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					                                       A New Model of
                       Clinical Placement Governance
                                         in Victoria


                                        Final Report
                                        to
                        Council of Victorian Health Deans
                                     and the
                         Department of Human Services


                                          June 2009




Darcy Associates Consulting Services
Clinical Placement Governance Project – Final Report



Table of Contents
ABBREVIATIONS ........................................................................................................ V


EXECUTIVE SUMMARY ............................................................................................. VII


1           INTRODUCTION ................................................................................................. 1

1.1         Training of health professionals in Australia ........................................................................... 1

1.2         Clinical education in context ................................................................................................. 1

1.3         Current arrangements for the organisation and management of clinical placements in Victoria ..... 2

1.4         Major issues affecting clinical placements in Victoria ............................................................... 3

1.5         Addressing the issues.......................................................................................................... 4

1.6         Background to this project: the new national context .............................................................. 5

1.7         Approach ........................................................................................................................... 6
    1.7.1        Project conduct and oversight ......................................................................................................... 6

    1.7.2        Project scope ................................................................................................................................ 6

    1.7.3        Project tasks................................................................................................................................. 7


2           LITERATURE REVIEW ........................................................................................ 8

2.1         Methods ............................................................................................................................ 8

2.2         Findings ............................................................................................................................ 8
    2.2.1        Multiple health service partnerships ................................................................................................. 8

    2.2.2        Partnerships between health services and non-medical disciplines ....................................................... 9

    2.2.3        Managing competition for sites ...................................................................................................... 11

    2.2.4        A database for clinical placement allocation ..................................................................................... 12


3           STAKEHOLDER CONSULTATIONS ..................................................................... 14

3.1         Methodology .................................................................................................................... 14

3.2         Findings .......................................................................................................................... 14
    3.2.1        Overall impressions: A sector ready for change and willing to act ....................................................... 15

    3.2.2        The need for a better placement allocation process .......................................................................... 15

    3.2.3        Building on the current system ...................................................................................................... 16

    3.2.4        Modifying the current system......................................................................................................... 17

    3.2.5        New elements for inclusion in the new system ................................................................................. 17

    3.2.6        Regional boundaries and network membership ................................................................................ 18

    3.2.7        How regional networks will conduct their business ............................................................................ 19

    3.2.8        Integrating regional networks into the broader context ..................................................................... 19




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    3.2.9        The role of simulation in clinical education ....................................................................................... 20


4           DIVIDING VICTORIA INTO REGIONS .............................................................. 21

4.1         Overview ......................................................................................................................... 21

4.2         Existing regional divisions in Victoria ................................................................................... 21
    4.2.1        DHS regions ................................................................................................................................ 21

    4.2.2        Health service delivery networks .................................................................................................... 22

    4.2.3        Health education networks ............................................................................................................ 24

4.3         Current clinical placement activity in Victoria ....................................................................... 24
    4.3.1        Methodology ................................................................................................................................ 25

    4.3.2        Findings ...................................................................................................................................... 26

4.4         Boundaries for the proposed regional clinical placement networks .......................................... 29


5           OPTIONS CONSIDERED IN THE DEVELOPMENT OF A NEW MODEL ................... 32

5.1         Overview ......................................................................................................................... 32

5.2         Regionally-based networks ................................................................................................ 33

5.3         Health setting-based networks ........................................................................................... 34

5.4         Education provider-based networks .................................................................................... 35

5.5         Discipline-based networks ................................................................................................. 35

5.6         Stakeholder feedback on the proposed models ..................................................................... 37


6           THE RECOMMENDED MODEL ............................................................................ 38

6.1         The proposed regional clinical academy model: an overview .................................................. 38

6.2         Fundamentals of the model ................................................................................................ 38

6.3         How the model will operate ................................................................................................ 43

6.4         Implementation ................................................................................................................ 56

6.5         Beyond implementation ..................................................................................................... 59
    6.5.1        Evaluation ................................................................................................................................... 59

    6.5.2        Sustainability ............................................................................................................................... 60

    6.5.3        Scalability ................................................................................................................................... 60

    6.5.4        Looking to the future .................................................................................................................... 61


7           SUMMARY AND CONCLUSIONS ........................................................................ 63


8           BIBLIOGRAPHY ............................................................................................... 64


9           APPENDICES ................................................................................................... 66




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Abbreviations

ACCV       Aged and Community Care Victoria
BECC       Bundoora Extended Care Centre
BMS        Bristol Medical School
COAG       Council of Australian Governments
CSP        Commonwealth Supported Places
CSSW       Combined Schools of Social Work
CVHD       Council of Victorian Health Deans
DEEWR      Department of Education, Employment and Workplace Relations
DHS        Department of Human Services
GP         General Practitioner
HSPnet     Health Science Placement Network
IMG        International Medical Graduates
LAMP       Latrobe and Monash Partnership
LGA        Local Government Area
MAP        Monash at Peninsula
NHWT       National Health Workforce Taskforce
OSA        Oregon Simulation Alliance
PCP        Primary Care Partnership
RCA        Regional Clinical Academy
RTO        Registered Training Organisation
TAFE       Technical and Further Education
VCPC       Victorian Clinical Placements Council
VET        Vocational Education and Training
VMA        Victorian Metropolitan Alliance
VTAC       Victorian Tertiary Admissions Centre




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Executive Summary
In 2007, the Victorian Department of Human Services (DHS) unveiled a comprehensive
strategy aimed at enhancing the capacity and quality of clinical placements across all health
disciplines in Victoria. This strategy promotes an integrated approach to allocation and use of
existing resources, innovation and efficiency in the development of new resources, and
planning and funding for clinical placements.

The DHS strategy has recently taken on a greater significance, as there is now considerable
activity at the national policy level in relation to clinical placements. In 2006, the Council of
Australian Governments (COAG) agreed to a range of health workforce reforms, including the
establishment of the National Health Workforce Taskforce (NHWT). The Education and Training
Program of the NHWT has established a Clinical Education and Training Project, to consider
possible new models for planning, management, allocation and resourcing of clinical
placements across all disciplines. In November 2008, COAG agreed to further significant health
workforce reforms, including an additional $1.1 billion over four years in Commonwealth
funding for health workforce initiatives across Australia.

In this new national context, Victorian initiatives have the potential to inform policy and
developments at the national level. To advance the process in Victoria, the DHS established a
Project Steering Group and invited the Council of Victorian Health Deans to lead the
development of a regionally-based model for managing clinical placements in Victoria.

This report details the findings of a project conducted over a ten-week period (March – June
2009). The first phase involved the collection of data from key stakeholders via interview and
mapping of current clinical placement activity, to inform the development of a set of options
for the new model. The second phase involved a series of roundtable discussions to consider
potential governance models.

This report also explores the recommended model for clinical placement governance within
Victoria. Significantly, the model proposed for Victoria is unique in the world, as it will involve
all disciplines, all health education providers, all clinical placement providers and all clinical
placements.

The proposed model for establishing regional clinical placement networks – termed regional
clinical academies – involves a multi-tiered matrix of councils and committees that will deal
with the hierarchy of issues that must be addressed to produce a system that functions
effectively and efficiently. The key to the success of the model is that it brings together
relevant stakeholders at each stage of the process to resolve the issues that are the building
blocks for the next stage.

The recommended model utilises health professional disciplines as the foundation for a new
system for managing and organising clinical placements. Discipline groupings – termed
discipline councils – will be responsible for developing the policies, principles and practices that
will serve as the framework for negotiations (at the regional level) between education
providers and health services. The advantage of this approach is that it is expected to result in
consistent practices that (a) facilitate inter-regional exchange; (b) reduce complexity for
health services that deal with multiple education providers; (c) improve consistency for
education providers dealing with multiple health services in multiple regions; and (d) assist
institutions with forward planning. The nature of the framework is expected to differ between
disciplines.

Once the framework has been developed for each discipline, sub-committees corresponding to
each region – termed regional discipline committees – will be convened to implement the
framework locally. Regional clinical academies will draw together all the regional discipline
committees for each region and provide a forum for sharing ideas and resources, discussing
and devising solutions in relation to interprofessional education and other issues of multi-
disciplinary interest or concern, developing regional priorities for capacity building and
infrastructure, and will serve as a platform for innovation and research.




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It is recommended that the regional groupings in the model be based on eleven regions across
Victoria, with five rural regions corresponding to the existing DHS regional boundaries and six
metropolitan regions. A „stakeholder owned and driven‟ body, the Victorian Clinical Placements
Council, will provide statewide leadership and advice on clinical placement issues and provide
oversight on projects that have an impact at state level.

This report is presented in nine sections.

Section 1: Introduction – provides context and background for the project and describes the
approach adopted for the conduct of the project.

Section 2: Literature review – presents the pertinent findings of a brief literature review,
highlighting papers of particular relevance to the Victorian context.

Section 3: Stakeholder consultations – presents the findings from 23 stakeholder
interviews involving 87 participants from a range of organisations including universities,
vocational education and training institutions, Regional Training Providers, public and private
health services, GPs, simulation facilities and the DHS.

Section 4: Dividing Victoria into regions – considers appropriate regional boundaries for
the new system against the backdrop of existing health service and health education regions.
Using the Google Earth software package, maps of current clinical placement activity (sorted
based on education provider and discipline) are presented.

Section 5: Options considered in the development of a new model – describes three
options to achieve a regional system for managing clinical placements. Feedback received on
each model at the roundtable discussions is also presented.

Section 6: The recommended model – presents greater detail on the workings of the
recommended model, as well as a discussion on implementation and post-implementation
issues.

Section 7: Summary and conclusions – provides a summary of the findings of the project
and identifies key success factors.

Section 8 Bibliography - includes all references cited in the report.

Section 9 Appendices – includes supplementary information for Sections 3, 4, 5 and 6,
including a list of likely stakeholders for each of the proposed regional clinical academies.




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1 Introduction

1.1 Training of health professionals in Australia
Entry-level training of health care professionals is the responsibility of the post-secondary
education sector, which develops the curricula for these courses. The major education
providers are universities, as well as Technical and Further Education (TAFE) institutes and
other Registered Training Organisations (RTOs) in the vocational education and training (VET)
sector. Funding for courses run by public tertiary institutions principally comes through
Commonwealth supported places (CSP) for students. All universities in Victoria offer courses in
one or more health care professions.

Historically, entry-level health professional courses at universities have been offered as
undergraduate programmes open to school-leaver applicants. There is a growing trend
towards graduate-entry courses that lead to bachelors, masters or doctoral qualifications,
although many of the higher degree courses still produce entry-level practitioners. There are
also a number of postgraduate awards and courses for qualified practitioners.

The majority of university-based health courses – and many courses offered by VET
institutions – include clinical training as an essential component of their curricula. The
requirement for clinical training is stipulated in the guidelines of the relevant registration or
accreditation bodies[1].

Importantly, the compulsory nature of clinical placements means that a significant share of
responsibility for training future health professionals lies with health services, with registered
clinicians being the main effectors of educational delivery in those settings. Furthermore, the
availability of clinical education places a natural limit on the number of health professional
student places. This is particularly important in times of actual or projected workforce
shortages, because simply increasing the number of students enrolled in health professional
courses without regard to the capacity for clinical education for those students places a
significant additional impost on an already over-burdened health service sector.

1.2 Clinical education in context
Clinical education is teaching and learning that is focussed on – and usually directly involving –
patients in clinical settings[2]. Clinical education is usually delivered to entry-level students
through clinical placements, which provide students with an opportunity to integrate and apply
knowledge, skills and attitudes taught in the classroom in a clinical setting. Clinical placements
also provide students with the opportunity to learn skills more difficult to teach in a classroom,
such as professional conduct and communication skills.

The term clinical placement covers a significant variety of activities. Among different health
professions clinical placements vary considerably in their format and duration (ranging from
less than 500 hours to over 2,500 hours), as well as in their philosophical underpinnings and
educational approaches. Within health professions, there is also considerable variation, with
different courses working from different educational and supervision models and scheduling
placements at different stages in their courses and for different periods of time [3].
Unsurprisingly, clinical placements also vary across health care settings, with the range of
experiences that students are exposed to varying depending on the location, acuity and
breadth of services offered by each setting. It should also be noted that some disciplines place
learners in non-health care settings, including social care and other service settings (such as
educational institutions), to gain the necessary practical experience.

Clinical placements are part of a continuum of education and training for most health
professionals that starts during a formal course offered by a university or VET institution and
continues post-qualification. After the early postgraduate years, further vocational or specialist
education may occur (depending on the profession) and all disciplines engage in ongoing
professional education/development that continues throughout professional practice.




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Importantly, post-qualification training does impact on the ability of health services to cater for
entry-level students, since some health service clinical education capacity must be devoted to
post-qualification learners.

1.3 Current arrangements for the organisation and management of clinical
    placements in Victoria
Most clinical training in Victoria occurs in the public health sector and, with very few
exceptions, most clinical placements for entry-level health professional courses arise through
bilateral negotiations between individual education providers and individual health services.
Thus, a key component of the current system is the set of relationships that exist between
education providers and the range of health services through which they place their students.
Some of these relationships are long-standing and may involve considerable investment
(personnel, infrastructure, other resources) made by the education provider in the health
service, while other relationships have been established more recently. In some cases, these
relationships have resulted in exclusive arrangements, whereby the health service only
accommodates students from a single education provider for a given discipline, although the
majority of arrangements do not fall into this category.

Although bilateral relationships underpin the whole system, the actual mechanism for
organising and managing clinical placements varies by discipline and by education provider.
This mainly reflects the different models of clinical education that different disciplines (or
education providers) employ, as well as structures that exist to support clinical education. For
example, in the case of medicine, hospital-based clinical placements for students are organised
through clinical schools based within hospital networks. The clinical schools accommodate an
agreed number of medical students in each year of the course and, although the clinicians who
are involved in teaching/supervising may vary from year to year, the programme remains
constant. Clinical schools are not simply a matter of placement numbers; they also represent
joint investment in staff, shared responsibility for curriculum development, sharing of
resources, clinical education support and research.

In recent years, disciplines other than medicine have started to make use of the clinical school
model, including physiotherapy (e.g. The University of Melbourne[4]) and nursing (e.g. La
Trobe University[5]). Although not referred to as clinical schools, the Monash at Peninsula
(MAP) programme[6] and Latrobe and Monash Partnership (LAMP) programme embrace a
similar concept, with a well-defined partnership between an education provider (Monash
University) and a health service (Peninsula Health and Latrobe Regional Hospital, respectively)
as the basis for an agreed nursing clinical education programme.

Where clinical school models are not employed, the organisation of clinical placements is far
more ad hoc and the numbers of students placed at a given site by a given education provider
from one year to the next is far more variable. Education providers make their placement
requests several months in advance and are notified of their placement allocation many weeks
(or months) later. Historical relationships do not necessarily guarantee continuity of allocation
in this system and health services may vary the numbers of places they offer according to a
range of factors. These include[7]:
 Willingness and workload of staff.
 Physical environment factors (such as the availability of tutorial rooms and other
    resources).
 Patient numbers and mix.
 Available caseload for learning purposes.
 Availability of clinical and educational staff.
 Staff expertise in the required clinical area.

Thus, the organisation of clinical placements is an annual – and usually ongoing – process for
most Victorian education providers. Even once placements are organised for a particular cohort
of students, clinical education coordinators at universities and VET institutions are kept busy
with placement re-scheduling resulting from unforeseen circumstances, such as unplanned




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ward closures and students being unable to complete a scheduled placement. The effort
required in re-scheduling even small numbers of placements is considerable, because this
usually occurs in an environment where most placement capacity is already allocated.

Although there is a growing body of evidence that coordination between education providers is
an important measure in addressing clinical placement shortages [8], there are currently very
few instances of this in Victoria. The most notable example is in Social Work, where the
Combined Schools of Social Work (CSSW) provides shared administrative management of
placement planning and implementation for the six Victorian university Social Work
programmes[9]. CSSW has developed a joint database resource that facilitates cooperative
placement allocation amongst the Social Work schools on the principle that all schools should
have equal access to quality field placements.

1.4 Major issues affecting clinical placements in Victoria
The two major issues in respect of clinical education in Victoria relate to the quantity of
available placements and the quality of those placements.

The problem of clinical placement shortages is not unique to Victoria (or Australia). Academic
literature from around the world indicates similar shortages in North America, Europe and Asia,
and the issues are well-defined[8]. Research and anecdotal evidence indicates placements are
in short supply because:
 There are more students undertaking health professional courses, as well as a greater
     number of education providers offering the same course[8].
 Patient care is shifting from acute settings (which can accommodate larger numbers of
     students) to ambulatory settings (which generally accommodate fewer students) [10].
 The changed profiles of service delivery and health issues affecting the population have
     placed new requirements on the skills and competencies needed by graduates, increasing
     the complexity of the clinical education they must undertake during their course[10].
 Clinical education for each discipline takes place at specific times in the overall curriculum,
     creating a series of peaks and troughs in demand.
 Health services have greater productivity demands (in terms of patient care) placed upon
     them and clinical education is seen as inefficient in this context[11].
 The health workforce is ageing and increasingly feminised; many experienced clinical
     educators have retired (or are close to retirement), while many potential clinical educators
     only work part-time[10].
 Private health services now play a greater role in patient care, so some clinical experiences
     are harder to find in public health care settings. However, private health services have
     different imperatives and drivers, with clinical education viewed as a lower priority[10].
 Student cohorts (on average) are older, more ethnically diverse, and have enrolled in their
     current course through a more diverse range of pathways (i.e. not all are school-leavers,
     some are mature age[12], some are undertaking their second degree, etc.); in many cases,
     this affects when and where they are able to undertake placements[10].
 Policy at different levels (or in different branches) of government creates competing – and
     sometimes conflicting – imperatives for health services and education providers.

In recent years, the Commonwealth government has responded to current and projected
shortages in the national health workforce by dramatically increasing the number of CSPs in
health professional courses. Victoria campaigned successfully to secure a significant proportion
of these places. As a result, since 2007, the state has seen substantial growth in the number
of CSPs allocated to its undergraduate health courses, including two new graduate-entry
medical schools, new schools in physiotherapy and occupational therapy, and large increases
in student numbers in a range of existing schools[13]. This increase, and the increase in VET
sector places, is necessary to provide the pipeline of health professional graduates needed in
Victoria in the next two decades. However, the corresponding increase in the number of clinical
placements required to appropriately train these students has added to the burden on health
services and created further competition amongst education providers for the limited clinical
placement capacity.




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The second major issue – that of placement quality – is, in some regards, another dimension
of the capacity issue. That is, increasing the number of students that must be accommodated
in an already over-burdened system, without increasing genuine capacity, is likely to reduce
the overall quality of clinical education that is delivered. Quality is a concept that is intuitively
understood but has not been well-defined in relation to clinical education. A recent project
looking at best practice in clinical learning environments in Victoria [14] defined six elements as
the essential underpinnings for a quality clinical learning environment:
 An organisational culture that values learning.
 Best practice clinical practice.
 A positive learning environment, which incorporates elements such as: a welcoming
    environment for students, appropriate learning opportunities, high quality clinical education
    staff, and appropriate ratios of learners to both educators and patients.
 A supportive health service-training provider relationship.
 Effective communication processes.
 Appropriate resources and facilities.

There is now general acknowledgement that when the issue of clinical placement capacity is
seen only as a question of the number of placements without examining the determinants of
quality, the outcome is not likely to really address the problem or be sustainable.

1.5 Addressing the issues
There are a number of reports in the literature of approaches to managing clinical placement
capacity issues and the literature review presented in Section 2 highlights some of the
initiatives that are particularly relevant to Victoria. Although the problems are usually defined
and addressed in relation to individual disciplines, the solutions tend to be similar regardless of
the discipline. Common approaches include:
 New (evidence-based) models of clinical education. These models involve changes to
     one or more variables, such as: clinical placement duration, timing of the placement in the
     context of the course/year, number or qualifications of supervisors, ratios of supervisors to
     students, expanded range of settings, and the increased use of simulation and other
     technology[10, 15].
 Removing barriers to taking students. This might be achieved through working with
     health services to change their perceptions about clinical education, providing
     infrastructure to equip health services to take students, increased funding, and education
     and training support for clinical educators[10, 16].
 Collective action (as a discipline) to create new sets of standards and facilitate
     coordination and communication[17]. This can include coordinated submissions to
     government to address government policies impacting on clinical education.
 New approaches to partnerships between education providers and health services
     to encourage innovation, research and mutual support[5].

Importantly, while most of the reported initiatives have been successful, the literature
highlights the difficulty in achieving change. For the most part, this is attributed to difficulty
convincing clinical educators about the value and effectiveness of alternate models.

In Victoria, the Department of Human Services (DHS) has developed a comprehensive strategy
aimed at enhancing the capacity and quality of clinical placements across all health disciplines.
The department‟s strategy, articulated in a document published in October 2007 (Clinical
Placements in Victoria: Establishing a Statewide Approach[13]), promotes an integrated
approach to allocation and use of existing resources, innovation and efficiency in the
development of new resources, and planning and funding for clinical placements. The
department has conducted scoping work in medicine, nursing and allied health to examine
existing clinical placement arrangements and assess the impact of recent growth in student
numbers[18]. It has also funded 19 innovation projects[18], commissioned the development of a
best practice framework for clinical learning environments[14] and conducted extensive
stakeholder consultation on the concept of a statewide clinical placement agency [19, 20].




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1.6 Background to this project: the new national context
The extent of involvement of state and territory governments in managing and organising
clinical placements varies around Australia, but there is now considerable activity at the
national policy level in relation to clinical placements. The Australian Government has always
been primarily responsible for policy and funding in the university sector (currently through the
Department of Education, Employment and Workforce Relations, DEEWR), with the
responsibility for determining medical school places shared between DEEWR and the
Department of Health and Ageing. The funding for medicine and nursing courses includes an
explicit clinical training component, although this has not been the case for allied health
courses. The Australian Government also contributes to funding of the VET sector, which is
also funded through state government budgets; there is no explicit clinical training component
of VET sector funding.

In 2006, the Council of Australian Governments (COAG) agreed to a range of health workforce
reforms, including the establishment of the National Health Workforce Taskforce (NHWT)[21].
The NHWT is hosted by the Victorian DHS and its role is to develop strategies in the major
programme areas of education and training, innovation and reform and planning, research and
data. According to the NHWT website:
“The key objectives of the Education and Training Program are to:
 Investigate ways to maximise the capacity of the health and education systems to provide
   sufficient numbers of appropriately trained and qualified graduates to meet projected
   demands.
 To develop strategies to ensure that education and training is appropriate, responsive and
   relevant to changing health system needs and that it supports innovation and reform in the
   workforce.”

The Education and Training Program auspices a number of projects, including investigation of
health sector education pathways and development of core competency frameworks. Of
particular relevance to the project described in this report is the Clinical Education and Training
Project, the primary purpose of which is the development of “a range of recommendations on
effective, sustainable approaches to the delivery and organisation of clinical training in all
medical, nursing and allied health professions involving all jurisdictions and relevant education
providers”[22]. This five-stream project was established to consider possible new models for
planning, management, allocation and resourcing of clinical placements across all disciplines.

