Healthcare Standards ACHS (no Aboriginal voice)
  2. DNV GL Business Assurance Australia Pty Ltd (no Aboriginal voice)
  3. BSI Group ANZ Pty Ltd, has accredited one Aboriginal and Torres Strait Islander Community Health Service (Mackay ATSICHS)
  4. AGPAL Group of Companies (the owner of Quality Innovation Performance, QIP) have a case study of accrediting an Aboriginal health service, and the website also has an acknowledgement of Aboriginal people (see also the response below).
  5. Global Mark Pty Ltd note that their staff attended cultural awareness training.
  6. SAI Global Certification Services Pty Ltd (no Aboriginal voice)
  7. HDAA Australia Pty Ltd have acknowledgement on their home page and highlight the Aboriginal experience of staff (Scott Douglas, Terrence O’Brien, and Mary Barram)
  8. TQCS International Pty Ltd have a partnership with independent Aboriginal business advisory firm, Yaran Business Services.
  9. Institute for Healthy Communities Australia Certification Pty Ltd. (no Aboriginal voice).

There is no public evidence available that these accrediting agencies are culturally aware, and there is no public information on how they are trained to accredit healthcare organisations.

I propose that the AHPRA, as part of the regulation and accreditation process, require that accrediting agencies publicly disclose how they received accreditation and how they intend to accredit health professions.


Response from AGPAL & QIP (from Croakey Facebook post):

AGPAL & QIP could certainly more effectively communicate what we currently do to ensure culturally safe assessments of Aboriginal and Torres Strait Islander health facilities on our websites.

AGPAL & QIP take the experience of the Surveying Team into account when assigning Surveyors to assess Aboriginal and Torres Strait Islander health facilities.

It is crucial that Surveyors either have experience working in culturally sensitive environments and/or assessing Aboriginal and Torres Strait Islander facilities, as accreditation can create anxiety for even the most experienced health professionals.

As cultural sensitivity is paramount, we are very careful when choosing the appropriate AGPAL and QIP Surveying Team.

The Australian Commission on Safety and Quality in Health Care is responsible for delivering Cultural Safety training for the the National Safety and Quality Health Service Standards (2ed); these new national standards stipulate that it is compulsory for all Surveyors assessing against the standards to be culturally competent.

AGPAL & QIP are greatly supportive of this requirement and are also currently developing internal cultural competency training to ensure all of the Group’s Staff, Surveyors and Assessors receive up-to-date training.


Dr Mark J Lock is Founder and Director of Committix Pty Ltd. He is founder and administrator of the Facebook Group, Cultural Safety and Security, from which this post was adapted. This group shares information about Indigenous Peoples’ Cultural Safety and Security, discusses that information, and makes connections to promote a global alliance for improving the cultural safety and security of corporate governance. On Twitter @MarkJLock  #culturalsafety #CSHPRA (culturally safe health practitioner regulation and accreditation).


Response from Australian Medical Council

(published 10 August, 2018)

Thank you for this post, discussing a very important issue. The Australian Medical Council (AMC) deeply values the contributions that Aboriginal and Torres Strait Island and Māori people make to the work that we do and actively encourages Aboriginal and Torres Strait Islander and Māori people and organisations to work with us.

The AMC is an independent national standards body for medical education and training. The AMC’s purpose is to ensure that standards of education, training and assessment of the medical profession promote and protect the health of the Australian community. The AMC develops standards and accredits education programs under the Health Professional Regulation National Law Act 2009. The preparation of students to become safe, competent practitioners, who are eligible to register with AHPRA as a medical practitioner, is structured and confirmed by assessment of programs against the relevant AMC accreditation standards.

The AMC introduced Indigenous health standards as part of its accreditation process in 2006, and has included Aboriginal and Torres Strait Islander and Māori representation in AMC accreditation assessment teams and consulted Aboriginal and Torres Strait Islander and Māori on the development and review of accreditation standards from this time. Organisations such as the Australian Indigenous Doctors Association (AIDA) and Leaders in Indigenous Medical Education (LIME) have been essential in critically questioning AMC proposals and informing and improving AMC developments.

Despite these important developments, the AMC recognised that they were to some extent, stand-alone facets, and that the AMC had not articulated and embedded its commitment to improving the health of Aboriginal and Torres Strait Islander and Māori people or supporting Aboriginal and Torres Strait Islander and Māori medical students and practitioners within the organisation. The AMC committed to a whole-of-organisation response which commenced with the establishment of the AMC Indigenous Planning Advisory Group in 2015, and continues today with the Aboriginal, Torres Strait Islander and Māori Strategy Group.