In November 2008, COAG agreed to further significant health workforce reforms, including an
additional $1.1 billion over four years in Commonwealth funding for health workforce initiatives
across Australia[23]. This includes:
 approximately $500 million for a new clinical placement subsidy (with full matching funding
    from the state and territory governments);
 $28 million for development of clinical training supervision capacity;
 over $90 million for simulated learning environments (including $45.6 million for capital
    infrastructure and $48.48 million for ongoing operation);
 $90 million to support innovative clinical teaching and training initiatives; and
 $40 million to establish or expand education and training at major regional hospitals.

The reform package also includes the establishment of a national health workforce agency
(Health Workforce Australia), which will subsume the NHWT and its work programme.

Since the November 2008 COAG announcements, the NHWT has produced a discussion paper
on clinical training governance and organisation, as well as a direction paper on data
management systems for clinical traininga. The NHWT has also conducted forums in early
2009, exploring how the new national agency can best support the management of clinical
education across Australia.



a
 These papers can be downloaded from the NHWT website http://www.nhwt.gov.au/training.asp (Accessed 7 June
2009).




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In this new national context, the DHS strategy to develop a more integrated and sustainable
approach to allocation and use of the state‟s clinical placement resources takes on a greater
significance, since Victorian initiatives have the potential to inform policy and developments at
the national level. To advance the process in Victoria, the DHS established a Project Steering
Group, which includes representation from major education provider and health service
provider stakeholders (see Appendix 1). The DHS invited the Council of Victorian Health Deans
(CVHD; see Appendix 2) to lead the development of a regionally-based model for managing
clinical placements in Victoria, reporting to the Project Steering Group, and the CVHD engaged
a consultant to assist them with this process.

1.7 Approach

1.7.1 Project conduct and oversight
The project was undertaken by Darcy Associates Consulting Services, who assembled a project
team of two consultants, namely Dr Donna Cohen and Dr Richard Huysmans. Dr Cohen was
responsible for project management, liaison with DHS and was the primary point of contact for
project participants and stakeholders.

The CVHD and the Project Steering Group provided oversight of the project.

1.7.2 Project scope
The consultants were engaged to assist the CVHD in addressing their brief to develop a model
of clinical placement governance that is expected to achieve the following outcomes:
 A functional governance structure that is able to bring stakeholders together to address
    clinical placement issues within any given network;
 A map of clinical placements within the geographical region served by the network,
    including accurate annual data on clinical placement activity;
 A clinical placement planning system that expands capacity, increases the quality of
    placements, and provides flexibility for addressing changes in arrangements;
 Identification and implementation of solutions for identified barriers to improving clinical
    placement capacity and quality;
 Identification and support of local innovation, particularly where an interprofessional
    learning approach is used;
 Identification and support of expanded settings for clinical placements, including through
    the use of simulated learning environments; and
 An evaluation of the new governance and planning system.

Specifically, the consultants were asked to:
 Consult with stakeholders about their views on a new model of governance.
 Develop a regionally based model for organising and managing clinical placements and
   simulation in Victoria that takes account of stakeholder preferences and is able to achieve
   the outcomes set out in the brief to the CVHD (listed above).
 Recommend an appropriate (and manageable) number of regional clinical placement
   networks and identify the stakeholders for each network.
 Identify the resources needed to implement the model.
 Discuss the sustainability and scalability of the proposed model.

Although the project was specifically aimed at developing a new model of governance for
clinical placements undertaken by students enrolled in entry-level health professional courses,
the consultants were also asked to consider how vertical integration of education and training
might work in the proposed model.




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1.7.3 Project tasks
Owing to the short timeframe for the project, most tasks were conducted concurrently over a
two-month period, April-May 2009. The major tasks of the project are set out in Table 1.
Table 1: Project tasks

 Task     Task
  No.
   1      Literature review
   2      Interviews with health deans and faculty managers
   3      Interviews with members of Project Steering Group
   4      Collecting and mapping current clinical placement data
   5      Devise basis for regional network boundaries and draft a starting position for
          principles of management and operation
   6      Roundtable discussions with two hypothetical regional networks
   7      Presentation to Council of Victorian Health Deans and Project Steering Group
   8      Report preparation




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2 Literature review
A literature review was conducted to provide context for this project and to determine how
other jurisdictions are dealing with the management and organisation of clinical education. It
was not intended to be a comprehensive literature review on the subject of clinical placement
issues and solutions and thus was not conducted as a systematic review. The information and
examples cited below are presented because of their potential applicability to Victoria.

2.1 Methods
Academic literature relevant to this project was identified through searches of online databases
including Ovid, Medline Ovid and PubMed. Some academic literature and web-based
information was obtained through searches using the Google internet search engine.
Participants also suggested specific reports for review.

In   internet and database searches, the following terms were used:
     Clinical placement (+/- governance)
     Clinical education
     Clinical education network
     Education network
     Clinical cluster
     Clinical school

2.2 Findings
Twenty-one articles were downloaded and examined in detail as part of this literature review.
Many more were viewed briefly online. As expected, many other countries around the world
are experiencing similar problems to Victoria and the rest of Australia. Solutions vary, but their
themes are the same. The following discussion reviews five reports in detail, as it was felt the
information they presented was of value when considering the management and organisation
of clinical education within Victoria.

2.2.1 Multiple health service partnerships
One of the unique elements of the clinical placement governance system being considered for
Victoria is the need to include many education providers and many health services in the
decision-making and educational processes. Although no reports could be found that
considered multiple disciplines, there were some that considered multiple (and varied) health
services. One such article, published in 2007, focused on a medical school in Bristol, UK [24].

In 2000, Bristol Medical School (BMS), a well-established medical school in England, increased
its student numbers by 50%, growing from 165 to 250 at each intake. Prior to the increase, it
was already widely recognised the services BMS was using for clinical education (primarily
located in the Bristol area) were approaching capacity. Thus, a 50% increase was expected to
exceed capacity. Although the medical school made use of surrounding counties, there was
resistance to expanding use of the counties for significant medical education. Similarly to the
Victorian situation, it was known health services in the counties provided a good educational
experience and there were clinicians willing to provide the education (albeit they were
untrained as educators).

Combining these factors (limited use of surrounding counties, good student experience and a
potential education workforce), BMS proposed the formation of Clinical Academies. As
described in the article, the major feature of the model is the decentralisation of clinical and
academic teaching through the formation of seven academies. However, of greater relevance
to clinical education within Victoria, is the multi-stakeholder partnerships that exist between
hospitals, mental health services, primary care services and BMS. Together, these
organisations are equally responsible for the clinical education, academic education, academic
leadership, seminars, administration and support of students within the academy.




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Of further relevance to Victoria is the location of the academies. There are two in Bristol itself,
and a further five in the surrounding counties. Although the five academies outside Bristol are
in locations BMS has traditionally made use of, BMS negotiated with three other nearby
medical schools to rationalise their clinical placements and avoid (potential) territorial disputes.

Acknowledging there might be difficulties implementing the new model, prior to its introduction
BMS conducted a series of road shows, explaining the concept and how it would work. In some
cases, senior hospital clinicians were enthusiastic and led developments from the start. In
other cases, clinicians were sceptical and the school had to identify key (enthusiastic)
individuals to provide and maintain the momentum for academy development.

The successful creation of each clinical academy has been attributed to the Academy Medical
Dean, responsible for leading each academy. Prior to making these appointments, BMS
recognised their importance and selected individuals who had the confidence and respect of
local colleagues. Academy Medical Deans were appointed from hospital or general practitioner
staff within the academy‟s catchment area. A track record in clinical leadership and
management was viewed as more important for these roles than a medical education
qualification.

From an education and student satisfaction perspective, the academies have been successful.
Firstly, the number of students undertaking clinical education increased (from 165 to 250 per
year level). Importantly student results are no different across academies and student
satisfaction is actually higher in the academies outside Bristol (compared to those within
Bristol). The academies have not been without their problems. For example, in the early
stages, one academy had limited local student accommodation, while there have been
difficulties recruiting some specialists for another academy. This has led to a modification of
the model that allows limited redistribution of students to other academies in situations where
the curriculum cannot be delivered.

Although there are differences between the Victorian and British health care and health
education systems, this paper indicates it is possible to have many health services working
together to increase the number of clinical placements.

2.2.2 Partnerships between health services and non-medical disciplines
Within Victoria, La Trobe University has developed some of the most progressive examples of
non-medical clinical schools. In 2004, in response to a desire to increase research-led practice
in nursing and to provide a better educational experience for their students, the La Trobe
University School of Nursing and Midwifery (now called the Division of Nursing and Midwifery)
established the Gerontic Nursing Clinical School at the Bundoora Extended Care Centre
(BECC)[5].

As with the traditional medical clinical school model, this clinical school locates its academic
staff at the health service, in this case BECC. The university provides resources to support and
deliver clinical education on site. These resources include educator training, library facilities,
research base (including the supervision of research students) and management of student
clinical placements. The role of BECC is to provide space for the school, clinical placement
opportunities, some funding for educator training and clinical staff support, and joint funding
for research activities.

Some of the intended outcomes from the formation of this clinical school were an improved
commitment to learning from the university and clinical site, stronger partnerships between
fewer agencies, clinical staff having better access to further education and reduced costs to
both parties.

For the most part, this clinical school has been described as a success. Academic staff from the
clinical school and BECC share the same facilities and health service staff have access to
undergraduate and postgraduate education (including starting student-led research projects).
As clinical and academic staff are working closer together, the student education model is
more team focused and student assessment tools have been modified to make them easier to




Darcy Associates Consulting Services                                                             9
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use without reducing their academic rigour. BECC has funded a research programme on clinical
practice improvement and this has ensured the research conducted in the clinical school
responds to problems affecting BECC clinicians.

The success of this model has been attributed to a strong commitment to the school by the
leadership of both organisations, but there have been challenges along the way. Relocating the
relevant academic nurses from campus to clinic increased IT, equipment and travel costs to
support those academics. There was also a sense of competition and fragmentation between
the clinical school and the main campus school site. Gerontic Nursing Clinical School staff who
indicated they identify more closely with BECC than with the university supported this finding.
Initially, the presence of academic staff at the centre was viewed as the university spying on
clinicians; however, with time this has been overcome. Clinicians do report feeling
overwhelmed trying to balance research, teaching and patient care.

This paper demonstrates it is possible to establish a successful clinical school covering a non-
medical discipline in a community care setting. Furthermore, it is possible to do so even if the
model of clinical education is significantly different to the medical model.

Building on this success, in 2008 the La Trobe University Faculty of Health Sciences released a
Green Paper discussing the structure and function of clinical schools that would serve the
entire faculty[25], not just nursing. The paper covers the reasons why a clinical school covering
several disciplines could (and should) be established and notes the current difficulties finding
and managing clinical placement sites and education. Recognising the term clinical school is
usually used in relation to medicine or nursing, the paper suggests an alternate name,
professional practice networks, to avoid confusion between the single- and multi-disciplinary
models.

In establishing the new professional practice networks, La Trobe University is hoping to gain
some certainty around clinical placement numbers, duration and quality and to put
arrangements in place for several years at a time. Educational activities would cover all levels
(i.e. undergraduate, early-graduate, postgraduate and professional development) and the
networks would have a research component. The paper is very detailed, covering specific roles
of each potential partner, the value of the network to each stakeholder and in some cases
even suggesting specific processes and procedures.

The paper contends that networks would be based around specific geographic regions. They
would not necessarily touch or overlap, but would be encouraged to interact with each other.
Each network would comprise various services including a major public hospital, mental health
agencies, community health centres, private practices and hospitals, as well as social outreach
agencies (i.e. anywhere a clinical placement could take place). Each network would have a
lead agency that would accommodate the network‟s (university funded) administrative staff.
These staff would be responsible for coordinating the clinical placement activities of the
network. They would also coordinate capacity- and capability-building exercises such as
educator training and facility development. La Trobe‟s expectation is that each network would
be responsible for at least 150 entry-level students, ensuring each student received the
appropriate educational experience, making use of the organisations involved in the network.

Similarly to the medical and nursing clinical schools, the intent with the practice placement
networks is to have students undertaking their theoretical units (often lecture and tutorial
based) at locations within the network, thus increasing the student‟s familiarity with the health
care environment. As is the case with the La Trobe University nursing school, large numbers of
university-based academic staff would move their workplace to the lead agency location.
Within the Green Paper (and of significance to the wider Victorian context), was the proposal
that all staff (academic and practitioners) from all disciplines investigate new models of
education that maintain current standards of quality, but increase capacity for professional
placements.

The La Trobe University proposal envisages the networks would have a management structure,
led by a director. The director would be a full-time appointment and would have clinical




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experience in a relevant discipline. This position would have ultimate responsibility for the
network‟s activities, namely network development, clinical education, relationship
management, financial management, innovative education and research activity. This position
would be supported by a senior academic, responsible for much of the (initial) research of the
network. Several clinical teachers would also be appointed to support students and agency
supervisors during placements in an interdisciplinary manner; they would also be responsible
for managing and maintaining quality and bridging the theory-practice divide. A range of other
teaching and research positions are also described.

As mentioned above, this model builds on the Gerontic Nursing Clinical School success, and
there are certain elements that warrant further consideration in the broader Victorian context.
The fact that this type of arrangement is being proposed suggests that creating a structure to
cover the clinical education of students from a range of disciplines is considered possible by at
least some education providers, despite the diversity of education methods and clinical
education requirements. It is also interesting to note that at least one education provider is
considering course modifications to increase clinical placement capacity and it is reasonable to
expect others may be doing the same. Notably for this project, one education provider is
altering their model of clinical education support. Thus, any governance model proposed for
Victoria needs to allow such developments to continue.

2.2.3 Managing competition for sites
Western Michigan in the United States has seven schools of nursing, teaching ten different
programmes to 1,200 students. As is the case in Victoria, this has caused a significant
competition between education providers and courses for clinical placements, with the highest
competition being for maternal and paediatric placements. All of the programmes have the
same goal of ensuring students receive appropriate clinical experiences to prepare them for
clinical practice. Given the high level of competition within this area, it soon became clear the
only way for all schools to meet their goal (without adversely affecting one another or the
health system) was work together. This led to the formation of the western Michigan Clinical
Placement Consortium[26].

The Clinical Placement Consortium is dependent on both people and technology to function.
The technology used is Blackboard, a web-based communication tool usually used to provide
courses to students over the internet. The people involved are representatives from the seven
nursing schools, educational liaisons from health services, IT experts and an administrative
assistant. These people meet three times per year (usually the semester before the
placements are needed) to finalise requests, identify areas of concern and (importantly)
resolve conflicts that have arisen.

Each meeting involves reviewing the schedule of placements at each site. If there are changes
that need to be made, negations take place immediately (i.e. during the meeting). This has
served to reduce the number of phone calls, emails etc. that occur between meetings and
provides a better understanding of the background behind a final decision.

The paper‟s authors indicate that Blackboard was chosen because it was available immediately,
adaptable to including clinical site information and was relatively easy to use. The information
is maintained within Blackboard by the administrative assistant, and requires about half a day
per week. Blackboard allows spreadsheets and other documents to be easily added to a
website. For those discussions that do not occur as part of the regular meetings, Blackboard
has an email function that allows all participants to be emailed simultaneously (replies are also
sent to all participants). Although this is not new functionality, the authors report it has
facilitated greater inclusion of health services in the discussion and decision-making processes.

Logistically, changes to the system can only be made by the administrative assistant. Outside
normal meeting times, when a person identifies their desire or need for a change, an email is
sent to all participants for approval or discussion. Once a decision is reached, the required
change is communicated to the administrative assistant, who then makes the change in the
database. In those instances where conflicts cannot be resolved at the meeting or via a group




Darcy Associates Consulting Services                                                           11
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email discussion, the parties concerned are encouraged to have a separate discussion and then
come back to the wider group with the final solution. The decision is reviewed for its
compatibility with the needs of the rest of the group and implemented as appropriate.

The authors do report problems around nomenclature. As different stakeholders use different
terminology, many separate database entries were made that actually referred to the same
thing. While the problem has been corrected for specific examples, it is unclear from the paper
if a longer-term solution (i.e. naming rules or set of definitions) has been implemented.

The Blackboard system is quite fluid, thus changes to models of care, ward creation, ward
mergers or splits can all be accommodated within the system. As all participants are interested
in the implications changes have to their organisation, there is a natural incentive to read and
respond to emails rapidly. Thus, many issues are resolved within a day or less.

The authors report they have sought feedback on the Clinical Placement Consortium concept.
The feedback indicates many participants value their involvement and for the first time see
why other schools or health services require certain clinical experiences at certain times of the
day, week or year. One piece of feedback also suggested the responsibility for clinical
placements has now shifted (appropriately) to the education programmes rather than being
with the health services. The involvement of health services has also proved beneficial, as the
appropriateness of certain wards for student‟s learning experience has been clarified. The
authors indicate the proof of the model‟s success is the desire of other (nearby) schools and
health services to join the consortium and the desire for other regions and disciplines to make
use of the model.

Of relevance to Victoria, this paper demonstrates that even with a large number of education
providers and a limited number of health services, communication can solve a lot of problems.
Furthermore, sophisticated or expensive software is not necessary to improve the clinical
placement allocation process.

2.2.4 A database for clinical placement allocation
There are few research papers covering models of clinical education management that involve
multiple disciplines, multiple education providers and multiple health services. However, there
are some in operation and one such example is in Canada.

In July 2001, the British Columbia Academic Health Council identified three issues to do with
human health resources within British Columbia but also across Canada:
 National and international shortages of health professionals;
 Difficulty recruiting health professionals to rural and urban sites;
 A widening gap between the practice and job readiness of graduates.

To solve these problems, the British Columbia Ministry of Health Services provided one-off
funding to develop a province-wide system for coordinating and streamlining clinical
placements. The ultimate aim was the creation of a system that could support planning efforts
and build placement capacity within the system. The result was the development and
implementation in 2003 of Health Sciences Placement Network (HSPnet) [27].

HSPnet is an on-line database and associated tools, initially aimed at improving clinical
placement coordination and communication. As it is a web-based system, no special software
is required (apart from a web browser and Adobe PDF reader, both freely available).

Since its establishment, HSPnet has grown in size, now serving over 1,200 users from 20
different disciplines in six Canadian provinces. Functionality has also grown beyond clinical
placement coordination and communication. Other tools, such as preceptor management and
recognition, capacity management, interprofessional practice education and student
employment tracking are all now part of the system. Indeed, the HSPnet website describes
itself as:
a comprehensive, web-enabled Practice Education Management system for the health sciences,
addressing challenges of discipline-specific and interprofessional student placements




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HSPnet maintenance and development is supported on a cost recovery basis through the
creation of the National HSPnet Alliance. Canadian provinces wishing to make use of the
system are issued a license at a cost based on the numbers of students and/or placements for
the coming year. License payments can be in the form of contributing to system management,
user training and support, or developing enhancements. In the event a user, user group or
province would like to develop a specific module or set of functions, they are encouraged to
fund that project. Any enhancements of the system, once deployed, are available to all
members of the alliance at no additional cost. A range of groups makes use of the system,
including universities, colleges, health services and schools.

As reported on the website, the benefits of HSPnet include:
 Improved communication and information exchange between education providers and
    health services throughout the placement process.
 Enhanced capacity and better planning as a result of greater access to more
    comprehensive data on placement activities, trends, reasons for change and cancellation of
    placements, etc.
 Reduced paper handling as a result of implementing an electronic system for clinical
    placement management.
 Improved turnaround on placement requests through automated reminders and alerts
    combined with instant communication tools.
 Reporting and productivity tools that make the creation of confirmation letters, student or
    educator schedules, etc. faster and easier.

HSPnet is managed by a steering committee comprising members from each of the provinces
using HSPnet. The National HSPnet Alliance has created a model for provinces wishing to use
HSPnet. This includes appropriate implementation and management structures. Thus, the roll
out of HSPnet to provinces beyond those already making use of it is well supported. This is
something that could be considered in Victoria if the model it develops is nationally applicable.

Currently, access to HSPnet is limited to academics and administrators involved in clinical
education and management. However, in the future there are plans to allow student access to
provide them with information about their placements, provide resources (orientation and
education materials) and seek feedback. Other planned enhancements include tracking clinical
education of graduates (e.g. international medical graduates).

This example demonstrates how one province, creating a good system and supporting its
development, can change activity at a national level. The development of HSPnet also shows
that a system initially developed to monitor and manage clinical placements can grow to cover
separate (but related) activities. Finally, HSPnet is an example of what can be achieved if
governments, education providers and health services work together.




Darcy Associates Consulting Services                                                           13
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3 Stakeholder consultations
The Victorian DHS has previously conducted stakeholder consultations to determine the type of
clinical placement coordination preferred within the state[19, 20]. Those consultations revealed a
clear preference for a regional model. The stakeholder consultations in this project aimed to
build on the earlier processes, to determine some of the details of a regional model.

A two-phased approach was used for consulting stakeholders. The first phase involved
separate interviews with education provider and health service stakeholders. The insights
revealed in those interviews are summarised below. The interviews informed the development
of several models for establishing regional clinical placement networks and the second phase
of stakeholder consultations involved roundtable discussions about those models with mixed
stakeholder groups. The outcome of the roundtable discussions is presented in Section 5.6.

3.1 Methodology
Stakeholders were selected for interview on the basis of their involvement in health
professional education within Victoria. All members of the Project Steering Group were invited
and were encouraged to include their colleagues (within their organisation or sector) in the
interview. Similarly, all universities represented on the CVHD were invited for interview and
were asked to ensure broad representation of all relevant courses offered by their institution. A
small number of interviews were conducted with stakeholders who are not part of the Project
Steering Group or the CVHD.

Nominated individuals for each stakeholder organisation were contacted via email, inviting
their participation in a 60-90 minute interview covering the following topics:
 Features of the current system/arrangements that need to be retained in the new model;
 Problems that need to be addressed by the new model;
 Governance arrangements;
 Structure and membership of regions;
 How a region would conduct its business; and
 Integrating the system across Victoria and Australia.

Although interviews were semi-structured and did not always follow a particular course, a set
of questions under these six topics was developed as a general guide to the conduct of
interviews (see Appendix 3).

Owing to the tight timelines for the project, interviews were conducted in a relatively short
period (26 March to 24 April 2009). Stakeholders unable to participate in interviews in that
period were invited to make written submissions.

3.2 Findings
The interview process resulted in the conduct of 23 interviews involving 87 participants. In
addition, two written submissions were received. A broad cross-section of stakeholders was
represented, including VET sector institutions, universities, regional training providers, public
and private health services (rural and metropolitan), community health services, aged and
community care facilities, GPs, simulation facilities and the DHS. The full list of participating
organisations is presented in Appendix 4.

In interpreting the information collected through interviews, it is important to note that,
particularly in the case of Project Steering Group members, the majority of interview
participants indicated they could not really represent the views of the sector they represent on
the Project Steering Group. The reasons for this were not explored, but it is likely the short
timeframe of the project meant that these individuals were not able to consult with other
colleagues within their sector about the specific issues being discussed. Therefore, while the
views presented in the following summary reflect the organisations of the individuals
interviewed, they do not necessarily reflect the views of the wider sectors to which those
organisations belong.




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3.2.1 Overall impressions: A sector ready for change and willing to act
Generally, interview participants were very positive about the development of an improved
clinical placement system and the overwhelming impression was of a sector ready for change.
Although many informants were cautious about giving up existing territory, they were open to
the idea of giving up a little in order that the system might gain a lot. For example, contrary to
expectations, the majority of education providers volunteered that their relationships with
health services fall into one of three categories: those they would never give up, those they
might give up and those available for immediate negotiation. Health services had a similar
view about the relationships they have with education providers. These responses indicate a
willingness to make changes to current arrangements, although education providers made it
clear that their willingness to give up placements at one site is predicated on the availability of
comparable placements at an alternate site.

3.2.2 The need for a better placement allocation process
A major issue – common to all education providers and most courses – concerned the current
process for obtaining clinical placements. For nursing and most allied health courses, education
providers are required to submit their requests in September, with notification of their
placement allocations received in December. By all accounts, education providers rarely
receive the full extent of their placement application. This means any shortfall has to be
organised over the Christmas-New Year period and in an environment where most clinical
placement capacity is already allocated.

These two factors (late notification and a shortfall in the number of placements allocated) help
to drive practices by education providers that exacerbate the problem, in particular, ambit
claims. In an attempt to reduce the number of places they need to find at short notice,
education providers have increased the number of placements they apply for, by making more
applications or asking for more places in each application. This sometimes results in education
providers receiving more placements than they require. However, due to the possibility of
emergencies arising and the general difficulties associated with obtaining clinical placements,
the surplus placements are often not cancelled until the very last minute (weeks or even days
beforehand). This usually results in unused placement capacity, at the same time as some
education providers struggle to meet their placement needs.

In instances of an emergency (e.g. the unexpected closure of a ward), all the issues are
amplified. Several stakeholders described a process involving 20 or 30 phone calls to place a
relatively small number of students, often without success.

Interestingly, all education providers indicated that, by year‟s end, they could usually find all of
the clinical placements they require. However, at any given time in the course of the year,
placement coordinators could not be sure this would be the case. Furthermore, in some cases,
graduation of students from their course has had to be deferred until placements could be
completed, while in other cases, students have undertaken clinical placements outside normal
(or planned) semester times.

Perhaps one of the most inefficient features of the current system is that, notwithstanding
preferred arrangements between health services and education providers, it appears the entire
clinical placement allocation is re-negotiated for most disciplines every year, with limited
consistency or continuity from year-to-year. The clear exception to this is medicine, where the
clinical school model employed by medical schools ensures a fixed number of medical student
placements are available to the university at a given hospital/health service each year. This
model does not usually cover non-hospital placements (such as GPs, community health
services and other facilities), where placements do need to be re-negotiated regularly. Thus,
hospital-based medical student placements aside, most disciplines appear to negotiate the
majority of clinical placements every year, in some cases each semester. Most stakeholders
indicated a desire to change this and move towards a system where the majority of
placements are set for a longer period (perhaps three years), with scope for review and re-
negotiation if arrangements are not working.




Darcy Associates Consulting Services                                                             15
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In the points discussed above, while capacity is clearly the underlying issue, most of the
problems cited relate to how existing capacity is allocated. Preferred or exclusive relationships
were consistently noted as an issue, although many education providers have such
relationships with one or more health services. It transpired that the problem with these
relationships is not that they limit other education providers‟ access to a site (although this
was clearly an issue in some cases), but more that education providers wasted time trying to
gain access to a site where the (unknown) existence of a preferred relationship made this
unlikely. Thus, if all preferred or exclusive relationships were known to all stakeholders, it
would immediately reduce the number of unsuccessful requests for placements.

The application process itself was also identified as an area needing improvement. The length
of time between application and notification results in limited time to obtain the unfilled
placements from alternate sites. Education providers all agreed that a standard application and
notification process, with several rounds, would be of benefit. Health services also like this
idea, as it would clarify when applications could be made and when they would be announced,
reducing the number of enquiries they receive about clinical placements. Indeed, informants
reported that some health services have begun implementing clinical placement application
processes. Health services indicated this has been introduced to create some equity and clarity
in the allocation of clinical placements. They also reported it reduces the number of ad hoc
phone calls they receive. However, some education providers felt these processes sometimes
conceal non-transparent arrangements between health services and education providers.

Finally, education providers generally agreed the placement allocation process could be better
handled through a database that logs capacity of health services and indicates how much
capacity is available in real time. This would particularly assist in handling emergencies.

3.2.3 Building on the current system
When asked what aspects of the current system should be retained in the new system, most
interview participants nominated relationships between education providers and health
services as a high priority. This was particularly the case amongst education provider
stakeholders. When asked why relationships are important, many respondents referred to the
importance of good relationships in securing clinical placements. Further discussion on this
point brought the realisation that if the new clinical placement governance system can secure
placement numbers as a matter of course, this would allow stakeholders to make use of their
relationships to focus on other aspects of clinical education, such as assessing, improving and
maintaining quality and capacity, as well as innovation and research in clinical education.

Also on the subject of relationships, there was general agreement that the nature of
relationships varies depending on the education providers and health services involved. Most
agreed the freedom to conduct the relationship as they see fit, including the ability to
negotiate directly (i.e. not involving a third party), needs to be a feature of the new system.

Apart from relationships, no other single aspect of the current system had such widespread
support for continuation in the new model. Amongst health services, there was agreement that
their current level of autonomy should be retained. That is, health services wish to be able to
determine for themselves the discipline, number and level of students they will accommodate.
Health services also want to retain their ability to determine when students undertake clinical
placements and what will be provided by the health service versus what will be provided by
the education institution.

Education providers noted the current system allows some flexibility, which allows them to
respond to student requests for placements in specific locations. Most indicated they would like
to see this flexibility maintained in the new system. Models of education were also nominated
as being important to education providers, and they were keen to ensure these would not have
to change in the new system.

Finally, there were a small number of interviewees who felt the current system is not working
well at all, and if it were entirely changed it would not be a bad thing.




Darcy Associates Consulting Services                                                           16
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3.2.4 Modifying the current system
Improved communication and transparent allocation of clinical placements were the two
changes to the current system most often nominated by both health services and education
providers. Indeed, stakeholders noted that many other issues in the current system could be
addressed through improved communication or increased transparency.

Communication issues seem to exist within sectors as well as between sectors. For example,
health service stakeholders suggested if they communicate better with each other, they might
be able to find additional capacity; at the moment there is little incentive and no process to do
this. Health services were also seeking better communication from education providers on a
range of operational issues, including when students will arrive and what they should be
taught, as well as issues that could impact on placement capacity (such as educator training,
content delivery, alternate clinical placement times) and quality (provision of feedback).

On the other side of the equation, education providers are also seeking better communication
with other stakeholders. For example, if clinical placements become available (through
cancellation by another education provider), education providers would like to be informed, as
they may immediately need those placements or may wish to make changes to their current
allocation. In an interesting mirror image of the input from health services, education
providers would like more communication from health services on the capacity, quality and
delivery of clinical placements. Education providers also expressed a desire for greater
communication with each other and some disciplines have made progress in this area
(particularly medicine, nursing and social work).

As discussed in Section 3.2.2, transparent allocation of clinical placements was often
mentioned in the context of exclusive or preferred relationships. Very few interviewees wished
to see an end to these relationships, although most agreed the existence of such relationships
should be disclosed. Another issue relating to transparency concerned how health services
reach their decisions about the clinical placements they offer. This was of particular importance
to VET sector institutions. They often described themselves as the poor cousins of universities
and indicated that university clinical placements are given preference over VET institution
clinical placements. VET institution representatives noted the inconsistency of health services
that indicate a certain proportion of their workforce must be trained through the VET sector,
yet they do not allocate the same proportion of clinical placements to VET sector students.

Funding was mentioned in every interview as an element of the current system that needs to
change. Both education providers and health services believe the money allocated for clinical
education (particularly clinical placements) is inadequate. Although it was acknowledged that
education providers and health services might have to cover some of the costs of clinical
education, most interviewees felt the current shortfall was unsustainable into the future. There
was also concern that money intended for clinical education was „disappearing into
consolidated revenue‟ and not being used for clinical education purposes.

Finally, many interviewees cited the lack of coordination between different levels of
government as an element of the current system that needs to change. Although it was
acknowledged this might be beyond the control of any regional clinical placement governance
system, stakeholders noted that uncoordinated government policies exacerbate placement
capacity issues by creating competing priorities for the health and education sectors. For
example, education is a large export earner for Australia and the Commonwealth government
has encouraged international students to come to Australia for an education and then return
home. However, health services, which are facing critical workforce shortages, are unwilling to
commit their limited clinical placement capacity to international students who are unlikely to
practice within Australia, let alone Victoria.

3.2.5 New elements for inclusion in the new system
The majority of new elements suggested for inclusion in the new system were responses to
perceived failures of the current system. For example, many stakeholders requested a defined
application process with several rounds of application and notification, as well as a database



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for logging clinical placement information. As discussed earlier, there was a preference for the
new system to negotiate placements every three years, rather than yearly.

Interviewees also requested improved processes for quality control and capacity development.
Most education providers noted the quality of clinical placements varies considerably. Although
all placements meet the various discipline-specific accreditation requirements (at least in
theory), there is broad acknowledgement that the quality is inconsistent between and even
within sites. Issues include: the quality of preceptoring or supervision; access to senior
clinicians; access to patients; access to other teaching and learning resources; induction and
orientation provided to students; the educational culture of the health service (including
whether students are made to feel welcome). Furthermore, some placement sites are not
suitable for all student learning styles or personalities.

Thus, education providers are looking for the new system to result in improvements to the
overall quality of clinical placements. Suggested approaches to this varied. Some respondents
mentioned providing a set of tools for education providers and health services to use, others
spoke about coordinated training and development activities for clinical educators, while others
indicated a preference for a semi-independent or fully independent body to take control of
these activities.

Another suggestion was for the inclusion of some mechanism for coordinating police and
working-with-children checks for students. Each year, each student needs to have these
checks updated and students who do not have valid checks at the start of a clinical placement
may be prohibited from undertaking the placement. Given the difficulty in arranging clinical
placements, failure to complete a scheduled placement through an avoidable bureaucratic
problem creates an unnecessary burden for placement coordinators.

3.2.6 Regional boundaries and network membership
At the time of interview, the work described in Section 4 had not been completed. Therefore,
interview participants were shown maps indicating the DHS regional boundaries as a starting
point for discussions. Respondents liked the idea of using a set of existing boundaries, rather
than creating a new set of boundaries. However, while most stakeholders agreed the five DHS
regions in rural Victoria would be appropriate, they noted the three metropolitan DHS regions
may be too large and might have to be divided into five or six smaller regions with fewer
health services in each. Some participants suggested other regional boundaries be considered,
such as those used for GP training or the Primary Care Partnership (PCP) networks.

There were some suggestions of creating regions that covered both metropolitan and rural
Victoria. Drawbacks of such an arrangement were also noted, such as rural stakeholders being
drowned out by metropolitan stakeholders, the large geographic area such a region would
have to cover and the logistics of getting all parties together for meetings. Noting the desire to
bring metropolitan and rural participants together and the drawbacks of networks covering
both areas, many interviewees either liked (or suggested themselves) the idea of pairing rural
and metropolitan regions.

Interview participants readily acknowledged there would be a trade-off between keeping the
number of regions small enough to be manageable (particularly from the perspective of
education providers, who will have to work in many regions) and having regions that are so
large the number of stakeholders in any region becomes unmanageable. Most agreed that
stakeholder numbers within regions are likely to be large, even where the geographical size of
the region is small (particularly in metropolitan areas).

Therefore, the possibility of limiting membership of regional committees or management
structures was discussed. Some interviewees felt there should be no limits on stakeholder
representation, as it would not otherwise be possible to adequately represent the views of all
stakeholders. However, they did acknowledge the difficulties this would create with
governance/management structures. Others felt appropriate sectoral representation could be
achieved, particularly for health services. For example, GPs could be represented by their




Darcy Associates Consulting Services                                                           18
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Division of General Practice, aged care services could be represented by ACCV and many
health services operate within a health service network. On the other hand, many interviewees
noted that education providers would most likely wish to represent themselves.

To make governance more manageable, many interviewees suggested a division of tasks or
responsibilities through the establishment of sub-committees within each regional clinical
placement network.

When it came to decision-making processes, there was little consensus amongst interviewees
on what would be appropriate. Some liked the idea of one vote per member; others suggested
weighting votes, perhaps based on the number of students (education providers) or clinical
placements offered (health services) within a region. It was acknowledged the weighting of
votes would likely result in a bias towards the larger educators and health services.

3.2.7 How regional networks will conduct their business

There was general agreement about the scope and role of regional clinical placement
networks. Most stakeholders agreed the scope of their activities and responsibilities would
include anything to do with clinical placements. Furthermore, the vast majority of interviewees
felt the networks should cover every single clinical placement in the state (i.e. no clinical
placement should be handled outside the new system of regional networks).

In terms of role, many stakeholders felt the regional networks should – above all else –
undertake activities that see the clinical placement capacity of each region increase, without
any adverse impact on quality. Indeed, interviewees felt the networks should have some role
in quality assurance/assessment, although some respondents noted the relevant discipline
professional bodies should be responsible for managing quality. Some interviewees also put a
number against the capacity increase, suggesting that a 10–30 percent increase in capacity is
required to make this exercise worthwhile. The methods suggested for increasing capacity
generally fell into three categories:
 Training educators;
 Developing new facilities;
 Removing barriers to taking students.

Recognising that at some point it is likely placement capacity will be greater than demand,
stakeholders indicated the networks should be responsible for managing the allocation of spare
capacity. This was of particular importance given the imminent complete deregulation of the
tertiary education sector. Indeed, it was interesting to note that many VET institutions and
universities intend to increase their student enrolments in health professional courses once the
enrolment caps are removed, despite the current difficulties with clinical placements.

Other suggestions about the role of regional networks included:
 Advocating for changes to policy, such as Commonwealth and state funding for clinical
   education or the creation of state- or nation-wide clinical education standards;
 Dispute resolution or mediation

Many participants noted each regional network will need to develop and document its policies
and procedures.

Interviewees were also asked if there is anything the networks should not do. There was
strong consensus that, once the new system is operational, the existence of regional clinical
placement networks should not result in an increase in the administrative workload of health
service or education provider clinical education coordinators. Interviewees also indicated the
networks should not consume large amounts of funding resources.

3.2.8 Integrating regional networks into the broader context
Stakeholders noted the importance of ensuring regional networks are able to communicate
with each other and integrate their activities where appropriate. It was generally agreed this
would be the role of the network secretariats.




Darcy Associates Consulting Services                                                             19
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The ability of regional networks to share their placement capacity was seen as critical to the
overall management of clinical education in the state.

The involvement of regulatory bodies in the activities of regional networks was also seen as
important, although there was no consensus about the nature of this involvement.

Finally, stakeholders were asked to comment on how the Victorian system might interact with
interstate and national clinical placement systems, particularly as several interstate education
providers place students in Victoria and vice-versa. Some respondents felt Victorian education
providers should be given priority in the Victorian system. Others noted that if there was any
hope or expectation that the new Victorian model would become a model for a national
system, it could not adopt overly parochial policies.

3.2.9 The role of simulation in clinical education
One solution sometimes put forward to address clinical placement shortages is increased use
of simulation. Stakeholders were asked their views on this and how simulation should be
integrated into a new system of managing clinical placements in Victoria.

Informants indicated that virtually all courses make use of some type of simulation, although
the level of sophistication/fidelity varies significantly. Some disciplines make use of simulated
body parts (e.g. an arm for venipuncture), others use highly computerised model patients and
others make use of simulated patients (actors). Each modality varies in cost and ease of
access and it was noted that many simulation facilities are run on a cost recovery (or for-
profit) basis, which restricts access for those unable to pay. Other simulation facilities have
been established as collaborative ventures. In these instances, non-partner organisations may
be granted access at an affordable price, but are often only able to obtain access for short
periods or at impractical times of the day.

While most stakeholders agreed that simulation is not a direct substitute for clinical
placements, there was also widespread acknowledgement that simulation is an important
adjunct to placement in a real clinical environment. Simulation ensures all students are
exposed to a minimum set of experiences and allows students to practice their skills, thereby
priming them for clinical placement and altering their learning experience. Those who believe
simulation might be able to change current clinical placement practices – including reducing
the amount of time needed for clinical placements, thereby reducing the overall demand for
clinical placements – indicated this would only be the case once the current time-served model
is replaced by a competency-based model. Importantly, it is very unlikely that the full potential
of simulation in improving the quality and outcomes of clinical education will be realised
without well-run simulation facilities that incorporate appropriate resources, are operated by
skilled simulation educators and are accessible to all learners.

Interestingly, most interviewees did not feel that existing simulation facilities should be forced
to change their current practices. Instead, they felt a new regional approach to managing and
organising clinical placements could also be used to coordinate simulation facilities within those
regions and possibly establish communal facilities. One interviewee suggested if simulation is
considered to be a key aspect of clinical education, it should be established, maintained and
operated similarly to a library.




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4 Dividing Victoria into regions

4.1 Overview
As mentioned in Section 1, the Victorian DHS has expended considerable effort in recent years
developing and implementing a strategy to improve clinical placements within Victoria. As part
of this effort, several rounds of consultation[19, 20] have revealed that education providers and
health services would prefer clinical placements to be dealt with regionally rather than at a
statewide or national[7] level. Therefore, the primary objective of this project was to develop a
model that would result in regional clinical placement networks.

Setting aside for a moment the question of how regional networks would manage and organise
clinical placements (which is explored in Sections 5 and 6), the basis for dividing Victoria into
regions has to be considered. This section explores the options for defining the regional
boundaries for the proposed regional clinical placement networks, taking into account the
current distribution of clinical placement activity across the state.

4.2 Existing regional divisions in Victoria
There are a number of regional groupings or networks operating within the health care and
health education sectors in Victoria.

4.2.1 DHS regions
The DHS delivers services through eight geographical regions, five in rural Victoria (Figure 1)
and three in metropolitan Melbourne (Figure 2). The DHS regional boundaries coincide with the
local government boundaries at the outer edge of each region. Information about the regions
is available on the DHS website[28].




Figure 1: DHS rural regions




Darcy Associates Consulting Services                                                           21
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Figure 2: DHS metropolitan regions


4.2.2 Health service delivery networks
Many Victorian hospitals and health services, particularly in metropolitan areas, have been
organised into health service networks with shared governance (e.g. Southern Health).
Although these health networks may cover considerable geographical area and are considered
to have particular catchment areas, in some cases these overlap with other health networks.
Thus, there are no clearly defined regional boundaries with respect to public hospitals and
health networks.

General practices are also grouped together, through Divisions of General Practice, although
Divisions do not provide any overarching governance to GPs. Victoria has 29 Divisions and the
divisional boundaries do not particularly map to DHS regional boundaries.

In recent years, health services have been encouraged to work together on the delivery of
particular categories of services, such as cancer (Integrated Cancer Services, ICS), mental
health (Area Mental Health Services) and primary health care (Primary Care Partnerships,
PCPs). The ICS boundaries coincide with the DHS regional boundaries and mental health
services generally align with local government boundaries. There are 31 PCPs in Victoria,
representing specific regions of the state that sit within the eight DHS regional boundaries (see
Figure 3 and Figure 4). PCPs bring together hospitals, community health services, Divisions of
General Practice, other health services and a range of other organisations and agencies.




Darcy Associates Consulting Services                                                          22
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Figure 3: DHS Rural PCP boundaries showing PCPs (black text) in the context of DHS regions
(white text).




Figure 4: DHS metropolitan PCP boundaries showing PCPs (black text) in the context of DHS
regions (white text).




Darcy Associates Consulting Services                                                        23
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4.2.3 Health education networks

The major health education network in Victoria relates to general practitioner (GP) training,
which is handled through Regional Training Providers (RTPs). RTPs operate within defined
regions, working with local GPs to provide training for GP registrars. There are currently five
RTPs operating within Victoria and their boundaries do not particularly align with DHS regional
boundaries. Indeed, two of the RTPs cross state boundaries into South Australia (Greater
Green Triangle GP Education and Training) and New South Wales (Bogong Regional Training
Network). Furthermore, the RTP responsible for GP training in Melbourne, Victorian
Metropolitan Alliance (VMA), includes Geelong in its catchment area but does not include
Melton (see Figure 5).




Figure 5: VMA catchment area


4.3 Current clinical placement activity in Victoria
A key consideration in creating regional clinical placement networks is how these networks will
map onto current arrangements for clinical placements in Victoria. That is, will the networks –
by imposing boundaries on a system that currently does not operate with such boundaries –
result in an unmanageable burden, particularly for education providers?

To gain a greater understanding of the complexity of existing clinical placement arrangements,
particularly as it relates to regional distribution of placement activity, the consultants set out to
plot as much placement data as possible on a map of Victoria. Various mapping strategies
were considered, including hard copies and static electronic maps. However, it was finally
decided to develop the maps using Google Earth.

Google Earth is similar to Google Maps; however, rather than operating from the internet, it is
a piece of software available free from the Google Earth website[29]. According to that website:

       Google Earth lets you fly anywhere on Earth to view satellite imagery, maps, terrain,
       3D buildings, from galaxies in outer space to the canyons of the ocean. You can explore
       rich geographical content, save your toured places, and share with others.

Some of the functionality that made Google Earth suitable for this mapping includes:
 The ability to place a marker (pin) at a very specific location anywhere on the Earth (in this
   case Victoria).
 The ability to edit the properties of that pin in terms of its style and colour, but also its title
   and description.
 The ability to sort pins into folders, allowing their properties to be edited as a group.




Darcy Associates Consulting Services                                                              24
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      Folders and/or pins can be saved as files that can be opened in Google Earth or Google
       Maps.
      The DHS has a Google Earth compatible file, locating and naming the majority of public and
       private hospitals within Victoria.
      Regional overlays and layers can easily be created and colour coded.
      Folders, pins, overlays and layers can be selectively turned on or off.

4.3.1 Methodology
Initially, relevant contacts within educational institutions were asked to provide data on clinical
placements for the 2008 academic year (including discipline, year level, number of students,
location and placement days). However, it soon became clear this process would not yield data
quickly enough, and it was decided that data from the DHS Student/Trainee Reporting Tool
(STaRT) would be used instead.

STaRT is used by the DHS to allocate funding to hospitals and other health services based on
the number of days of undergraduate teaching that take place. As some health services and
disciplines are not eligible for this funding, not all disciplines or all placements are included in
the database. However, as will be demonstrated below, the data in STaRT was sufficient to
provide a good overall understanding of the geographical distribution of clinical placements by
both discipline and education provider. The database also contains information from interstate
universities placing students in Victoria. Only data from Charles Sturt University and University
of Notre Dame Australia were mapped, as the other universities placed very few students in
Victoria in 2008.

As STaRT only includes university placement data, the consultants made use of another DHS
data set covering VET institution clinical placement data (2007 projections of 2009 demand), in
particular for Division 2 nursing courses (but not other VET sector courses requiring clinical
placements).

Each entry in STaRT (a total of 4,291 records) and the VET database (a total of 301 records)
was added to Google Earth as a pin on the map. The title of the pin was in the form:

[health service], [location (if required)] – [education provider abbreviationb].