The Advisory Group brought together Indigenous stakeholder organisations and AMC leaders to support inclusive planning and development across all of the AMC functions. Over a two year period, the Advisory Group developed a work plan for the AMC which is now being taken forward across the organization. To date, some of the actions have been:

  • A statement of AMC purpose and values for Indigenous health
  • Aboriginal and Torres Strait Islander and Māori representation on all AMC standing committees and Council (as well as on accreditation assessment teams)
  • Commitment to cultural safety training.

The AMC has finalised its strategic plan, which includes a dedicated pillar devoted to promoting Aboriginal, Torres Strait Islander and Māori health and ensuring culturally safe practice to improve health outcomes. The Aboriginal, Torres Strait Islander and Māori Strategy Group will oversee the implementation of the AMC’s strategy in Indigenous health and advise AMC Directors on key matters related to Indigenous health, including AMC’s stated purpose of making health systems free of racism and inequality.

The AMC has been challenged by and has benefitted from embarking on these activities. We would encourage other organisations to explore ways to include Aboriginal, Torres Strait Islander and Māori voices in their own organisation. The AMC welcomes input from an individuals or organisations who might be able to contribute to our journey.

Comments 2

  1. Mark Lock says:

    Just a follow-up comment. The AGPAL and QIP responses are unsupported by any publicly available evidence. As private companies any information they provide to the ACSQHC on the cultural competency of their staff is covered by corporate confidentiality protection. Therefore, it is impossible for Aboriginal citizens to judge the ‘safety’ of accrediting agencies – and it is Aboriginal citizens who should determine if an organisation is ‘culturally safe’ (a key principle of cultural safety). Therefore, how are Aboriginal citizens to trust if healthcare organisations are safe if the accreditors’ competency is non-disclosed? Furthermore, the ACSQHC awards accreditation to accreditation agencies and the information they provide to the ACSQHC is also corporate-in-confidence. A conflict of interest then becomes apparent. Accreditors assess healthcare organisations who receive accreditation from ACSQHC who also accredit the accreditors. All information provided is corporate-in-confidence, that provided from accreditors to ACSQHC, from healthcare organisations to accreditors, and from healthcare organisations to ACSQHC. Within this triangle of relationships (healthcare organisations, accreditors, and ACSQHC), the c-suite decision makers are non-Aboriginal, and they have agreed that Aboriginal citizens are locked-out of reviewing information and their decisions which goes against the governance principles of transparency and accountability to stakeholders and thus contradicts the second standard (partnering with consumers) of the NSQHS Standards 2nd Ed. This reveals the greatest contradiction of requiring healthcare organisations to partner with consumers but the accreditors and the ACSQHC are not subject to the standards they wish others to abide by. These challenges are faced by the AHPRA in the pursuit of culturally safe health professional accreditation – the challenge is to focus inward to the corporate governance of the organisation because cultural safety should be more than clinician and patient interactions but also extend to how the interactions between people in governance and administration influence the cultural safety of an organisation.

  2. Mark Lock says:

    Thanks to the Australian Medical Council for providing a response to this Croakey health post. The AMC shows (being transparent and accountable) that it is working hard to improve its governance processes so that cultural voice is included in medical accreditation.

    I’ll make a fuller assessment in due course but just for today I will highlight that this information from their post could be provided on the AMC’s website: a formal report of these activities to Australian Aboriginal citizens who may access the website, and transparency about the membership, terms of reference, activities, and decisions of the committees ( AMC Indigenous Planning Advisory Group, Aboriginal, Torres Strait Islander and Māori Strategy Group, AMC Standing Committees, or AMC Strategic Plan). Therefore, I cannot ‘see’ the ‘how’ the AMC processes flow through the organization and its accreditation processes.

    As an external auditor, I would like evidence and justification for the effectiveness of these processes for improving cultural safety through medical accreditation. One of the main points in the Croakey post is that accrediting organisations (e.g. AMC) are self-regulated and not subject to external and independent oversight – who assess the accreditors?

    This is philosophically important because cultural safety implies a separation of power between Western-derived mainstream colonial structures and Australia’s First Peoples and…here the argument is complicated and I don’t propose answers at this point…this could be put in practice through formal partnerships with, e.g. NACCHO Aboriginal Health Australia (who have an excellent paper on cultural safety training). As it stands, the AMC has ‘internal’ processes and engages professional Aboriginal ‘experts’ (not community representative organisations) such as members of the Australian Indigenous Doctors’ Association and The Leaders in Indigenous Medical Education (LIME) Network. I am not arguing if this is right, wrong, or otherwise. I’m arguing that these arguments need to be discussed through critical, theoretical, and research processes that are transparent and accountable to Aboriginal citizens.
    #AFPcultural_safety #CSPHRA

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