Each pin also had a description field. This was completed with the format:

Line 1: [discipline or discipline abbreviationc]
Line 2: [number of students] students, yr [year of study], [placement days] days

Line 2 was duplicated as required for each year of study placed at that location for that
discipline. For pins concerning the training of nurses and midwives at the same location by the
same education provider, Line 1 was also duplicated to have a separate listing for nursing and
midwifery within the same pin. Thus, an entry for Monash University medical students at
Monash Medical Centre in Clayton would appear as follows:

Pin title:           Monash Medical Centre, Clayton – MU

Description:         Medicine
                     40 students, yr 4, 1000 days
                     50 students, yr 5, 1000 days

To assist with the location of private and public hospitals and health services, the DHS Google
Earth vic_hospitals.kmz file was used[30]. Pins were copied and pasted to the relevant folder
and the details edited to match the format described above. This file provided most of the
hospital and health service location data. Where a hospital or health service was not in this list
(or if its location was incorrect), a new pin was created.


b
    See Appendix 5 for list of education provider abbreviations used in Google Earth.
c
    See Appendix 6 for list of discipline abbreviations




Darcy Associates Consulting Services                                                             25
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The result was the placement of over 3,000 pins covering 18 disciplines from 35 education
providers, on the Google Earth map of Victoria. To reduce the clutter on the map, pins for each
education provider were given unique combinations of colours, numbers, letters and shapes.
Pins were grouped into folders for their discipline and education provider.

4.3.2 Findings
The allocation of pins into discipline-based folders allowed analysis of both the distribution of
clinical placements by discipline and also by education provider. Although the maps are most
effectively viewed in the Google Earth application, where it is possible to move between an
overview of the whole state and street-level detail, snapshot images of the maps also provide
a useful summary of clinical placement activity across the state. The complete set of snapshot
images for all education providers is presented in an Appendix separate to this report (Clinical
Placement Governance Project – Clinical Placement Maps). Selected images are included here
to illustrate key points.

For the most part, universities place students well beyond the regions in which their campuses
are located and there is little correlation between the location of universities and the clinical
placement sites used. Figure 6 shows the distribution of La Trobe University placements as an
illustrative example. Although the reasons behind this lack of correlation were not
investigated, it is probably a combination of historical precedent, university reputation,
personal relationships, student preferences, the number of universities teaching the particular
discipline and the relative age of the university and the course in question.




Figure 6: Map of La Trobe University clinical placements against DHS regions.

On the other hand, most VET sector institutions place their students closer to the location of
the campus. Figure 7 and Figure 8 show two illustrative examples, one involving a
metropolitan-based institution and one involving a regionally-based institution. Appendix 7
presents a table summarising the regional distribution for all education providers for which
data was available for analysis. It can be seen that all universities and two-thirds of VET sector
institutions currently place students in more than one Victorian region.




Darcy Associates Consulting Services                                                           26
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Figure 7: Map of RMIT University (TAFE Division) clinical placements against DHS regions.




Figure 8: Map of University of Ballarat (TAFE Division Horsham) clinical placements against
DHS regions.

When the distribution of placements is considered by discipline, some disciplines show more
separation of the areas used by individual education providers than others. For example, in the
case of medicine, the four universities placing students in Victoria are reasonably distinct in
the regions they use (see Figure 9), whereas with Division 1 nursing, there is considerably
more overlap between education providers (see Figure 10).




Darcy Associates Consulting Services                                                          27
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Figure 9: Map of medicine clinical placements against DHS regions. Key: University of
Melbourne, red pins; Monash University, blue pins; University of Notre Dame Australia, green
pins; Deakin University, pale blue pins. Note: If there are multiple pins at a single site, only
the front-most pin can be seen in this static view.




Figure 10: Map of Division 1 nursing clinical placements in metropolitan Melbourne against
DHS regions. Each different coloured pin represents a different university. Note: If there are
multiple pins at a single site, only the front-most pin can be seen in this static view.




Darcy Associates Consulting Services                                                             28
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4.4 Boundaries for the proposed regional clinical placement networks
In dividing Victoria into regions with responsibility for clinical placements, the initial intent was
to make use of existing health service or health education boundaries. As described above,
there are a number of regional groupings that could be considered.

In terms of health education boundaries, the only clearly defined regions are those relating to
the RTPs. Organisations responsible for the postgraduate training of other medical specialists
and other health professionals tend to organise themselves at a national level and their regions
are the states of Australia. The mapping of current undergraduate placement activity in
Victoria (described in Section 4.3) revealed there are no clear-cut divisions between education
providers that could usefully delineate regional clinical placement networks.

On the other hand, the boundaries used to define health service delivery are a more useful
starting place for defining the boundaries of the proposed regional networks. Indeed, with the
exception of Divisions of General Practice, most other regional groupings for health service
delivery coincide with, or map within, the DHS regional boundaries. It was decided the current
rural and metropolitan DHS regions would be a better starting point than the PCP boundaries,
since 31 regional networks is likely to be too many, in light of feedback from stakeholders.

Initially, when stakeholders were presented with maps indicating the DHS boundaries (see
Figure 1 and Figure 2) and asked for their comments on the practicalities of making use of
these boundaries, they felt that:
 Three regions was too few for metropolitan Melbourne;
 The specialist hospitals located in central Melbourne may need to be in their own region or
    separated entirely;
 The regions may have to be modified to avoid splitting health services across regions.

Furthermore, general feedback on regionalisation indicated:
 Health service networks should not be split across regions;
 Education providers may be involved in one or more (or all) regions; and
 Health service providers may group together (for example, by health care setting) to allow
   appropriate representation within regions.

In light of these comments, the DHS rural boundaries were adopted unchanged for the five
proposed rural clinical placement networks and the metropolitan boundaries were modified.

The first round of modification involved the Monash local government area being relocated
from the DHS Eastern Metropolitan Region to the DHS Southern Metropolitan Region and the
Boroondara local government area being moved from the DHS Eastern Metropolitan Region to
the DHS North and West Metropolitan Region. This modification solved the problem of health
services being split across regional boundaries.

The second round of modification aimed to create a larger number of metropolitan regions
without splitting health service networks. To do this, metropolitan health services and health
service networks were mapped to local government areas. Starting with one local government
area, adjacent areas were progressively added to each region, until complete health networks
were incorporated into that region. If the inclusion of an adjacent local government area
introduced a second health network, further areas were added to the region until the second
health network was completely incorporated. This resulted in five metropolitan regions being
created:
 Peninsula (consisting of Peninsula Health)
 Southern (consisting of Southern Health, Alfred Health (formerly known as Bayside
    Health), Melbourne Health and several specialist hospitals, including the Royal Children‟s
    Hospital, the Royal Women‟s Hospital, the Peter MacCallum Cancer Institute, the Victorian
    Eye and Ear Hospital
 Eastern (consisting of Eastern Health)
 Northern (consisting of Northern Health, Austin Health and St. Vincent‟s Health)
 Western (consisting of Western Health)




Darcy Associates Consulting Services                                                               29
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This was considered to be a suitable number of regions, particularly as there are five rural
regions and this would facilitate direct pairing of rural and metropolitan regions. However, in
this model the Southern region is geographically large and includes a very large number of
health service networks and many specialist hospitals.

Therefore, the third round of modification removed the Melbourne local government area from
the Southern region to create a sixth region, the Central region, which includes Melbourne
Health and the specialist hospitals. A further minor modification was made, to excise The
Alfred Hospital from the south-east tip of the Melbourne local government area and add it to
the Junction local government area (which is part of Southern region), so that Alfred Health is
not split between two regions (see Figure 11).




Figure 11: Melbourne local government area (beige) and Junction (light pink) highlighting the
area (white) removed from Melbourne and added to Junction.

The final (recommended) regional boundaries for clinical placement networks in Victoria are
shown in Figure 12 (metropolitan Melbourne) and Figure 13 (Rural Victoria). The composition
of these regions, in terms of the number of education providers, disciplines and health service
networks, is summarised in Table 2, with further detail provided in Appendix 8.
Table 2: Summary of clinical placement region components
                                                           Education      Public health services
Region name                Location          Disciplines
                                                           providers       or health networks
Barwon South-              Rural                    15        17                     11
Western
Central                    Metro                    18        12           1 + specialist hospitals
Eastern                    Metro                    14        16                      1
Gippsland                  Rural                    12         9                      5
Grampians                  Rural                    14        13                      8
Hume                       Rural                    14        13                      8
Loddon-Mallee              Rural                    13        15                     10
Northern                   Metro                    17        20                     4*
Peninsula                  Metro                    13        16                      1
Southern                   Metro                    17        21                      2
Western                    Metro                    16        15                     2*
* Mercy Health is split across these two regions.




Darcy Associates Consulting Services                                                              30
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As Table 2 indicates, there are likely to be many organisations involved in each region. It
should be noted that, in rural areas, each health service might be a single hospital, whereas in
metropolitan areas, health networks include multiple sites. Furthermore, the table does not
include other health service settings, such as community health services, mental health
services, private hospitals and other private services (GPs, physios, dentists, etc).




Figure 12: Proposed metropolitan clinical placement regions. Region names are in white.




Figure 13: Proposed rural clinical placement regions. Region names are in white.




Darcy Associates Consulting Services                                                          31
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5 Options considered in the development of a new model

5.1 Overview
It was clear from the discussions with stakeholders (Section 3) that there is general agreement
amongst education providers and health service providers alike that the current system of
managing and organising clinical placements in Victoria is beset by inefficiencies and problems.

Given the issues that were raised in these consultations (and which mirror the outcomes of
consultations conducted in 2008 by DHS[19]), any new model that is developed should – at a
minimum – aim to achieve the following:
 Reveal the true level of capacity for placements and provide this information to all
   stakeholders. This includes information about:
       o The number of learners that can be accommodated at each level of study.
       o Other (non-discriminatory) preferences/requirements; for example, health services
           in regional areas may have a preference for local students.
       o Timing, including shifts, days and time blocks when learners can be accommodated.
 Identify capacity development needs within health services and formulate coherent plans to
   meet them. This includes:
       o Preceptor/educator training.
       o Placement support.
       o Infrastructure needs (including simulation facilities).
 Develop and/or facilitate the implementation of quality assurance tools as a mechanism to
   ensure consistently high standards at all placement sites.
 Improve communication between health services and education providers.
 Improve communication between education providers.
 Establish mechanisms for communication and negotiation between regions.
 Facilitate development of policies for equity of access amongst education provider
   stakeholders, handling emergencies, access to placements by education providers from
   other regions and conflict/dispute resolution.
 Provide a platform for innovation and research.
 Provide a forum for discussing issues beyond the control of regional networks (and
   proposing solutions).
 Achieve sustainability, particularly in light of anticipated further deregulation of the
   education and training sectors. This includes ensuring that clinical education is delivered
   where and how health services are delivered (i.e. in a range of settings and with an
   increased focus on team-based primary care).

Importantly, there has consistently been clear opposition amongst stakeholders for any
centrally controlled entity, although most stakeholders have recognised the need for a
systemic solution[19]. Therefore, the objectives listed above need to be realised in the context
of a model that offers local input and control, most likely featuring regional networks that
preserve the autonomy of institutions and support existing beneficial relationships.

Four models were considered as the basis for establishing regional networks. Each model
results in regional groupings, but arrives at this grouping as a first, second or third order
arrangement. The models are named according to the first order grouping that is proposed.
For the purposes of consulting with stakeholders about these models, it was assumed the eight
DHS regional boundaries would be used to delineate regions (five in regional Victoria and three
in metropolitan Melbourne; see Figure 1 and Figure 2 respectively), although, as discussed in
Section 4.4, it is likely that more than three regions will be used in metropolitan Melbourne.

The remainder of this section briefly presents the four models that were considered, including
a summary of the issues impacting on the feasibility of each model.




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5.2 Regionally-based networks
As most stakeholders were of the view that the new model should involve regionally- or sub-
regionally-based networks (some stakeholders have used the term clusters) that are member-
owned and operated (See Clinical placement agency – report on consultation workshops, 2008,
p. 19[19]), the first model that was considered simply divided the state into eight regions in the
first instance. On this basis, the membership of each network would include:
 Education providers (university, VET institutions) currently placing students in that region;
 General Practice Regional Training Providers (RTPs) based in that region;
 Health services in that region (hospitals/health networks, community health services, aged
     care, clinics, etc), both public and private;
 Representative bodies, such as Aged and Community Care Victoria (ACCV), Divisions of
     General Practice, peak professional associations, etc;
 DHS.

Each region would have responsibility for developing policies and principles that will serve as
the framework for negotiations between education providers and health services within that
region. The region may decide to establish an executive committee or may operate as a
cooperative with all stakeholders having a seat at the table for major decision-making. While it
is very likely that each education provider would wish to have a seat at the table for policy
discussions, it is possible that some health services would be happy to have a shared
representative who speaks on behalf of specific health care settings. Such an arrangement will
work well provided there is adequate two-way flow of information and sufficient time is allowed
in decision-making processes for representatives to discuss issues with their constituents.

In this model, it is expected that each network would collect information about current clinical
placement capacity, as well as capacity development needs (in terms of preceptor/educator
training and placement support and infrastructure, including simulation facilities). Ideally, a
common database template would be used across all regions to collect clinical placement
capacity information (to allow for sharing of information between and across regions). Each
region would also formulate a plan for meeting its capacity development needs, which would
serve as the basis for funding and other support requests to government.

Once the policy framework for managing the regional supply and demand of clinical
placements has been defined, it is anticipated negotiations about placements would be handled
by individual disciplines, rather than on a whole-of-network basis. Thus, each of the regions
would be expected to establish a set of disciplinary sub-committees, as shown in Figure 14.




Figure 14: Regionally-based network model




Darcy Associates Consulting Services                                                           33
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Although relationships between individual health services and education providers would be an
important ingredient of these discussions, it is anticipated that one-to-one negotiations will not
be the principal modus operandi of the network. Instead, it is most likely that multiple
stakeholders will be involved in iterative rounds of placement allocations for each discipline, to
ensure all placement needs are met as equitably as possible.

One variation on this model is that regional boundaries are defined by existing health network
boundaries (e.g. Alfred Health, West Wimmera Health Service, etc), rather than by DHS
regional boundaries. The major problem with this approach is that there are a large number of
health networks in Victoria, which will result in a large number of clinical placement networks
that may be too small to achieve the desired objectives of the new model. Furthermore, many
health service providers are not defined as being part of these health networks (aged care,
community health services, GPs and other clinics) and therefore new geographical boundaries
would have to be drawn anyway to define the clinical placement networks.

Issues affecting the feasibility of the regionally-based model
Although this model appears to deliver what stakeholders indicated they want – by delegating
the control of policies and processes directly into the hands of local stakeholders within a given
region – this model does not take account of current clinical placement arrangements. As
indicated in Section 4, all universities and two-thirds of VET sector institutions currently place
students in more than one Victorian region. Therefore, education providers may expect – at
least in the first instance – to be involved with more than one regional clinical placement
network for any given course they offer. The problem with a model in which each region
develops its own policies, principles and practices is what might be termed the Galapagos
Islands effect[31], whereby different arrangements evolve in each region for any given
discipline. This could make it very difficult to achieve consistency between regions and would
potentially create a complex maze across the state for education providers to negotiate.

5.3 Health setting-based networks
Figure 15 depicts how a model based on health care settings would be established.




Figure 15: Health care setting-based model




Darcy Associates Consulting Services                                                           34
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In this model, the responsibility for developing policies and principles that will serve as the
framework for negotiations between education providers and health services is determined for
each different type of health care setting.

The initial decision-making process would involve discussions between the following
stakeholders:
 All Victorian health services in that category of setting;
 Education providers (university and VET institutions) that currently place students in that
   health care setting;
 Regional Training Providers, where appropriate;
 Representative bodies or peak associations, as appropriate;
 DHS.

It is expected that each health care setting would collect information about current clinical
placement capacity, as well as capacity development needs (in terms of preceptor/educator
training, placement support and infrastructure, including simulation facilities) for that category
of setting. This information could be collated (or sorted) on a regional basis to facilitate the
preparation of funding and other support requests to government.

Once the policy framework for managing placements in each category of setting has been
defined, it is anticipated there would need to be further refinement of policies based on
regional groupings (since issues in regional and metropolitan areas are likely to be different).
Once this is accomplished, as with the regionally-based model, negotiations about placements
would be handled by individual disciplines, rather than on a whole-of-region basis.

Issues affecting the feasibility of the heath care setting-based model
This model builds on work that has already been done in some health care settings (such as
GP clinics) to coordinate placement activities on a region-by-region basis. It has the benefit of
producing a consistent approach for particular health service settings and potentially allows a
greater voice for health service stakeholders in the process. However, this model will have the
same issue as noted for the regionally-based model, namely the potential for a Galapagos
Islands effect, with different arrangements evolving in each region – and each health care
setting – for any given discipline. Furthermore, this model works against the established
domains of health networks, which usually include a range of health care settings.

5.4 Education provider-based networks
In this model, the first-order grouping is based on individual education providers, in particular,
universities. This model was not developed or considered in any detail, since it quickly became
apparent in mapping current clinical placement data (see Section 4) that universities do not
work within well-defined boundaries. The high degree of overlap between universities in their
regional presence, as well as overlaps with other education providers (VET sector institutions
and RTPs), makes this model completely impractical.

5.5 Discipline-based networks
In this model, the responsibility for developing policies and principles that will serve as the
framework for negotiations between education providers and health services is determined for
each discipline. This will result in a consistent set of guidelines across the whole state for a
given discipline and will reduce the likelihood of a Galapagos Islands effect.

The initial decision-making process would involve discussions between the following
stakeholders:
 Victorian health services that offer placements for that discipline;
 Education providers (university and VET institutions) that offer courses in that discipline;
 Regional Training Providers, where appropriate;
 Representative bodies or peak associations, as appropriate;
 DHS.




Darcy Associates Consulting Services                                                             35
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Because of the large number of health service providers involved, it might be considered
appropriate for health service providers to organise themselves into relevant groupings and
nominate representatives to speak on their behalf during the initial discussions.

It is expected that each discipline would collect information about current clinical placement
capacity, as well as capacity development needs (in terms of preceptor/educator training,
placement support and infrastructure) for that discipline.

Once the policy framework for managing placements in each discipline has been defined, it is
anticipated that negotiations about placements would be handled on a regional basis, rather
than on a whole-of-discipline basis. This would effectively result in regional discipline-based
networks. Therefore, to ensure there are mechanisms for learning between professional
disciplines, sharing of resources (particularly simulation facilities) between disciplines,
development of interprofessional education initiatives and research projects, it is envisaged
that all the discipline-based networks for a particular region would be grouped together in a
regional clinical academy (see Figure 16).




Figure 16: Discipline-based network model

Regional clinical academies would provide a mechanism for information sharing and
coordination between disciplines (where required or desired), developing regional priorities for
capacity building and infrastructure, and a platform for innovation and research. Importantly,
this model would be most conducive to addressing the objectives of interprofessional learning
and preparing students for work in multi-disciplinary settings.

Issues affecting the feasibility of the discipline-based model
This model builds on work already done in some disciplines (such as Social Work) to coordinate
placement activities across Victoria. It has the advantage of providing consistency across the
state for each discipline, at the same time avoiding a one-size-fits-all solution that might work
better for some disciplines than for others. The establishment of regional clinical academies
serves to bring all the disciplines together for those activities where inter-disciplinary exchange
and collaboration is desirable. The major feasibility issue with this model is how the
discussions at the discipline level will be managed, given the number of stakeholders in each
discipline is likely to be quite large.




Darcy Associates Consulting Services                                                             36
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5.6 Stakeholder feedback on the proposed models
Stakeholders in the education provider and health service sectors were given an opportunity to
consider and provide feedback on the models set out in this section through three discussion
sessions, namely:
 VET sector representatives, at a meeting of the Moderation Delivery Committee (MDC) on 1
   May 2009 (see Appendix 9 for a list of participating institutions).
 Education provider and health service stakeholders in the Eastern Metropolitan Region, at a
   roundtable conducted in Melbourne on 11 May 2009 (see Appendix 10 for a list of
   participating institutions).
 Education provider and health service stakeholders in the Barwon South-Western Region,
   at a roundtable conducted in Geelong on 12 May 2009 (see Appendix 11 for a list of
   participating institutions).

For the meeting with VET institution representatives, the models were explained to participants
through a Power Point presentation. For the roundtable sessions, a discussion paper setting
out the regionally-based, health care setting-based and discipline-based models (see Appendix
12) was circulated to roundtable participants on 8 May. In all cases, the sessions included
discussion of the pros and cons of each model, identification of a preferred model for further
consideration and robust discussion of how the preferred model would operate, particularly in
relation to some of the more pressing issues currently impacting on clinical placement
arrangements.

All discussion groups nominated the discipline-based model (presented in Section 5.5; Model 3
and Model 3 Extended in the discussion paper; see Appendix 12) as the preferred model for
further development. There was also a general consensus that more detail about how the
model would operate needs to be presented to stakeholders before a final decision can be
made. A small number of participants expressed scepticism that any of the models could
address the problems of the current system, but no alternative models were proposed. On the
other hand, as each discussion session unfolded and the potential workings of the discipline-
based model were explored, a growing number of participants – both education providers and
health service providers – began to embrace the concept and develop enthusiasm for the
possibilities it presents.

In addition to providing further stakeholder input to the process of developing a new
governance model for clinical placements, these discussion sessions served two important
functions. Firstly, the sessions produced a clear consensus about which model should be
developed in greater detail. Secondly, the sessions raised many important issues that need to
be considered as the model is developed. These issues, as well as the questions set out in the
discussion paper (see Appendix 12), are addressed in Section 6.3 below




Darcy Associates Consulting Services                                                        37
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6 The recommended model
As discussed in Section 5.6, stakeholders nominated the discipline-based model as the
preferred model for further development. This model is also the model recommended by the
consultants. This section explores this regional clinical academy model in greater detail,
including how the proposed model is expected to fit into the broader context of clinical
placement governance in Victoria and nationally.

6.1 The proposed regional clinical academy model: an overview
Stakeholder input to this project and previous consultative processes have indicated that the
current system for managing and organising clinical placements in Victoria is characterised by
lack of communication and coordination between institutions and between sectors.
Importantly, the lack of communication and coordination seems to be the root cause of many
of the problems with the current arrangements. It stands to reason, therefore, that a model
that improves this situation will be one that facilitates communication and coordination across
the system. However, as with any complex system involving multiple stakeholders with
competing (and sometimes conflicting) interests, there is a hierarchy of issues that have to be
addressed to produce a system that functions efficiently and effectively. That is, some issues
have to be resolved before others can be considered and some issues are universally important
while others are of more parochial concern.

The proposed model for establishing regional networks utilises health professional disciplines
as the fundamental grouping for addressing the hierarchy of issues relating to clinical
placements. This approach is a natural fit with the overarching system of health professional
education and training, in which curricula, competencies, registration and accreditation are all
handled on a discipline-by-discipline basis. Furthermore, while interprofessional education and
multi-disciplinary use of resources are all issues of importance, they are second- or third-tier
issues compared to the intra-disciplinary competition for clinical placements.

With disciplinary groupings as the foundation, this model draws together clinicians and
academics with shared interests and objectives as the starting point for system-wide
negotiations. It also provides an appropriate forum for considering state level and national
level policy on health workforce. Importantly, while the disciplinary groupings are a major
feature of the initial establishment of regional clinical academies, they are not simply a means
to achieve that end, and an ongoing role for disciplinary groupings is envisaged in the
operation of the model.

6.2 Fundamentals of the model
Figure 17 depicts the proposed model for establishing regional clinical placement networks in
the broader state and national context for clinical placement governance. While there are
expected to be Commonwealth and state agencies providing oversight and controlling funding
(shown in the top half of Figure 17 and discussed further below), the regional clinical
placement networks – termed regional clinical academies in this model – actually arise from
below (as indicated by the vertical arrow on the lower left side of the figure), as a product of
the disciplinary groupings (termed discipline councils) shown at the bottom of the figure.

Therefore, as a starting point for establishing the new model – and as on ongoing reference
point once the model is operational – discipline councils will be convened. These councils will
comprise:
 Victorian health services that offer placements for that discipline, including public and
   private hospitals, community health services, mental health services, residential aged care
   facilities, rehabilitation services, general practices and other private practice clinics;
 Victorian service providers in other sectors, such as education and social care, that offer
   placements for students in some disciplines;
 Education providers (university and VET institutions) that offer courses in that discipline;




Darcy Associates Consulting Services                                                          38
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   Regional Training Providers, where appropriate;
   Representative bodies or peak associations, as appropriate;
   DHS representatives.




Figure 17: The proposed model in the broader context of clinical placement governance

Currently, there are more than 20 health professional disciplines offered as professional entry-
level courses in Victoria (the STaRT data set includes 19 disciplines, but does not include
disciplines taught only in the VET sector). Therefore, it is anticipated that a corresponding
number of discipline councils would be convened in the first instance.




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The main function of the discipline councils is the determination of policies, principles and
practices that will serve as the framework for negotiations (at the regional level) between
education providers and health services. The outcome will be consistent practices that (a)
facilitate inter-regional exchange; (b) reduce complexity for health services that deal with
multiple education providers; (c) improve consistency for education providers dealing with
multiple health services in multiple regions; and (d) assist institutions with forward planning. It
is anticipated the nature of the framework will differ between disciplines.

Therefore, at the outset, each discipline council would have to develop its own modus
operandi, including consideration of the following:
 Stakeholder representation. It is anticipated that education providers might all wish to
   participate in discussions and decision-making on their own behalf, whereas health service
   providers may be happy to be represented by one or more delegates for a particular health
   care setting (e.g. GPs may prefer to be represented by their Division of General Practice;
   aged care facilities may be represented by their regional ACCV branch; categories of
   hospitals may nominate representatives; etc).
 Issues that merit negotiation and resolution for that discipline and, for each issue, whether
   statewide consistency is required as opposed to region-specific solutions. This will allow
   each discipline council to set its terms of reference, as well as the terms of reference for
   regional discipline committees.
 The need for sub-discipline groupings. For example, in medicine it might be appropriate to
   sub-divide the council into those concerned with hospital-based placements, those
   concerned with GP-based placements and those concerned with placements in community-
   based settings.
 Data rules and terminology to allow collection and collation of meaningful data on clinical
   placement capacity and capacity development needs. Some data rules may also need to be
   consistent across all disciplines.
 How the council will conduct its business. This includes frequency and location of meetings,
   how meetings will be convened and chaired, how negotiations will be moderated and
   mediation of disputes/disagreements, how the operation of the model will be evaluated
   within that discipline.

Once the ground rules have been agreed, each discipline council would be expected to
prioritise the issues it will address and formulate a work plan for the first twelve months. This
must include a schedule of meetings that allows time for adequate consultation between
sectoral or institutional representatives and their constituents.

At the point at which the terms of reference for the regional discipline committees have been
agreed, these groups can be convened. Each regional discipline committee would comprise:
 Health services in that region that offer (or would like to offer) placements for that
    discipline;
 Service providers in other sectors, such as education and social care, in that region (only
    for some disciplines) that offer or would like to offer placements;
 Education providers (university and/or VET institutions) that place students in that region;
 Regional Training Providers, where appropriate;
 Representative bodies or peak associations, as appropriate;
 DHS representatives.

The regional discipline committees have five main functions, namely:
 Audit clinical placement capacity for that discipline within their region and provide this data
   to the discipline council (and later, to their respective regional clinical academy).
 Assess existing demand for clinical placements within their region and provide this
   information to the discipline council (and later, to their respective regional clinical
   academy).
 Within the framework developed by the discipline council, negotiate the equitable allocation
   of placements across education providers placing students in that region.




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   Audit infrastructure (including simulation facilities) and capacity development requirements
    for their region, prioritise needs and formulate plans to meet those needs.
   Within the framework developed by the discipline council, develop regional standard
    operating procedures for organisation and management of clinical placements.

Given the function of regional discipline committees, it is likely the majority of health services
would be individually represented during discussions and negotiations.

Once the regional discipline committees are underway with their negotiations, the regional
clinical academies (RCA) can be established. At the most basic level, these academies are a
mechanism for drawing together all the regional discipline committees within a particular
region of the state. The regional clinical academies are expected to provide a forum for:
 Sharing ideas and resources;
 Discussing and devising solutions in relation to interprofessional education and other issues
    of multi-disciplinary interest or concern (such as preceptor/educator training, student
    accommodation and support, common use facilities, etc);
 Developing regional priorities for capacity building and infrastructure.
The academies will also serve as a platform for innovation and research, as well as monitoring
the quality of clinical education and training in the region and advocating on behalf of the
region in wider forums.

In essence, the regional clinical academies are seen as virtual intellectual units, comprising all
the stakeholders in clinical education in each region of Victoria. As members of any given
academy, organisations/institutions and their employees would be expected to have access to
the communal resources of that academy and could engage with the academy and the
activities it auspices to whatever extent deemed appropriate or necessary. Each academy
would have its own secretariat that would manage the business and resources of the academy
and support its operations (see below).

In some regards, the regional clinical academies could be seen as a new model of clinical
school. Whereas clinical schools have traditionally been focussed on a single discipline (usually
medicine, but there is a growing trend towards clinical schools for nursing and allied health
disciplines) and represent a relationship between a single education provider and a single
health service (or health service network), the regional clinical academies will incorporate
multiple disciplines, multiple education providers and multiple health services. Once the
discipline-by-discipline audit of clinical placement capacity has been completed, each regional
clinical academy will be the de facto broker of that capacity, in much the same way as clinical
schools represent a mutually agreed number of clinical placements available to the education
provider member of the partnership. Furthermore, just as clinical schools provide student
support, regional clinical academies could serve a similar function, particularly for the students
of education providers that do not have a major campus presence in the region.

Therefore, once the regional clinical academies are established and operational, they could be
expected to have the following roles:
 Maintain real-time regional data on the current usage of clinical placement capacity and
   any unused placement capacity;
 Assist in arranging ad hoc clinical placements;
 Management and oversight of simulation facilities;
 Management and oversight of other communal assets or resources;
 Compilation of regional data relevant to demand modelling and forward planning;
 Supporting regional discipline committees in their annual review of placement activity and
   in their periodic renegotiation of placement allocations;
 Engaging health services not currently involved in clinical education to encourage their
   participation and provide assistance to new recruits in meeting their capacity development
   needs;
 Auspice research and innovation projects within the region;




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   Convene working groups to address specific issues;
   Prepare discussion papers and reports on regional activities for broader dissemination;
   Identify regional development priorities and prepare proposals to government for
    infrastructure and other support;
   Provide student support, including assistance with student accommodation;
   Auspice preceptor/educator training programmes;
   Monitor quality indicators at clinical placement sites across the region and auspice quality
    improvement initiatives;
   Work with other regional clinical academies to share ideas and innovation and resolve
    issues of mutual concern;
   Advocate on behalf of the region in statewide and nationwide forums.

As indicated in this list of roles, one of the important functions of the regional clinical
academies would be the collection of data relating to clinical placement capacity and activity in
their region and maintenance of a real-time database on current usage of that clinical
placement capacity. This database, which is likely to be part of a statewide (and possible a
nationwide) database, is essential to the operation of the model. It is envisaged that all
stakeholders would have read-only access to this database, allowing them to monitor their
own activity and facilitating ad hoc placement activity when this becomes necessary. However,
the ability to make changes to the database should be restricted to regional clinical academy
secretariats and there must be stringent data rules to ensure data entered into the system is
consistent, meaningful and up-to-date.

Although individual regional clinical academies may develop their own model of governance,
one possible arrangement is shown in Figure 18.




Figure 18: Possible governance arrangements for regional clinical academies




Darcy Associates Consulting Services                                                           42
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All stakeholder organisations (and, by extension, their employees) within a particular region
would be members of the academy. Each organisation (or institution) would nominate
representatives to sit on the Regional Clinical Academy Board, which would have major
responsibility for convening working groups that examine particular issues, develop proposals
and oversight shared resources. These working groups could include Board members and could
also second members from the general membership of the academy. A Regional Clinical
Academy Executive, comprising sectoral representatives from the Regional Clinical Academy
Board, would have responsibility for budget oversight, reporting and accountability.

As shown in Figure 17, the regional clinical academies would sit within a broader statewide and
nationwide context. At the next level beyond the academies, the Victorian Clinical Placements
Council (VCPC; proposed in a DHS draft document[32]) would provide statewide leadership and
advice on clinical placement issues and oversee clinical placement projects that have an impact
at the state level. In particular, the VCPC would oversee activity in the five action streams
identified in the Victorian Government‟s clinical placement strategy [13], namely: capacity
building, targeted funding, innovation, better data and evidence, and improved governance.
The VCPC would be accountable to the DHS (and through DHS to Health Workforce Australia)
for disbursement of government funds that support clinical placement governance in Victoria.

The VCPC is envisaged as „stakeholder-owned and driven‟, with representation from education
providers, health services and other relevant stakeholders, and a rotating chair. The agenda of
the Council will be set by the stakeholders, rather than by government, although DHS would
most likely be a member of the VCPC and would be expected to provide policy priorities.

Key roles of the VCPC would include:
 Working with Health Workforce Australia, both to provide advice and information that will
   inform the national agenda, and to ensure Victoria meets its requirements for the
   distribution of Commonwealth funds attached to clinical education;
 Advocating on behalf of Victoria in the national context;
 Convening and supporting the discipline councils that provide the foundation for the
   Victorian model;
 Providing a big picture view to guide activities and priorities for regional clinical academies;
 Serving as mediator in dispute resolution within and between regions;
 Assisting in the dissemination of innovation and ideas between regional clinical academies;
 Collating and disseminating statewide clinical placement capacity information and reporting
   collectively on the state‟s clinical placement activities;
 Oversight allocation of special purpose funds for specific projects of statewide significance.

It is expected the roles of the VCPC would most likely be further refined once the discipline
councils, regional discipline committees and regional clinical academies are established and
settled into their operational modes. This is because the VCPC, as well as serving as a conduit
between state and national activities, should be an entity that serves the needs of the system,
rather than an entity that sets rules regardless of the needs of the system.

Similarly, it would be expected that – at least to some extent – Health Workforce Australia
would serve a role at a national level that reflects the role of the VCPC at a state level. Health
Workforce Australia would also have significant roles in national strategic workforce planning,
identifying national priorities in research, innovation and quality improvement, and in setting
overall funding policy and guidelines.

6.3 How the model will operate
This section explores in greater detail how the model may operate, by addressing questions
posed in the discussion paper (see Appendix 12) and raised by participants in the roundtable
discussions. It should be noted the answers provided below are recommendations based on
current thinking about how the model could operate, as well as feedback provided by
stakeholders. In many cases, other options are also possible and it is likely, as the model is
implemented, that other options may turn out to be more appropriate or feasible.



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General

Q1     What are the major differences between the current arrangements and the new model?
There are two major differences between current arrangements and the proposed model. The
first major difference relates to the nature of negotiations. Presently, the vast majority of
negotiations involve bi-lateral discussions between individual education providers and
individual health (or other) service providers. This has resulted in a fragmented, opaque,
uncoordinated and inefficient system. The new model proposes a multi-lateral negotiation
process that occurs across all tiers of the system. All stakeholders – both education providers
and health service providers – will have input to the development of policies and principles that
govern negotiations, and all stakeholders will participate in the negotiation of placement
allocations between education providers and health service providers.

The second major difference relates to inter-disciplinary activities. The current system does
not have any mechanism for information sharing and coordination between disciplines (where
required or desired), or for addressing the objectives of interprofessional learning and
preparing students for work in multi-disciplinary settings. The new model, through the regional
clinical academies, provides such a mechanism and creates a forum for developing regional
priorities for capacity building and infrastructure, as well as a platform for innovation and
research.

It is important to note that the new model is not intended to replace or dismantle all the
arrangements and relationships that currently exist, which represent many years of effort by
stakeholders. Rather, the new model will incorporate arrangements that work well and ensure
good ideas and innovations are disseminated throughout the system for the benefit of all
stakeholders. The new model will add structure to the system where it is needed, while
allowing autonomy and choice where it is appropriate. Importantly, the new model will reduce
complexity for health services that deal with multiple education providers, improve consistency
for education providers dealing with multiple health services in multiple regions and assist all
institutions with forward planning.

Regional boundaries

Q2     What regional boundaries will define the regional clinical academies?
It is recommended that, at least in the first instance, Victoria is divided into eleven regions,
with five regions in rural Victoria and six regions in metropolitan Melbourne (see Figure 12 and
Figure 13). This number of regions is large enough to deal with the complexities and
differences across the state, but not so large as to be unmanageable. With only very minor
exceptions, the regional boundaries follow local government area (LGA) boundaries, thereby
ensuring that area mental health services and community health services that are the
responsibility of local government are not split by the boundary definitions.

The five rural regions correspond to the five existing DHS regions, namely:
 Barwon South-Western region
 Grampians region
 Loddon-Mallee region
 Hume region
 Gippsland region

The six metropolitan regions, as proposed, would be derived from the three existing DHS
metropolitan regions, with some readjustment of boundaries to avoid splitting health service
networks across regions. Thus, the DHS North and West Metropolitan region is split into two
regions and the DHS Southern Metropolitan region is split into three regions, resulting in the
following six metropolitan regions:
 Western metropolitan region
 Northern metropolitan region
 Eastern metropolitan region




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    Central metropolitan region
    Southern metropolitan region
    Peninsula region

It is possible that, once the system is established and running smoothly, the six metropolitan
regions could be combined into three or four regions similar to the DHS metropolitan regions,
but maintaining the arrangements that keep health service networks within a single region.

Q3      How will private sector health providers that operate health services in a number of
        regions be impacted by the recommended regional boundaries?
It is not possible to develop a regional model that accommodates private health services that
have a dispersed distribution of sites, such that all of the sites can be located within a single
region. It is the consultant‟s understanding that, unlike public health service networks that
often make network-wide decisions about clinical placement capacity, private health providers
usually make placement capacity decisions site-by-site. Where decisions that cover more than
one site are being made, it is probably because the sites are close geographically; in this case,
the sites are very likely to end up in the same region.

Nevertheless, there may be instances where several private health service sites that are used
to operating as a consortium for the purposes of considering their clinical placement capacity
are split by the regional boundaries. In such cases, it may be possible to change the regional
affiliation of individual private health services for the purposes of the negotiation and allocation
of clinical placements.

Policies and principles

Q4      What policies, principles and practices need to be determined by the discipline councils?
The model proposes that discipline councils will be charged with the responsibility of
developing the framework for negotiations (at the regional level) between education providers
and health services. The framework is very likely to be different for different disciplines, in line
with the particular issues and challenges that each discipline faces, now and in the future. As
the discipline councils will be statewide entities, the policies, principles and practices they will
develop will be those that require statewide consistency. Where regional variations can be
tolerated, the discipline councils may delegate the policy-making to the regional discipline
committees, but the ultimate objective is to introduce a level of consistency and continuity that
streamlines and improves on current arrangements.

With this in mind, the following list identifies issues that individual discipline councils might
address. This list is not exhaustive and not all issues will be relevant to all disciplines.
 Common timelines for placement request/offer rounds, analogous to the system used by
   the Victorian Tertiary Admissions Centre (VTAC) for offering students places in tertiary
   courses. These timelines would apply to all education providers and all health services with
   placement capacity across the state. Thus, education providers would submit their
   placement requests by a given date, receive their offer of placements on a given date and
   could then move into the next round of placement requests as required.
 The frequency of re-negotiation of placement allocations. At the present time, most
   disciplines re-negotiate all their placement allocations every year. It is envisaged that the
   new system would allow the vast majority of recurrent placement activity to be negotiated
   for a longer period, perhaps three years. There could be annual (or bi-annual) reviews of
   arrangements to ensure all stakeholders are satisfied and allow any issues to be resolved in
   a timely manner. Thus, only a relatively small number of placements would need to be
   negotiated in any one year, in particular, new placements (representing growth in student
   numbers), one-off requests that are arranged to meet student needs, or emergencies that
   arise through unforseen circumstances. Every three years, there could be a spill of all
   placements for that discipline, allowing all stakeholders to change their clinical placement
   profile. Of course, if both parties in a clinical education arrangement are satisfied and wish
   to maintain their relationship, there does not need to be a large change. Nevertheless, the




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     possibility that the status quo could change may serve to keep all stakeholders vigilant
     about maintaining their side of partnerships they wish to retain.
    Processes for handling emergency or other ad hoc requests for placements, both for
     education providers within each region and for education providers who normally do not
     place students in that region. The use of common forms and other documentation across
     the state might be explored.
    How growth in the education sector will be managed. The deregulation of the higher
     education sector, as recommended by the Bradley Review[33], could potentially see further
     large increases in student numbers in health professional courses. Assuming the audit of
     clinical placement capacity (by regional discipline committees) reveals some unused
     capacity, or that targeted capacity development over the next couple of years results in
     capacity above current demand, the knowledge that this spare capacity exists could
     encourage education providers to increase student numbers once Commonwealth caps are
     removed. If completely unregulated, this could result in a worse situation than currently
     exists with respect to oversubscription of clinical placement capacity. Therefore, individual
     disciplines may need to reach agreement about how future growth in enrolments will be
     managed and equitably distributed amongst education providers.
    How specialist resources will be shared. Many health professional courses include specialist
     blocks or rotations such as women‟s health (particularly obstetrics and gynaecology), child
     and adolescent health, mental health/psychiatry and oncology. Although most large
     hospitals and many community-based health services deliver these services, there are also
     a small number of health services that specialise in these fields (such as the Peter
     MacCallum Cancer Centre, The Women‟s, The Royal Children‟s Hospital, The Royal Victorian
     Eye and Ear Hospital, etc). Each discipline may need to determine the most appropriate
     way to share limited specialist health services (whether at a specialist site or an equivalent
     clinical education experience in the context of a generalist health service) amongst all
     education providers in that discipline.
    Rules and/or processes for negotiations across regions. This could encompass anything
     from who the appropriate first point of contact is, through to creating hierarchies for
     dealing with ad hoc requests (e.g. a decision might be taken that stakeholders within
     regions are dealt with before requests from external stakeholders are considered).
    The development of common assessment tools, to reduce the complexity for health
     services working with multiple education providers for a given discipline.
    Processes for mediating disputes, both within regions and between regions.
    Monitoring and evaluation of the system, both during its initial establishment phase and
     once the system is fully operational.
    Quality assurance issues and other issues relating to professional standards. This could
     include development and/or adoption of common student/educator experience surveys or
     other quality assurance tools, or the development of quality benchmarks or indicators for
     categories of clinical placement sites.
    How simulation can be used to augment or enhance clinical education. Discipline-wide
     agreement on minimum desired use of simulation would assist regional discipline
     committees, when they are auditing current regional access to simulation facilities, to
     identify their resource development needs. Discipline-wide solutions, such as mobile
     simulation facilities, could be developed where fixed facilities are not feasible.

Membership of councils, committees and regional clinical academies

Q5      Who will have a seat at the table for discussions in discipline councils, regional
        discipline committees and regional clinical academies?
The objective is that all stakeholders for a given discipline or a given region will have a voice in
discussions and negotiations. Table 3 (overleaf) summarises who these stakeholders are likely
to be at each level of negotiations.

Of course, given the numbers of stakeholders involved, it may be the case that individual
organisations or institutions are not always represented in all discussions. Instead, sectoral




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representatives may be used where appropriate and these representatives would be expected
to consult extensively with their constituents to ensure their views are represented. It should
also be noted that health services will be involved with many discipline councils, although in
most cases different health service staff will represent their organisation on different discipline
councils. Furthermore, health services will only be involved in a single region.

On the other hand, education providers will be involved in as many discipline councils as they
offer courses (different individuals will be involved with different councils). For each discipline,
they will be involved with as many regions as they place students. This may encourage
education providers to rationalise their spread of clinical placement activity, to limit the
number of regional discipline committees and regional clinical academies they work with.

It should be noted that this new system will replace the current arrangements, whereby each
discipline for a given education provider individually negotiates placements with scores of
health service sites (one institution reported up to 150 different placement sites for a single
course). Furthermore, although the rounds of discussions and negotiations will require a
significant amount of effort as the system is established, once the system is operational, the
discipline councils and regional discipline committees will only need to meet infrequently.
Table 3: Categories of members for councils, committees and regional clinical academies

      Discipline councils                    Regional discipline                    Regional clinical
                                                committees                            academies
    Health services that offer (or       Health services in that region         Health services in that
     would like to offer)                  that offer (or would like to            region that offer clinical
     placements for that discipline        offer) placements for that              placements
                                           discipline
    Service providers in other           Service providers in other             Service providers in other
     sectors, such as education            sectors, such as education and          sectors that offer
     and social care, that offer (or       social care, that offer (or would       placements
     would like to offer)                  like to offer) placements for
     placements for students in            students in that region (only for
     some disciplines                      some disciplines)
    Education providers                  Education providers (university        Education providers
     (university and VET                   and/or VET institutions) that           (university and VET
     institutions) that offer              place students (or would like to        institutions) that place
     courses in that discipline            place students) in that                 students in that region
                                           discipline in that region
    Regional Training Providers,         Regional Training Providers,           Regional Training Providers
     where appropriate                     where appropriate
    Representative bodies or             Representative bodies or peak          Representative bodies or
     peak associations, as                 associations, as appropriate            peak associations, as
     appropriate                                                                   appropriate
    DHS representatives                  DHS representatives                    DHS representatives

Q6       Will membership be weighted?
It is not recommended that membership of any of the tiers be weighted (for example,
according to the number of students an education provider enrols or the clinical placement
capacity of a health service). All stakeholder views should be heard during discussions and
negotiations, and every effort should be made to accommodate the preferences of individual
institutions, regardless of size. The objective of the discussions and negotiations is to ensure
equitable, transparent access to limited resources, not to force conformity; for this to happen,
individual voices should be heard, regardless of whether they represent majority preferences
or practices. Nevertheless, it is expected that commonsense will prevail and in those instances
where a common policy or practice must apply to all players, the views of a stakeholder with a
very small interest in a particular region will not be imposed on stakeholders with a much
larger interest.




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Q7     What level of institutional representative will be required at each tier of the model?
This is a decision that each stakeholder institution will need to make for itself and will vary
between institutions, depending on their internal structure and how decision-making and other
responsibilities are delegated. Generally, individuals with detailed knowledge and
understanding of clinical placement requirements (for education providers) or clinical
placement capacity (for health services) would be best placed to represent their institution.
However, representatives must also have positional authority to be able to make decisions or
commitments on behalf of their institution. It is possible that, for some negotiations or
discussions, more than one representative per organisation may be needed.

It is anticipated that it will soon become apparent to organisations who their most appropriate
representative will be for each tier of the model. Furthermore, different issues may require
different representatives. Thus, it is particularly important that each tier (i.e. discipline
councils, regional discipline committees and regional clinical academies) develop a work plan
and maintain an agreed schedule of discussions, so that stakeholders can ensure the most
appropriate individuals attend each meeting and that there is time between meetings to
discuss decisions within their organisation or representative groups.

Q8     Will education providers who currently place only a few students in a region (perhaps in
       response to special students needs or requests) have a seat at the table for discussions
       about policies and principles?
Yes, any education provider that currently places students in a region will be included as a
stakeholder in that region in the first instance. Indeed, an education provider who does not
currently place students in a particular region – but who may wish to place students in that
region in the future – may also be included as a stakeholder in that region. However, as noted
under Q5, education providers will most probably wish to rationalise their regional activities,
provided they are able to access the number of high quality placements they require in a small
number of regions. It is not recommended that education providers be allocated to particular
regions, but rather that each education provider makes its own strategic decisions about this
based on current and projected needs.

Q9     How will interstate education providers who currently place students in Victoria be dealt
       with in this model?
It is recommended that interstate education providers be treated in the same way as
education providers based in Victoria. That is, each education provider that currently places
students in Victoria will be invited to participate in the discipline councils, regional discipline
committees and regional clinical academies relevant to them. If they decline membership, they
may still make applications to the relevant regional clinical academies for placement of their
students, but these requests are most likely to be considered after the needs of the member
education providers are met (Note: this will depend on relevant decisions made by each
discipline council on how to handle requests by external education providers).

Q10    How will new education providers enter the system?
This is unlikely to work differently than is currently the case. That is, whatever regulations and
controls currently govern the establishment of a new educational institution (more often within
the VET sector) or the establishment of a new course within an existing education provider will
still operate. It may be the case that the application to establish the new course would require
evidence of consultation between the education provider and the relevant discipline council
(and regional clinical academies) concerning the availability of suitable placements. Once a
new course is approved, the education provider would become a member of the relevant
discipline council and regional clinical academies.

Q11    Health services are already members of a large number of regional networks. How will
       this model mesh with existing arrangements?
It is certainly the case that significant use of networks and consortia is made within the
Victorian health system and many health services are members of a number of these entities.
Some of these are predominantly concerned with delivery of health services (such as Primary




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Care Partnerships, Care in Your Community planning networks and Integrated Cancer
Services), others are primarily concerned with health service delivery but have education and
training responsibilities as well (such as the Victorian trauma system coordination model),
while others are mainly involved with education and training, particularly at the post-
qualification level (such as the Postgraduate Medical Council of Victoria and the Basic Physician
Training consortia).

None of the existing networks would be appropriate entities to govern the management and
organisation of undergraduate clinical education across the range of health professional
courses offered in Victoria. Furthermore, it would not be appropriate to graft the governance
arrangements for undergraduate clinical education onto other entities in a piecemeal manner.
Therefore, a separate system with responsibility for this activity has been proposed. This is not
to say the proposed clinical placement governance arrangements will work in isolation from
other networks; indeed, there are many benefits to close alignment between the proposed
system and networks that coordinate post-qualification education and training. It is also
expected that health services would bring relevant information to the table from their
involvement in other networks and consortia, to ensure undergraduate clinical education in
general – and the organisation of clinical placements in particular – reflects trends in health
care and service delivery.

Q12    What will happen to existing discipline-based consortia or groupings under the new
       system?
Some disciplines have already established mechanisms for coordination of clinical placement
activities, particularly between the various education providers that deliver courses in that
discipline. One example is Social Work, which has established the Combined Schools of Social
Work (CSSW)[9], bringing together the six university social work schools in Victoria in a
collaborative model of placement management and planning. It is anticipated that the Social
Work discipline council in the proposed model would build on the foundation established by the
CSSW, the main difference being that the discipline council would include health and other
service stakeholders, not just the education provider stakeholders.

Any existing discipline-based arrangements would need to be considered on a case-by-case
basis, but the objective would be to build on current efforts, rather than duplicate them.
Whether the new discipline councils ultimately replace existing arrangements or work
alongside them would be a matter for each discipline to determine.

Q13    How will health and other services that are not currently involved in clinical education
       be recruited to the regional clinical academies?
This is envisaged as one of the roles of the regional clinical academies. That is, building on the
audit of current clinical placement capacity and the identification of health services (mainly in
the private sector) that are not involved in clinical education, each regional clinical academy
would be expected to engage with appropriate service providers to determine their interest in
participation and any barriers to their involvement in educational activities. The regional
clinical academies may also take responsibility for capacity development of existing and newly
recruited clinical placement providers and the implementation of quality assurance/ quality
improvement tools and other common practices/processes in those settings.

Q14    How will new and emerging roles be handled in this model?
This will most likely vary depending on the individual case, particularly in relation to whether
an entirely new course of study is used to train individuals for the new role, or whether the
new role is a sub-specialty or extended version of an existing role. In those cases involving a
new course of study, a separate discipline council should be established, sitting alongside the
existing discipline councils and slotting into relevant regional clinical academies. In other
cases, training for new/emerging roles might fall under an existing discipline council and be
treated as a sub-discipline.




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Q15    Will student representatives be included as members in any tier of this model?
It is not recommended that student representatives be included at any tier of the model (i.e.
discipline councils, regional discipline committees or regional clinical academies). There are
several reasons for this. Firstly, logistically, it would be almost impossible to select student
representatives who would be able to contribute meaningfully to discussions about placement
allocations for the following year/semester, as many students are only at a particular site in a
particular region for a matter of weeks. Not only will this impact on their attendance at
meetings, it is difficult to envisage how student representatives would be able to gather input
from their peers or provide feedback to them from meetings.

Secondly, most of the discussions in discipline councils, regional discipline committees and
regional clinical academies will be policy-related or concerning the logistics of allocating overall
placement capacity between education providers. Students are not currently involved in
negotiating placements between education providers and health services and it is doubtful that
students would wish to spend time considering these issues.

Finally, the responsibility for ensuring an appropriate student focus and that student needs are
taken into consideration when assigning placements lies with individual education providers.
Once an education provider knows which sites will host its students, it is up to that education
provider to ensure that students are allocated to those placements as appropriately as
practicable, taking into account their needs, access, support and preferences.

However, it is recommended that student feedback on their clinical placement experiences be
factored into regular evaluation of the operation of the model and regular evaluation of clinical
placement arrangements. Student input is important, but it will be more effectively gathered
through targeted feedback processes that address issues of direct concern to students.

Negotiations about placement capacity

Q16    How is clinical placement capacity defined?
This will vary by discipline and should be defined by discipline councils. One common definition
of clinical placement capacity is not a prerequisite for the establishment or operation of the
proposed governance model.

Q17    How will placement capacity, once determined, be equitably distributed between
       competing education providers?
This will vary by discipline and possibly also by region. The discipline councils will primarily be
responsible for setting the ground rules for negotiations, which will then be implemented by
the regional discipline committees. Each regional discipline committee will conduct an audit of
clinical placement capacity for that discipline in that region and will also identify mechanisms
to increase capacity. Once these tasks are completed, it is expected that each education
provider for that discipline will present its case for its placement requests in that region, which
will most likely reflect the aspects of its current arrangements that work, as well as issues
where modifications or improvements are sought. It is likely the current distribution of
placement capacity will serve as the starting position for negotiations, with requests for change
(and the rationale for each request) being considered on a case-by-case basis.

It is important to note the objective is to maintain as far as possible the existing education
provider-health service partnerships that are satisfactory to both partners. However, where
maintenance of the status quo will perpetuate inequitable arrangements, every attempt should
be made to redress the situation. This might be accomplished by changed arrangements within
a single region, or might require a cascade of changes across several regions, or may require a
less immediate solution such as structural changes to curricula (to permit offset placement
requirements) or development of additional educational capacity through infrastructure or
personnel developments.




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Q18    How will clinical placements in specialist settings be handled?
This will vary by discipline. As discussed under Q4, each discipline council will have to consider
its specialty requirements and identify settings where the appropriate clinical experience can
be offered to students. This will certainly include specialist hospitals, but may also include
specialist services within non-specialist hospitals and other health care settings. In those cases
where a discipline council determines that a specialist hospital offers placement experiences
for which no equivalent can be found elsewhere, the council will have to decide how best to
allocate the available placement capacity amongst the relevant education providers.

It should be noted that in the proposed regional breakdown of Victoria, all the specialist
hospitals are located in the Central metropolitan region (see Section 4.4).

Q19    How will competition for placement sites between different disciplines be handled?
In the first instance, when health services are considering their capacity for accommodating
learners, they will have to take into account competing needs of different health professional
courses for the same resources. This will occur in much the same way as happens at present.
Thus, when health services sit down to negotiate capacity allocation in regional discipline
committees, their position will be informed by knowledge of other discipline‟s likely
requirement for the same resources. In this way, most competition between disciplines for
health service placement capacity will be handled by planning and consultation within the
health service or health service network before negotiations with education providers
commence.

However, it may become clear through the negotiation process that there are significant and
counterproductive imbalances in the access of disciplines to particular resources across the
whole region. Addressing these imbalances is expected to be one of the roles of the regional
clinical academies, which is a forum that brings together all disciplines involved in clinical
education in a given region.

Q20    How will differences in acuity between health services be handled in terms of giving
       education providers access to all relevant levels of acuity?
The proposed model is expected to handle this issue in much the same way as the current
system does. Indeed, the proposed model may actually improve the access of some education
providers to health services they have had difficulty accessing.

Presently, education providers identify the type of health service and level of acuity necessary
to deliver an appropriate clinical education experience for the students and then negotiate with
as many health services as necessary to accommodate their student numbers. In transitioning
to the new model, education providers will be stakeholders in any region where they currently
place students, so they will be able to request continuity of placements that meet their present
demands. Furthermore, if they are not satisfied with their current arrangements, they will be
able to request alternative placements and be part of the negotiations for those allocations.

It is important to note that education providers will not be restricted to particular regions to
obtain their clinical placements and therefore all education providers can participate in
negotiations for whatever levels of acuity or types of health services are relevant to their
curricula. There may need to be some juggling of placement allocations to address all
stakeholder needs and there is no guarantee that first preferences will always be met.

Q21    Would all placements be handled under the auspices of the model, or might some
       private arrangements also be used?
All placements will be handled under the auspices of the regional clinical academy model. No
private arrangements will be permitted, as these will undermine the operation of the system
and result in lack of transparency and breakdown of trust between stakeholders. It is expected
that all stakeholders will have a role to play in maintaining the integrity of the system,
referring enquiries made outside of the system to the appropriate channels.




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Q22    What role will established relationships have in a new system of transparent, multi-
       lateral negotiations?
Established relationships are likely to form the basis of the first round of negotiations of
placement allocations in the new system. Education providers and health services that have
worked together for some time and are satisfied with the arrangements may wish to continue
those arrangements and this will be encouraged as far as practicable.

However, some of these relationships have effectively shut out later entrants to the field. In
these cases, some redistribution of placement capacity might be appropriate, but this will only
happen through negotiation and once alternative placement capacity of suitable standard and
content has been identified.

Indeed, it is important to recognise that placements covered by established relationships
(including preferred or exclusive relationships) are part of the total demand for placements
across the state. If the existing relationships were all dissolved, the placements they cover
would need to be found elsewhere in the system. Therefore, changing existing relationships
does not really improve the supply-demand equation, it only alters the distribution of the
available supply.

Q23    How will a level playing field be maintained?
It is unlikely that a truly level playing field could be established or maintained under any
system of governance for clinical placements. It is a fact that different education providers (in
particular) have different qualities, resources and opportunities that make them more or less
attractive to health services as partners in clinical education. A research-intense university
with funds to contribute to joint positions, or that is able to offer access to desirable resources,
will no doubt be a partner of choice compared with an institution that does not have the
capacity to offer these enticements. Likewise, educational institutions that have invested in
facilities at a health service over many years will benefit from the historical relationship when
competing for placements with an education provider without such an association. These are
the foundations on which the system is built and they cannot be set aside or changed in the
short-term. Indeed, it would not be in the interests of the system to do so.

Nevertheless, it is also not in the interests of the health system as a whole that students
enrolled at different education providers for the same course should have significantly different
clinical placement experiences, either in terms of content or quality. Therefore, the overall
objective of the new governance arrangements should be to ensure that adequate high quality
placements are available for all trainees, regardless of the institution at which they are
enrolled. This will be achieved by regional discipline committees providing a forum for all
education providers to table their needs and sponsoring debate on how placement resources
can most appropriately be allocated. Furthermore, the regional clinical academies, acting on
advice from regional discipline committees on capacity development requirements, will be
responsible for developing plans to improve and maintain the quality of placements across
their region.

Q24    How will emergencies be handled?
An emergency would be a situation where, for example, a health service has to cancel access
to placements at short notice or a student is unable to undertake a scheduled placement. In
these circumstances, an education provider would need to find alternative placements for the
affected students, most probably at a different health service.

Initially, the cancellation of the scheduled placements would be notified to the relevant
regional clinical academy secretariat, so that the change can be recorded and, if necessary or
appropriate, the issues resulting in the cancellation can be noted in the placement database.
The education provider may seek assistance from the secretariat to arrange alternative
placements for the affected students, or may review the placement database themselves to
identify sites with unused capacity that could accommodate the students. Suitable health
services would be contacted and, if an arrangement were reached, this would be notified to the




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relevant regional clinical academy secretariat (i.e. the placement may need to be in another
regional network) so the placement database can be updated.

Different disciplines and/or regional clinical academies may develop variations on this process,
such as the use of online placement request forms or particular protocols for notifying
changes. However, the essential features of the process – namely, notifying cancellations and
new ad hoc arrangements to the secretariat, and use of the placement database to identify
where unused capacity exists – are likely to be consistent across the model.

Q25    Who will be the independent arbitrator for resolution of conflicts and disagreements?
It is recommended the VCPC be designated as the independent arbitrator for conflict and
dispute resolution. The VCPC, being a stakeholder body with broad cross-sectoral
representation and charged with responsibility for strategic oversight of the system, would be
well-placed to consider the wider implications of issues and would be aware of how similar
issues are being handled in other jurisdictions. If any member of the VCPC were affiliated with
organisations involved in a particular dispute, that member would be expected to excuse
his/herself from the deliberations.

Q26    How will non-members negotiate placements within a region?
As noted for Q24, different disciplines and/or regional clinical academies may develop different
processes or protocols for education providers from another region (or another state) who are
not members of a particular regional clinical academy to negotiate placements within that
region. It is envisaged the education provider would contact the relevant academy secretariat
with their request and seek guidance on the process, which could be mediated or handled by
the secretariat or could be handled through direct negotiation between the education provider
and health services with available placement capacity. As discussed earlier in relation to
handling emergencies, any placement arrangements that are reached would be notified to the
secretariat for recording.

If a non-member education provider wished to convert an ad hoc placement arrangement into
a more permanent arrangement, the education provider would be expected to become a
member of the regional clinical academy and take up a seat on the relevant regional discipline
committee.

Inter-regional negotiations

Q27    How will regions work with each other and on what issues will this be necessary?
For the most part, each region is expected to operate as a self-contained entity, developing
and managing its own clinical placement capacity and handling negotiations between
stakeholders. However, the regions are part of a statewide system, linked by common policies
and practices developed by the discipline councils and serving the shared objective of meeting
the state‟s clinical education requirements, thereby creating a sustainable pipeline to an
appropriately skilled health workforce. Therefore, although the regions can work independently
of each other, their activities and processes must be complementary and there may be
occasions where they assist each other through sharing of resources or providing ad hoc
access to their placement capacity.

Thus, the regions will be expected to have a cooperative relationship and there are several
mechanisms envisaged for inter-regional cooperation. On a day-to-day basis, it is expected
that regional clinical academies will be in regular contact with each other through their
secretariats. This will involve exchange of information and ideas, as well as sharing of
resources. Assisting with emergencies would also be part of this relationship, if a placement
cancellation in one region could not be rescheduled within that region. The secretariats may
wish to establish a regular discussion forum (perhaps meeting quarterly) to ensure
dissemination of information occurs across all regions and also to use the collective experience
and expertise of the group to address issues of common concern.

Regional clinical academies would also be expected to report on their activities to the VCPC,
which would include reports on local innovation, local problems and their solutions, progress




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with infrastructure and other capacity development initiatives, quality audits and research
outcomes. These reports would be made available to all regional clinical academies for their
information. It might be considered appropriate to establish a VCPC website, which could
include separate web pages for each regional clinical academy.

Q28    How will the Victorian system interact with interstate systems (particularly NSW and
       SA)?
This cannot be fully addressed at this time, as the nature of clinical placement systems being
developed by other states to fit within the new national context is not known. However, the
proposed Victorian model allows for education providers based in other states to be fully
included in the discipline councils, regional discipline committees and regional clinical
academies established in Victoria. Furthermore, there is nothing in the proposed model that
would preclude Victorian education providers similarly fitting into the models established in
other states.

Importantly, the proposed model could be implemented in other states, or even nationally, as
there is nothing in the concept that is uniquely applicable to Victoria. Indeed, the regional
clinical academy concept can be realised with an unlimited number of academies.

Simulation

Q29    How will simulation facilities be handled in the context of this model?

Victoria has a range of simulation facilities and resources (including high- and low-fidelity
simulation centres, clinical skills laboratories and cohorts of simulated patients), some of which
are education provider owned and operated and others that are situated within health services.
Arrangements for financing, maintaining and operating the facilities vary, with some of the
facilities utilising a full- or partial-cost recovery model. Although simulation facilities hosted by
education providers tend to be used mainly for skills development for students enrolled in
entry-level health professional courses, facilities at health services are used for student
education, post-qualification learners and staff training, international medical graduates (IMGs)
and training clinical educators. However, as Victoria‟s simulation facilities have been
established with little coordination or consistency of approach, there is an uneven distribution
of resources, variable access for learners and limited educator training.

One of the objectives of the new model could be to consolidate the state‟s diverse simulation
resources along the lines of what was achieved in the US state of Oregon, through the Oregon
Simulation Alliance (OSA)[34]. The OSA is a coordinating body, not an owner/operator of
simulation facilities or resources. It assists local coalitions of stakeholders to pool their
resources and centralise their efforts in relation to: acquiring and maintaining infrastructure;
developing sustainable programmes; creating minimum standards, general policies and
procedures, including common language and approach; and training experts in simulation
education.

The VCPC and regional clinical academies could serve a similar role in organising simulation
facilities in Victoria. With the VCPC as the overarching governing body providing a consistent
and coordinated approach across the state, each regional clinical academy could provide direct
support for simulation in their region. For example, the academies could coordinate an audit of
existing resources and auspice sound purchasing decisions. They could sponsor multi-
disciplinary forums on expanding the use of simulation in clinical education, coordinate
innovation and research projects, and develop educator training. The regional clinical
academies would not own or operate the simulation facilities, but, as the regional forum for all
stakeholders in clinical education, the academies would be well placed to ensure simulation
facilities are optimised for the benefit of stakeholders.




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Communal resources

Q30    What communal resources will be established?
One of the by-products of efforts to coordinate activities and implement consistent protocols is
the development of common-use resources. To ensure all end-users have access to the same
resources, it is often useful (and more efficient) to establish communal resources. It is
important to note the proposed model is not dependent on the establishment of communal
resources for its successful implementation or operation. Nevertheless, examples of communal
resources might include:
 Secretariat staff in each regional clinical academy
 Preceptor/educator training programmes
 Other capacity development resources
 Simulation facilities, including
       o Fixed simulation facilities
       o Mobile equipment that can be transported to small rural centres where it might not
           be feasible to maintain a fixed simulation resource
       o Skilled staff, particularly those able to train others as simulation educators
 Student support resources, including accommodation

Q31    How will these be funded?
There are two options for funding communal resources. The first option is for all stakeholder
organisations within each regional clinical academy to be levied a fee for membership of the
academy, sufficient to cover the costs of communal resources.

The second option taps into the Commonwealth and state funding that will follow the students
to their clinical placement sites under the new national arrangements. If this funding from
government was channelled through the regional clinical academies, an agreed off-the-top
amount could be used to fund communal goods. The remaining funds would then flow to the
health services of each region as intended, pro-rated for the number of student placement
days at each site.

Financial and legal issues

Q32    What will be the legal status of the regional clinical academies?
Advice has been sought on whether the regional clinical academies can be established as
entities that can receive and disburse government funds and employ staff.

If this is not possible, each regional clinical academy may need to be established under the
auspices of an incorporated entity, such as one of the education providers or one of the health
services in that region. That entity would be designated as the lead institution for the academy
and would have to account for the disbursement of funds that it receives and controls on
behalf of the other academy members.

Miscellaneous issues

Q33    Will there be opportunities for inter-discipline communication at the discipline council
       level, or will all inter-discipline communication occur at the regional clinical academy
       level?
It is anticipated that discipline councils will be convened under the auspices of the VCPC and
therefore opportunities for discipline councils to communicate directly with each other,
particularly during the establishment phase of the new model, can be mediated through the
VCPC. There may be issues of relevance to all disciplines, such as the common database that
will house placement capacity/usage information, where it would be useful to get all disciplines
together (a Council of Councils) prior to commencement of their separate policy development
processes. For such inter-disciplinary meetings, a small delegation from each discipline –
including education provider and service provider representatives – would be appropriate.




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Q34    Where will the regional clinical academies (i.e. academy secretariats) be housed?
The answer to this question probably depends on the legal status of the regional clinical
academies. If academies have to be established under the auspices of an existing institution, it
would be appropriate for the secretariat to be housed in that institution. Furthermore, once
established in that institution, the secretariat would most likely remain there.

If the academies can be established as independent entities, they could be housed anywhere
there is sufficient space and facilities, although most stakeholders are not in favour of regional
clinical academies being hosted within DHS regional offices. In addition, independent
academies could move their location every couple of years, to avoid the perception that the
academy belongs to one group of stakeholders or another.

On this last point, it is worth considering that the physical location of the academy secretariats
is likely to become less of an issue over time, as the model becomes established and
stakeholders develop trust and a sense of ownership of the system.

6.4 Implementation
The implementation of the recommended model for managing and organising clinical
placements in Victoria presented in this section should be undertaken as a two-phase process.
Phase I involves a series of steps to get to the point where the new system of allocating
placement capacity is operational. Phase II commences with the establishment of the regional
clinical academies, which will mark a new era in cooperation and coordination of clinical
education.

Phase I
This phase will involve the following steps and activities:
Step 1: Establish the VCPC.
Step 2: Convene the discipline councils, each of which must – over a series of meetings –
       determine:
       o Modus operandi for that council;
       o Issues requiring negotiation and resolution for that discipline;
       o Terms of reference for that council and for its regional discipline committees;
       o Twelve-month work plan for that council, including a schedule of meetings;
       o Data rules and terminology for data collection;
       o Representatives for the Council of Councils meetings convened by the VCPC.
Step 3: VCPC convenes a Council of Councils meeting to discuss issues of relevance to all
        disciplines.
Step 4: Councils establish their regional discipline committees, which must undertake the
        following activities over a 9-12 month period:
       o Develop a work plan against their terms of reference, including a schedule of
           meetings;
       o Audit clinical placement capacity for that discipline within their region;
       o Assess current demand for clinical placements in that discipline within their region;
       o Audit infrastructure and capacity development requirements for that discipline for
           their region;
       o Develop regional standard operating procedures for organisation and management
           of clinical placements for that discipline;
       o Negotiate equitable allocation of clinical placements across education providers for
           that discipline in that region.
Step 5: VCPC develops framework for establishment and operation of regional clinical
        academies.
Step 6: Evaluation of Phase I activities




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It is difficult to predict how much time will be required for each step of Phase I. It is very likely
that some discipline councils will resolve their issues quickly, particularly where some
groundwork has already been done (for example, in the case of Social Work, where there has
been significant discipline-wide coordination of clinical placement activity for some time), or for
small disciplines with few education provider or health service stakeholders. Other discipline
councils may require much more time to conduct their initial business, particularly for
disciplines like nursing where there are large numbers of stakeholders and time will be needed
just to work out appropriate representation of the interested parties. It should also be noted
that Phase I will be operating simultaneously with current arrangements, particularly during
late-2009 – early-2010 and to a lesser extent in late-2010. This will impact on the amount of
time that key personnel can devote to the process.

However, if there is an expectation that the new model of governance will be established in
time to allow the allocation of placements for the 2011 academic year, then the discipline
councils need to be convened in early September 2009 and a Council of Councils meeting
should be held in mid-October 2009. This will allow all-of-discipline issues to inform the
deliberations at both discipline council and regional discipline committee levels. Each discipline
council should aim to establish their regional discipline committees before the end of
November 2009, so that these groups can develop their work plan before the Christmas break
and be ready to commence their work early in 2010.

Therefore, over the last four months of 2009, there will be a gradual shift of emphasis and
workload from the VCPC, first to the discipline councils and then to the regional discipline
committees. During this time – and also throughout 2010 – the VCPC and discipline councils
will continue to meet as required to progress their respective work plans and to oversight the
activities being undertaken at the next level. By mid-2010, the VCPC should commence
formulation of the framework for the establishment and operation of the regional clinical
academies. This framework will be informed largely by the work undertaken by the regional
discipline committees, which is expected to provide the detail necessary to define and delimit
the roles of the regional clinical academies suggested in Section 6.2.

The final step of Phase I is an evaluation of the activities and processes undertaken during this
phase. Each council or committee should be evaluated against its terms of reference and any
objectives or performance indicators that were defined for that grouping, and input and
feedback should be sought from participants and stakeholders. It is very important that a
framework for evaluation be established from the outset of the implementation process, to
ensure that appropriate data is collected for a thorough evaluation.

Phase II
This phase commences with the establishment of the regional clinical academies and the steps
and activities for this phase will be developed during Step 5 of Phase I. On the one hand, the
regional clinical academies could be established at any time after the regional discipline
committees are underway with their negotiations. However, in reality, most stakeholders will
be fully occupied throughout 2010 with discipline-specific issues relating to clinical placement
allocation under the new model. Furthermore, the regional clinical academies will not have a
role to play in the ongoing operation of the new allocation system until the regional discipline
committees have completed their work, with the inter-disciplinary functions of the academies
being second- or third-order issues compared to placement allocation within disciplines.
Therefore, it is recommended that Phase II commence in 2011 after the new academic year
has started and once any problems with placement allocation are resolved (and only the new
clinical placement governance model is in place).

Personnel
As all of the tiers of the proposed model will involve input from education provider and health
service staff whose time is already accounted for in their substantive positions, the successful
implementation of the new model will depend on the availability of dedicated secretariat staff.
These staff will be responsible for convening and organising the series of meetings for each tier




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of the model, for supporting each council/committee in the conduct of its business, and for
undertaking many of the activities that will comprise the work plan of each group.

It is anticipated the VCPC will have its own dedicated secretariat, but it is very likely that the
other tiers of the model – the discipline councils, regional discipline committees and regional
clinical academies – could share the same pool of support staff. That is, individuals recruited to
support the discipline councils in the first instance could move on to support the regional
discipline committees as the emphasis shifts to activities in that tier of the model, and those
same individuals could then become the secretariats of the regional clinical academies. Once
the academies are established and the model is fully operational, the activities of the regional
discipline committees would be subsumed within their respective academy (so their functions
would be handled by the secretariat anyway) and responsibility for convening the infrequent
meetings of the discipline councils could be shared amongst the eleven academy secretariats.

It is difficult to anticipate the precise number of secretariat staff that will be required through
Phase I of implementation, as there are many variables that will not be defined until the
discipline councils have met for the first time, identified their tasks and developed their work
plans. There are more than 20 health professional courses offered in Victoria that include a
clinical training component, but a number of these are quite small in terms of student numbers
and clinical training requirements. Discipline councils for the large disciplines would probably
require one full-time staff member to support their activities (under Step 2 of Phase I
implementation), whereas discipline councils for smaller disciplines may be able to share one
full-time staff member between several councils.

Similarly, it is difficult to anticipate how much support the regional discipline committees for
each discipline will require. Each committee has a significant agenda of work, but the
processes for auditing placement capacity, current demand and capacity development
requirements will be common from region to region. Furthermore, the secretariat staff are
expected to support academics and clinicians in undertaking these tasks, not undertake all the
tasks themselves. Therefore, it is unlikely that each regional discipline committee will need its
own full-time staff member and quite possible that a single full-time individual could support at
least half of the regional discipline committees for a given discipline. It is also possible that
some of the smaller disciplines will not have the full complement of eleven regional discipline
committees, as students may only be placed in a few of the state‟s regions.

Once the regional clinical academies are established, the staff that have been supporting the
discipline councils and regional discipline committees would become the academy secretariat
staff. Again, it is difficult to predict the workload of each academy, which will vary depending
on the range of disciplines and number of students placed in that region. The workload will
also vary across the year in line with placement activity cycles; when major placement
allocation rounds are completed, secretariat staff will be able to support other activities.

The only information in the literature about staffing levels was found in the paper describing
the western Michigan Clinical Placement Consortium[26]. The authors noted that, once the
system was operational, maintenance of the web-based system that supports the activities of
the consortium requires an average of half a day per week of an administrative assistant. Each
year, this consortium arranges clinical placements for 1,200 nursing students enrolled at seven
nursing schools in the region and utilising over 50 clinical agencies. Direct translation of this
workload into the Victorian context is not really possible (or particularly informative), but it
suggests that one or two administrators could manage the workload of regional clinical
academies of the size and complexity envisaged for the eleven proposed Victorian regions.

Therefore, as an estimate, it is recommended that 16 individuals be recruited as secretariat
staff in the first instance. This will translate into an average of about 1.5 full-time staff per
regional clinical academy. Prior to the establishment of the academies, these staff will be
deployed across the discipline councils (and their regional discipline committees) to support
their deliberations and activities.




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Secretariat staff will need to be reasonably highly skilled individuals, preferably with some
understanding of clinical education in one or more disciplines and with experience in either the
health service or education sectors. High-level organisational skills will be essential, as will
experience with stakeholder management and negotiations. Given very few examples of this
type of model exist elsewhere (i.e. to serve as a template), staff will need to be comfortable
working in evolving environments with a degree of uncertainty. The staff may be called upon
to travel and some of the positions will end up located in regional clinical academies based in
regional centres in Victoria.

In addition to administrative support staff, each council, committee or academy will need to
have a Chair. These individuals will most likely be drawn from the membership of the group
and the positions will probably rotate amongst the stakeholders at regular intervals. In some
cases, it may be deemed appropriate for there to be Co-Chairs, one drawn from the education
provider sector and the other drawn from the health service sector. Chairs will not be paid
positions, although expenses incurred in executing the office of Chair would be covered from
the overall budget.

Financial considerations
The major cost associated with the implementation and operation of the recommended model
will be staff costs associated with the secretariat positions, in particular, salaries and on-costs
for 16 full-time staff. To attract applicants at an appropriate skill level, appointments in the
university HEW 7 ($64,642 - $69,973) or HEW 8 ($72,725 – 81,089) range (or health sector
equivalent) may be required.

Other costs will relate to office space, office fit-out, computer workstation purchases, IT
support, telecommunications (phones, teleconferencing and video-conferencing), printing and
stationery, travel costs, and meeting-related expenses (venue hire and catering). There will
also need to be a budget for specific tasks or activities undertaken by councils/committees,
including research and innovation projects, quality audits and evaluation processes.

In terms of funding, the DHS has indicated that it has allocated funds to provide secretariat
support for the VCPC and to fund research projects and educator training initiatives conducted
under its auspices. The Department has also quarantined funds to provide administrative
support for an initial one-year period, while the new model is being established. Furthermore,
the COAG agreement of November 2008 includes funding to support educator training
initiatives, innovation in clinical teaching, and the development and operation of simulated
learning environments. The clinical training subsidy that will follow students to the health
services that provide the clinical placements may also be used in part to fund the activities of
the regional clinical academies. This could occur through an off-the-top payment directed to
regional clinical academies from the gross funding received from Commonwealth and state
governments, or through a fee levied on stakeholders for membership of the academy.

6.5 Beyond implementation

6.5.1 Evaluation
As discussed in Section 6.4, it will be important to evaluate Phase I of the implementation of
the model, not only to complete the process, but also to ensure that unworkable or
unsustainable elements do not become foundation stones of the regional clinical academies. It
will be necessary to evaluate Phase II of the implementation for similar reasons.

It will also be important to evaluate the model – as a model – over the first couple of years, to
examine how the tiers (i.e. the VCPC, discipline councils, regional discipline committees and
regional clinical academies) are functioning, both independently and as part of the whole
system. Examples of issues that might be explored include:
 Is the distribution of responsibility between the tiers appropriate?
 Is each level of the model adequately resourced for its function?
 Is there unnecessary duplication of effort between tiers of the model?




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   Are some functions not addressed?
   Do the various councils and committees interact appropriately?
   Are the regional boundaries workable?
   Can the model be improved?

The model will also need to be evaluated regularly as a new system established to address a
set of systemic issues and problems. The first evaluation may take place after 18 months or
two years, but thereafter, evaluation should occur every three years. Examples of issues for
evaluation include:
 Are stakeholders and participants satisfied with the model?
 Does the model address the existing systemic issues and problems?
 Is the model delivering against its objectives (as set out in Section 5.1)?
 Is the system working better under the new model than under the previous arrangements?

It is possible the model will work better in some disciplines than in others, or in some regions
better than others. Therefore, the evaluation process should include a mechanism for dialogue
between disciplines and between regions, so that problems and successes can be addressed
and viewed in a broader context.

6.5.2 Sustainability
The implementation of the recommended model represents a significant shift in the way
clinical placements are organised and managed in Victoria. The implementation process will be
labour-intensive. It is likely to be challenging for all concerned and for most disciplines, will
probably be disruptive of established routines and practices. The challenges and disruptions
will be worthwhile, provided the system that emerges on the other side is a sustainable
improvement on current arrangements.

For the new system to be sustainable, it must meet the following criteria:
 The model must achieve its objectives.
 The model must operate efficiently. This relates to minimising waste and duplication within
    the tiers of the model itself, but also to reducing inefficiencies in the system being served,
    so that resources within health services and education providers are used optimally.
 The level of resourcing must be realistic and sustainable. This includes cash and in-kind
    funding from all sources (Commonwealth and state governments, education providers and
    health services), as well as staffing and material resources that are fit for purpose.
 Stakeholders must be committed to the model; they must work only within the system and
    encourage others to do likewise.
 The model must be flexible enough to accommodate changes in policy and practice
    imposed from outside the system, but structured enough to deal with them. An important
    hurdle for the model will be the full deregulation of the higher education system due to
    occur over the next three years.
 The model must be reflective, with capacity for self-review and evaluation, as well as
    mechanisms for changing policies and practices.

6.5.3 Scalability
At the present time, all states and territories have different systems in place for the
management and organisation of their clinical placements. A nationally consistent approach
would probably be in the best interests of all stakeholders, since a number of education
providers make use of interstate placements. Major differences in policy and practice are
particularly problematic for Victorian education providers located close to the New South Wales
and South Australian borders.

The recommended model described in this report has considerable potential to be implemented
in other jurisdictions, or even to serve as the template for a single national model. There is




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nothing in the model that applies uniquely to Victoria and the model can operate with as many
regional clinical academies as is necessary to cover the geographical area of a jurisdiction.

Thus, the model could be cloned for implementation in another state or territory, whereby a
state clinical placement council and complete set of discipline councils, regional discipline
committees and regional clinical academies are established. However, depending on how
closely the new discipline councils model their policies and practices on the Victorian model,
there could be quite significant differences between the models operating in the two states.

Alternatively, the discipline councils established in Victoria could serve more than one state, so
that the overarching policies, principles and practices are consistent across multiple states and
only the local interpretation and implementation of those standards – through the regional
discipline committees and regional clinical academies – would differ. If this approach were
adopted, it is very likely that representation on the discipline councils would change to include
appropriate representatives from the states and territories covered by those councils. Indeed,
this would be the most appropriate way to scale the model up to national applicability. That is,
national discipline councils, with representatives from all states and territories and starting
from the template that will be developed in Victoria over the next 12 months, develop
nationally consistent policies and principles that provide the framework for negotiations
between education providers and health services in each region.

The other major aspect of scalability involves the application of the new system beyond clinical
placements for entry-level health professional courses. The brief for the new model was to
develop a system that would streamline and improve clinical placement governance for entry-
level (or undergraduate) courses. However, as noted in Section 1, clinical education continues
into early-graduate, post-graduate and professional development domains for most health
professionals and these learners must be accommodated in the system.

The recommended model presented in this report has the capacity to incorporate all levels of
learners. Stakeholders in early-graduate, postgraduate and specialist education and training –
which includes RTPs, colleges and other professional associations – would have representation
on the VCPC, discipline councils, regional discipline committees and regional academies as
appropriate and participate in policy development and negotiations. In the first instance,
existing systems for managing placements or rotations for post-qualification learners would sit
alongside systems for managing placements for entry-level students. At a later stage, if
appropriate, these systems could be merged.

6.5.4 Looking to the future
As noted earlier, the implementation of the new model is likely to be a challenging process that
will take up to two years to work through. During the implementation phases, the overall form
of the new governance model may be difficult to discern, as different components of the
system move through their work plans at different rates and with different degrees of success.
What can we expect the system to look like in five – or even ten – years time?

Figure 17 is a fairly good representation of how the system will appear from an external
perspective once it is well established and fully operational. That is, an observer would see
Health Workforce Australia at a national level and the VCPC (and its interstate counterparts) at
a state level as the major policy-setting entities. The discipline councils would be key
contributors to, and conduits for implementation of, clinical education policy and they would
meet once or twice a year. The regional clinical academies (by now, incorporating the regional
discipline committees), would be the major effectors of clinical education policy, managing
multi-lateral negotiations in relation to clinical placement allocation, collecting and
disseminating data, oversighting simulation facilities and other communal resources and
auspicing research and innovation projects.

It is anticipated that, once the system is fully operational, the majority of clinical placement
allocations would be fixed for three-year periods, with only a small proportion of all placements




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having to be negotiated each year. All placements would be handled through the model and
decisions about growth would be a matter for multi-lateral consideration and agreement.

Finally, it is expected that implementation of the recommended model will reveal the true
clinical placement capacity of the Victorian health system. Over the next five years, a variety
of measures will result in sustainable increases in that capacity, resulting in high quality clinical
training experiences for Victoria‟s future health professionals.




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7 Summary and conclusions
This report and others before it have highlighted the problems with the current system of
managing and organising clinical placements within Victoria. These problems are not unique to
Victoria (or Australia) and in recent years other jurisdictions have been implementing a range
of solutions with varying degrees of success. Significantly, in addressing this problem, Victoria
is attempting to develop a solution that appears to be unique in the world, as it will involve all
disciplines, all health education providers, all clinical placement providers and all clinical
placements.

Previous stakeholder consultations have demonstrated a preference for a regional, rather than
a statewide, solution. The major impetus for this is the maintenance of existing relationships
between education providers and health services.

After reviewing existing health education and health service boundaries, mapping current
clinical placement activity in the state and surveying stakeholders, it is recommended that
eleven regions be used to govern clinical placements within Victoria, with five rural regions and
six metropolitan regions. Health services will be involved with the regions in which they sit
geographically, while education providers will be invited to be a participant in any region in
which they currently place students. The nature of the system will – over time – probably
encourage education providers to rationalise their clinical placement activity to as few regions
as necessary to meet their needs.

To develop the regional clinical placement networks – termed regional clinical academies in the
recommended model – a multi-tiered model of councils and committees has been proposed to
deal with the hierarchy of issues that must be addressed to produce a system that functions
effectively and efficiently. The key to the success of the model is that it brings together
relevant stakeholders at each stage of the process to resolve the issues that are the building
blocks for the next stage.

Broadly speaking, there are three stakeholder groups involved in clinical education: education
providers, health services and government. Each group has a role to play in ensuring the
success of the new system. Education providers need to be receptive to feedback from health
services and prepared to amend their models and practices. Health services need to treat
education as a high priority and commit as far as practicable to long-standing arrangements.
Governments have a role in adequately funding the system and in resolving policy conflicts
that create competing and conflicting interests between health services and education
providers.

As the literature demonstrates, increased communication between health services and
education providers can lead to the creation of new models of clinical education that are more
suitable for both parties. Importantly, stakeholder consultations throughout this project have
indicated a willingness, from all concerned, to make changes to their own practices in order
that the system as a whole can improve.

This is a significant and critical foundation on which to build a new system of governance for
clinical placements in Victoria.




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       Occupational Therapy, 1999. 62(7): p. 295-298.
12.    Stansfield, J., Issues and innovation in clinical education: Regulation, collaboration and
       communication. Advances in Speech-Language Pathology, 2005. 7(3): p. 173-176.
13.    Department of Human Services. Clinical Placements in Victoria: Establishing a
       Statewide Approach, 2007. (Report prepared by Department of Human Services).
14.    Department of Human Services. Best practice clinical learning environments within
       health services for undergraduate and early-graduate learners, 2009. (Report prepared
       by Darcy Associates Consulting Services). Cited 7 June 2009. Report available from:
       http://www.health.vic.gov.au/__data/assets/pdf_file/0007/338407/BPCLE-Final-
       Report.pdf
15.    Fisher, A. and Savin-Baden, M., Modernising fieldwork, part 2: Realising the new
       agenda. British Journal of Occupational Therapy, 2002. 65(6): p. 275-282.
16.    Doubt, L., Paterson, M. and O‟Riordan, A., Clinical education in private practice. Journal
       of Allied Health, 2004. 33(1): p. 47-50.
17.    Health Professionals Council of Australia. Solving the crisis in clinical education for
       Australia’s health professions, 2004. (Report prepared by Health Professionals Council
       of Australia).
18.    Department of Human Services website, Clinical Placements In Victoria. Cited 4
       January, 2009. Web address: http://www.health.vic.gov.au/workforce/placements.htm.




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19.    Department of Human Services. Clinical placement agency – report on consultation
       workshops, 2008. (Report prepared by DLA Phillips Fox). Cited 7 June 2009. Report
       available from: http://www.health.vic.gov.au/workforce/agency-concept.
20.    Department of Human Services, Discussion of a Clinical Placement Agency Concept.
       Cited 7 June, 2009. Web address: http://www.health.vic.gov.au/workforce/agency-
       concept.
21.    National Health Workforce Taskforce, National Health Workforce Taskforce. Cited 7
       June, 2009. Web address: http://www.nhwt.gov.au/nhwt.asp.
22.    National Health Workforce Taskforce, Education and Training. Cited 7 June, 2009. Web
       address: http://www.nhwt.gov.au/training.asp.
23.    Committee of Australian Governments. National Partnership Agreement on Hospital and
       Health Workforce Reform, 2009. (Report prepared by Committee of Australian
       Governments). Cited 7 June 2009. Report available from:
       http://www.nhwt.gov.au/documents/COAG/National%20Partnership%20Agreement%2
       0on%20Hospital%20and%20Health%20Workforce%20Reform.pdf
24.    Mumford, D.B., Clinical Academies: Innovative school-health services partnerships to
       deliver clinical education. Acad Med, 2007. 82(5): p. 435-450.
25.    La Trobe University. Developing a Health Sciences Clinical School, 2008. (Report
       prepared by Faculty of Health Sciences).
26.    Kline, K.S. and Hodges, J., A rational approach to solving the problem of competition
       for undergraduate clinical sites. . Nursing Education Perspectives, 2006. 27(2): p. 80-
       83.
27.    Health Sciences Placement Network. Cited 5 June, 2009. Web address:
       http://www.hspcanada.net/index.asp.
28.    Department of Human Services, Regions. Cited 2 June, 2009. Web address:
       http://www.dhs.vic.gov.au/operations/regions
29.    Google, Google Earth. Cited 4 June, 2009. Web address: http://earth.google.com/.
30.    Department of Human Services, Interactive Maps. Cited 26 Mar, 2009. Web address:
       http://www.health.vic.gov.au/maps/index.htm.
31.    Wikipedia, Galapagos Islands Cited 3 June, 2009. Web address:
       http://en.wikipedia.org/wiki/Galápagos_Islands.
32.    Department of Human Services. Clinical placements in Victoria: An action plan in the
       new national context, 2009. (Report prepared by Department of Human Services).
33.    Department of Education, Employment and Workplace Relations, Review of Australian
       Higher Education. Cited 29 May, 2009. Web address:
       http://www.deewr.gov.au/HigherEducation/Review/Pages/default.aspx.
34.    Seropian, M.A., Driggers, B., Taylor, J., Gubrud-Howe, P. and Brady, G., The Oregon
       Simulation Experience: A statewide simulation network and alliance. Simul Healthcare,
       2006. 1: p. 56-61.




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9 Appendices
Appendix 1: Clinical Governance Project Steering Group
Name             Institution                   Position                              Represents
Christine        GPDV                          CEO                                   GPs
Macdonald
Dan Jefferson    DHS                           Manager                               -
Deb Clark        Epworth Healthcare            APHA Rep                              Private Hospitals
Jennifer Gale    Kyneton District Health       CEO                                   Small Rural Hospitals
                 Service
Olive Aumann     Whitehorse Community          Acting CEO                            Community Health
                 Health Service (CHS)
John Ferguson    Austin Health                 Chief Medical Officer                 Public Hospitals
Karen Dodd       La Trobe University           Associate Dean, Division of Allied    Council of Victorian
                                               Health                                Health Deans
Karen Riley      Bendigo CHS                   Deputy CEO                            Regional
Kem Sedick       Box Hill TAFE                 Special Projects Manager -            Vocational Education
                                               Nursing Skills Centre of Excellence   and Training
Kim Sykes        DHS                           Director                              -
Michelle         Victoria University (Higher   Acting Executive Dean                 Council of Victorian
Towstoless       Education)                                                          Health Deans
Peter Lowthian   Cabrini                       Executive Director, Cabrini           Catholic Health
                                               Institute                             Australia
Rae Wilson       ACCV                          ACCV Manager, Training and            Aged Care
                                               Consultancy
Sally Dennis     DHS                           Policy Adviser                        -
Steve Kozel      DHS                           Team Leader                           -
Steven           Monash University             Dean, Faculty of Medicine,            Council of Victorian
Wesselingh                                     Nursing and Health Sciences           Health Deans
(Chair)




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Appendix 2: Members of the Council of Victorian Health Deans
University                    Name               Position
University of Ballarat        Lynette            Professor and Head of School of Nursing
                              Stockhausen
University of Ballarat        Cecil Deans        Assoc Professor & Deputy Head of School of Nursing
Deakin University             John Catford       Dean, Health Sciences
Deakin University             Alan Taylor        Faculty General Manager, Faculty of Health Medicine
                                                 Nursing & Behavioural Sciences
La Trobe University           Hal Swierissen     Dean, Faculty of Health Sciences
La Trobe University           Karen Dodd         Professor and Associate Dean, Division of Allied Health
Monash University             Andrew Evans       Faculty Manager, Faculty of Medicine, Nursing and
                                                 Health Sciences
Monash University             Steve Wesselingh   Dean, Faculty of Medicine, Nursing and Health Sciences
RMIT University               Ken Greenwood      Head, School of Health Sciences
University of Melbourne       James Angus        Dean, Faculty of Medicine, Dentistry and Health
                                                 Sciences
University of Melbourne       Doris Young        Associate Dean, Faculty of Medicine, Dentistry and
                                                 Health Sciences
University of Melbourne       Richard            Faculty Manager, Faculty of Medicine, Dentistry and
                              Frampton           Health Sciences
University of Notre Dame      Alan McLean        Associate Dean (Melbourne) and Mercy Chair in
Australia                                        Medicine
University of Notre Dame      Julie Quinlivan    Dean of Medicine and Pro-Vice Chancellor
Australia
Victoria University (Higher   Sarah Farrugia
Education)
Victoria University (Higher   Daryl Cornish      Faculty General Manager
Education)
Victoria University (Higher   Michelle           Acting Executive Dean, Faculty of Health, Engineering
Education)                    Towstoless         and Science




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Appendix 3: Interview questions




                                                                                                                                   Rural/ regional Health
Question




                                                                                                               Private Hospitals
                                                                                            Public Hospitals
                                                                         VET institutions
                                                            University




                                                                                                                                                            Aged care

                                                                                                                                                                        GPs
Introductory questions
1. Are the views you express today representative of        N            Y                  Y                  Y                   Y                        Y           Y
   the sector you are in or the organisation you work
   for?
Features of the current system/arrangements
2. How are clinical placements currently                    Y            Y                  Y                  Y                   Y                        Y           Y
   organised/arranged? That is, are placements
   predominantly supply-driven or demand-driven?
Is this discipline specific?
3. How do you currently “see” the health system? That       Y            Y                  N                  N                   N                        N           N
   is, do you organise placements at an individual
   organisation level, at a health service network level,
   at a DHS region level, or some other level?
4. When you consider your placement capacity, do you        N            N                  Y                  N                   Y                        Y           N
   think at an individual organisation level, at a health
   service network level, at a DHS region level, or some
   other level?
5. Do you have exclusivity arrangements in relation to      Y            N                  N                  N                   N                        N           N
   the provision of clinical placements?
If so:
         a. Are they discipline specific?
         b. Would you like these retained in the new
            model? Why/Why not?
6. Do you have access to all of the clinical                Y            Y                  Y                  Y                   Y                        Y           Y
   placements/students you need/would like?
7. If/when you need more or different clinical              Y            N                  N                  N                   N                        N           N
   placements, how do you obtain them?




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                                                                                                                                      Rural/ regional Health
Question




                                                                                                                  Private Hospitals
                                                                                               Public Hospitals
                                                                            VET institutions
                                                               University




                                                                                                                                                               Aged care

                                                                                                                                                                           GPs
8. Are there clinical placements you would like to have        Y            N                  N                  N                   N                        N           N
   access to, but currently do not?
If so:
          a. Why would you like access?
          b. Why are you unable to get access?
          c. If this relates to exclusivity arrangements and
             you have your own such arrangements, would
             you be willing to allow others access to your
             exclusive areas in exchange for access to
             their exclusive areas (assuming the number
             of clinical placements you have does not
             drop)?
9. Do you currently use simulation in the training of          Y            Y                  Y                  Y                   Y                        Y           Y
   health professionals?
If yes:
          a. Which disciplines use simulation?
          b. What modalities (e.g. simulated patients, Sim
             Man, etc.) are in use?
          c. Is simulation an integral component of clinical
             education?
          d. Who is driving the use of simulation?
10. If there were more simulation facilities, would you        Y            Y                  Y                  Y                   Y                        Y           Y
    make more use of them?
          a. If no, why not?
          b. If yes, what in particular would you like?
Features of the new system
11. What elements of the current system/ arrangements          Y            Y                  Y                  Y                   Y                        Y           Y
    would you like retained in a new system?
12. What elements of the current system/ arrangements          Y            Y                  Y                  Y                   Y                        Y           Y
    would you like changed in a new system?
13. What elements would you like to add to the new             Y            Y                  Y                  Y                   Y                        Y           Y
    system that are not in the old system?
Local network business
14. Given that structure should reflect function, what         Y            Y                  Y                  Y                   Y                        Y           Y
    functions do you think the local networks should
    have?
15. What should be the scope of their activities?              Y            Y                  Y                  Y                   Y                        Y           Y
16. Is there anything they must do?                            Y            Y                  Y                  Y                   Y                        Y           Y




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                                                                                                                                  Rural/ regional Health
Question




                                                                                                              Private Hospitals
                                                                                           Public Hospitals
                                                                        VET institutions
                                                           University




                                                                                                                                                           Aged care

                                                                                                                                                                       GPs
17. Is there anything they must not do?                    Y            Y                  Y                  Y                   Y                        Y           Y
18. Would all placements be covered by the network, or     Y            Y                  Y                  Y                   Y                        Y           Y
    might some private arrangements fall outside the
    remit of the network?
19. How would these local networks conduct their           Y            Y                  Y                  Y                   Y                        Y           Y
    business? For example, would decision-making be a
    democratic process (ie one organisation, one vote),
    or would some form of proportional representation
    apply (and if so, how would small players have a
    voice)?
20. What rules and regulations or principles should        Y            Y                  Y                  Y                   Y                        Y           Y
    govern their activities?
       a. How should interactions between and across
          education providers (i.e. universities and
          TAFEs) and clinical placement providers be
          handled?
       b. How should the acquisition and trading of
          clinical placements be governed in the new
          system?
Local network structure and organisational
arrangements
21. What will be the composition of the networks?          Y            Y                  Y                  Y                   Y                        Y           Y
       a. Should there be a limit on the geographic
          area covered by the local network?
       b. Should each network include metro, rural and
          regional centres?
       c. Should the boundaries of the networks align
          with existing boundaries (e.g DHS regions,
          health service networks, local government
          boundaries, GP Divisions)?
       d. Should there be a limit on the number of
          organisations (or interest groups)
          represented? If yes, how will smaller
          organisations (e.g. private physiotherapy
          clinics) get involved?
       e. What level of representation is appropriate
          (i.e. should everyone have a seat at the table
          or should there be a hierarchy of
          representation)?
22. Should the functions of the local network be handled
    by the whole network membership or by a number of




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                                                                                                                                    Rural/ regional Health
Question




                                                                                                                Private Hospitals
                                                                                             Public Hospitals
                                                                          VET institutions
                                                             University




                                                                                                                                                             Aged care

                                                                                                                                                                         GPs
   sub-committees (or working groups)?
Integrating Victoria
23. How would networks work with each other?                 Y            Y                  Y                  Y                   Y                        Y           Y
24. Will organisations in a network be able to interact      Y            Y                  Y                  Y                   Y                        Y           Y
    directly with organisations of another network or will
    they have to go through network management?
25. Will the networks need to interact with regulatory       Y            Y                  Y                  Y                   Y                        Y           Y
    bodies?
       a. If so, how will this be done, as a group or
          one-on-one?


Integrating Australia
26. Can you comment on whether such a model might            M            N                  M                  M                   M                        N           N
    work in other states? If it wouldn‟t work, what would
    need to change so that it can?




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Appendix 4: Number and affiliation of interview participants

Organisation                                 Number of         Representing
                                            Participants
Australian Catholic University                    2            -
Aged & Community Care Victoria (ACCV)             3            Aged care
Austin Health                                     1            Public hospitals
Bendigo Community Health Service                  1            Regional CHS
Box Hill Institute of TAFE                        4            VET sector
Cabrini Hospital                                  2            Catholic hospitals
Deakin University                                 6            -
DHS                                               3            -
Epworth Healthcare                                2            Private hospitals
General Practice Victoria                         8            GPs and RTPs
Kyneton District Health Service                   1            Small rural hospitals
La Trobe University                               3            -
Monash University                                 9            -
RMIT University                                   3            -
Southern Health Simulation Centre                 2            -
St John of God                                    1            Regional Catholic hospitals
University of Ballarat                            3            -
University of Melbourne                          10            -
University of Notre Dame Australia                3            -
VET sector institutions                          11            Victorian VET institutions
Victoria University (Higher Education)            9            -
Whitehorse CHS                                    1            Community Health




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Appendix 5: Abbreviations used for education providers in Google Earth

Abbreviation     Education Provider
ACU              Australian Catholic University
ACU              Australian Catholic University TAFE
BH TAFE          Box Hill Institute
BRIT             Bendigo Regional Institute of TAFE
CARE             CARE Training Australia
GIT              Central Gippsland Institute of TAFE
CSU              Charles Sturt University
CIT              Chisholm Institute of TAFE
DU               Deakin University
EGIT             East Gippsland Institute of TAFE
ETEA             Education Training and Employment Australia
FATS             Flexible Advanced Creative Training Solutions
GoIT             Gordon Institute of TAFE
GOvIT            Goulburn Ovens TAFE
GOvIT-W          Goulburn Ovens TAFE (Wangaratta)
HETS             Health Education Training Services
HIT              Holmesglen Institute of TAFE
LTU              La Trobe University
MEC              Mayfield Education Centre
MU               Monash University
RMIT             RMIT TAFE
RMIT             RMIT University
SWIT             Southwest Institute of TAFE
SIT-M            Sunraysia Institute of TAFE (Mildura)
SIT-SH           Sunraysia Institute of TAFE (Swan Hill)
SU               Swinburne University
UoB              University of Ballarat
UBMines          University of Ballarat (School of Mines)
UBTAFE           University of Ballarat (TAFE division)
UoM              University of Melbourne
UNDA             University of Notre Dame Australia
VU               Victoria University (Higher Education)
VUTAFE           Victoria University (Vocational Education)
WIT-W            Wodonga Institute of TAFE, Wodonga
WIT-Y            Wodonga Institute of TAFE, Yarrawonga




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Appendix 6: Abbreviations used for each discipline in Google Earth

Abbreviation     Discipline
Audiology        Audiology
D&N              Dietetics and Nutrition
HIM              Health Information Management
Medicine         Medicine
MLS              Medical Laboratory Sciences
MRS              Medical Radiation Sciences
Nursing          Nursing
Optometry        Optometry
Orth             Orthoptics
OT               Occupational Therapy
P&O              Prosthetics and Orthotics
Pharm            Pharmacy
Physio           Physiotherapy
Pod              Podiatry
Psych            Psychology
SP               Speech Pathology
SW               Social Work




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Appendix 7: Regional distribution of placements by education provider

                                                                       Number of placement sites (all disciplines) by DHS region
                                                                Barwon-
                                                                 South                  Loddo n                       North &
    Education Provider                                          W estern   Gram pians   Ma llee   Hum e   Gippsland   W estern   Eastern   Southern
    Australian Catholic University                 University    3-6         >6         3-6       3-6      1-2         >6        >6         >6
    Charles Sturt University                       University    >6          >6         >6        >6       >6          >6        >6         >6
    Deakin University                              University    >6          >6         >6        >6       >6          >6        >6         >6
    La Trobe University                            University    >6          >6         >6        >6       >6          >6        >6         >6
    Monash University                              University    >6          3-6        >6        >6       >6          >6        >6         >6
    RMIT University                                University    >6          >6         3-6       3-6      >6          >6        >6         >6
    Swinburne University of Technology             University    1-2          -          -         -        -          3-6       3-6        1-2
    University of Ballarat                         University    3-6         >6         3-6       1-2       -          >6        >6         1-2
    University of Melbourne                        University    3-6         3-6        3-6       >6       1-2         >6        >6         >6
    University of Notre Dame Australia             University     -           -          -         -        -          1-2       1-2         -
    Victoria University                            University    1-2         1-2         -        1-2       -          >6        >6         >6
    ACU St Patricks                                   VET         -           -          -         -        -          >6        >6         >6
    Box Hill TAFE                                     VET         -          1-2         -         -        -           -        >6         1-2
    BRIT (Bendigo & Echuca)                           VET         -           -         3-6        -        -           -         -          -
    CARE Training Australia                           VET        1-2          -          -         -        -          3-6       3-6        3-6
    Central Gippsland Inst of TAFE                    VET         -           -          -         -       >6           -         -         1-2
    Chisholm Inst of TAFE                             VET         -           -          -         -        -           -        3-6        >6
    East Gippsland Inst of TAFE                       VET         -           -          -         -       >6           -         -          -
    Education, Training and Employment Australia      VET         -           -          -         -        -          1-2       1-2        1-2
    Flexible Advanced Training Solutions              VET        3-6         1-2         -         -        -          1-2        -          -
    Gordon Inst of TAFE                               VET        >6           -          -         -        -           -         -         1-2
    Goulburn Ovens Inst of TAFE (Shepparton)          VET         -           -         1-2       >6        -          1-2       1-2         -
    Goulburn Ovens Inst of TAFE (W angaratta)         VET         -           -          -        >6        -           -         -          -
    Health Training Education Services                VET         -           -          -         -        -           -        1-2        >6
    Holmesglen Inst of TAFE                           VET        1-2          -          -         -        -          3-6       >6         >6
    Mayfield Education Centre                         VET         -           -          -         -        -           -         -         1-2
    RMIT TAFE                                         VET         -           -          -         -        -          >6        >6         3-6
    Southwest Inst of TAFE                            VET        >6           -          -         -        -           -         -          -
    Sunraysia Inst of TAFE (Mildura)                  VET         -           -         >6         -        -           -         -          -
    Sunraysia Inst of TAFE (Swan Hill)                VET         -           -         3-6        -        -          1-2        -          -
    Uni Ballarat (Horsham)                            VET        1-2         >6         1-2        -        -           -         -          -
    Uni Ballarat (Sch of Mines)                       VET        3-6         >6         1-2        -        -           -         -         1-2
    Victoria Uni                                      VET         -           -         1-2       1-2       -          >6        >6         3-6
    Wodonga Inst of TAFE (Wodonga)                    VET         -           -          -        3-6       -           -         -          -
    Wodonga Inst of TAFE (Yarrawonga)                 VET         -           -          -        3-6       -           -         -          -




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Appendix 8: Constituents of the proposed clinical placement regional networks
Region name          Location    Included local              Health service         Health Services                Universities                VET Sector
                                 government areas            networks
Barwon South-        Rural       Colac Otway                 South West             Barwon Health                  Australian Catholic         Care Training Australia
Western                          Corangamite                 Healthcare             Casterton Memorial Hospital    University                  Flexible Advanced Creative
                                 Glenelg                     Western District       Colac Area Health              Charles Sturt University    Training Solutions
                                 Greater Geelong             Health Service         Lorne Community Hospital       Deakin University           Gordon Institute of TAFE
                                 Moyne                                              Moyne Health Services          LaTrobe University          Holmesglen Institute of TAFE
                                 Queenscliff                                        Otway Health & Community       Monash University           Southwest Institute of TAFE
                                 Southern Grampians                                 Services                       RMIT University             University of Ballarat - School
                                 Surf Coast                                         Portland District Health       Swinburne University        of Mines
                                 Warrnambool                                        Terang & Mortlake Health       University of Ballarat      University of Ballarat TAFE
                                                                                    Service                        University of Melbourne     division
                                                                                    Timboon & District             Victoria University
                                                                                    Healthcare Service             (Higher Education)

Central              Metro       Melbourned                  Melbourne Health       Dental Health Services         Australian Catholic         ACU TAFE
                                                                                    Victoria                       University                  RMIT TAFE
                                                                                    Peter MacCallum Cancer         Charles Sturt University
                                                                                    Centre                         Deakin University
                                                                                    Royal Children‟s Hospital      LaTrobe University
                                                                                    Royal Victorian Eye & Ear      Monash University
                                                                                    Hospital                       RMIT University
                                                                                    Royal Women‟s Hospital         Swinburne University
                                                                                                                   University of Ballarat
                                                                                                                   University of Melbourne
                                                                                                                   Victoria University
                                                                                                                   (Higher Education)
Eastern              Metro       Knox                        Eastern Health                                        Australian Catholic         ACU TAFE
                                 Manningham                                                                        University                  Box Hill Institute
                                 Maroondah                                                                         Charles Sturt University    Central Gippsland TAFE
                                 Whitehorse                                                                        Deakin University           Chisholm Institute of TAFE
                                 Yarra Ranges                                                                      LaTrobe University          Holmesglen Institute of TAFE
                                                                                                                   Monash University           RMIT TAFE
                                                                                                                   RMIT University             Victoria University (Vocational
                                                                                                                   Swinburne University        Education)
                                                                                                                   University of Melbourne
                                                                                                                   Victoria University
                                                                                                                   (Higher Education)




d
    This local government area is slightly modified, removing the area bounded by Toorak Road (north), Punt Road (east), High Street (south) and St Kilda Road (west).



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Region name      Location   Included local       Health service   Health Services                Universities               VET Sector
                            government areas     networks
Gippsland        Rural      Bass Coast                            Bairnsdale Regional Health     Australian Catholic        Central Gippsland TAFE
                            Baw Baw                               Service                        University                 East Gippsland TAFE
                            East Gippsland                        Bass Coast Regional Health     Charles Sturt University
                            Latrobe                               Latrobe Regional Hospital      Deakin University
                            South Gippsland                       West Gippsland Healthcare      LaTrobe University
                            Wellington                            Group                          Monash University
                                                                  Yarram & District Health       RMIT University
                                                                  Service                        University of Melbourne
Grampians        Rural      Ararat                                Ballarat Health Services       Australian Catholic        Box Hill Institute
                            Ballarat                              Dunmunkle Health Services      University                 Flexible Advanced Creative
                            Golden Plains                         East Grampians Health          Charles Sturt University   Training Solutions
                            Hindmarsh                             Service                        Deakin University          University of Ballarat - School
                            Horsham                               Edenhope & District Hospital   LaTrobe University         of Mines
                            Northern Grampians                    Hepburn Health Service         Monash University          University of Ballarat TAFE
                            West Wimmera                          Stawell Regional Health        RMIT University            division
                            Yarriambiack                          West Wimmera Health            University of Ballarat
                                                                  Service                        University of Melbourne
                                                                  Wimmera Health Care Group      Victoria University
                                                                                                 (Higher Education)
Hume             Rural      Alpine                                Alexandra District Hospital    Australian Catholic        Goulburn Ovens TAFE -
                            Benalla                               Alpine Health                  University                 Shepparton
                            Greater Shepparton                    Beechworth Health Service      Charles Sturt University   Goulburn Ovens TAFE -
                            Indigo                                Goulburn Valley Health*        Deakin University          Wangaratta
                            Mansfield                             Northeast Health               LaTrobe University         Victoria University (Vocational
                            Mitchell                              Wangaratta                     Monash University          Education)
                            Moira                                 Seymour District Memorial      RMIT University            Wodonga Institute of TAFE
                            Murrindindi                           Hospital                       University of Ballarat
                            Strathbogie                           Upper Murray Health &          University of Melbourne
                            Towong                                Community Services             Victoria University
                            Wangaratta                            Wodonga Regional Health        (Higher Education)
                            Wodonga                               Service




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Region name           Location     Included local              Health service           Health Services                 Universities                  VET Sector
                                   government areas            networks
Loddon-Mallee         Rural        Buloke                                               Bendigo Health Care Group       Australian Catholic           Bendigo Regional Institute of
                                   Campaspe                                             East Wimmera Health             University                    TAFE
                                   Central Goldfields                                   Service                         Charles Sturt University      Goulburn Ovens Institute of
                                   Gannawarra                                           Echuca Regional Health          Deakin University             TAFE - Shepparton
                                   Greater Bendigo                                      Kyabram & District Health       LaTrobe University            Sunraysia Institute of TAFE -
                                   Loddon                                               Services                        Monash University             Mildura
                                   Macedon Ranges                                       Kyneton District Health         RMIT University               Sunraysia Institute of TAFE -
                                   Mildura                                              Service                         University of Ballarat        Swan Hill
                                   Mount Alexander                                      Maryborough District Health     University of Melbourne       University of Ballarat - School
                                   Swan Hill                                            Service                                                       of Mines
                                                                                        Mildura Base Hospital                                         University of Ballarat TAFE
                                                                                        Mt Alexander Hospital                                         division
                                                                                        Rochester Elmore District                                     Victoria University (Vocation
                                                                                        Health Service                                                Education)
                                                                                        Swan Hill District Hospital
Northern              Metro        Banyule                     Austin Health                                            Australian Catholic           ACU TAFE
                                   Boroondara                  Mercy Public                                             University                    Box Hill Institute
                                   Darebin                     Hospitalse                                               Charles Sturt University      Care Training Australia
                                   Hume                        Northern Health                                          Deakin University             Chisholm Institute of TAFE
                                   Moreland                    St Vincent‟s Health                                      LaTrobe University            Education Training and
                                   Nillumbik                   Melbourne                                                Monash University             Employment Australia
                                   Whittlesea                                                                           RMIT University               Goulburn Ovens Institute of
                                   Yarra                                                                                Swinburne University          TAFE - Shepparton
                                                                                                                        University of Ballarat        Holmesglen Institute of TAFE
                                                                                                                        University of Melbourne       RMIT TAFE
                                                                                                                        University of Notre Dame      Victoria University (Vocational
                                                                                                                        (Australia)                   Education)
                                                                                                                        Victoria University
                                                                                                                        (Higher Education)

Peninsula             Metro        Frankston                   Peninsula Health                                         Australian Catholic           ACU TAFE
                                   Mornington Peninsula                                                                 University                    Care Training Australia
                                                                                                                        Charles Sturt University      Chisholm Institute of TAFE
                                                                                                                        Deakin University             Education Training
                                                                                                                        LaTrobe University            Employment Australia
                                                                                                                        Monash University             Health Education Training
                                                                                                                        RMIT University               Services
                                                                                                                        Swinburne University          Holmesglen Institute of TAFE
                                                                                                                        University of Ballarat
                                                                                                                        University of Melbourne
                                                                                                                        Victoria University
                                                                                                                        (Higher Education)


e
    This health service is split across two regions, however the hospitals concerned have vastly different functions (specialist versus generalist)



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Region name           Location    Included local             Health service          Health Services                Universities                VET Sector
                                  government areas           networks
Southern              Metro       Bayside                    Alfred Health           Calvary Health Care            Australian Catholic         ACU TAFE
                                  Cardinia                   Southern Health         Bethlehem                      University                  Box Hill Institute
                                  Casey                                              Queen Elizabeth Centre         Charles Sturt University    Care Training Australia
                                  Glen Eira                                                                         Deakin University           Chisholm Institute of TAFE
                                  Greater Dandenong                                                                 LaTrobe University          Gordon Institute of TAFE
                                  Kingston                                                                          Monash University           Health Education Training
                                  Monash                                                                            RMIT University             Services
                                  Port Phillipf                                                                     Swinburne University        Holmesglen Institute of TAFE
                                  Stonnington                                                                       University of Ballarat      Mayfield Education Centre
                                                                                                                    University of Melbourne     RMIT TAFE
                                                                                                                    Victoria University         University of Ballarat - School
                                                                                                                    (Higher Education)          of Mines
                                                                                                                                                Victoria University (Vocational
                                                                                                                                                Education)
Western               Metro       Brimbank                   Mercy Public            Tweddle Child and Family       Australian Catholic         ACU TAFE
                                  Hobsons Bay                Hospitalse              Health Service                 University                  Flexible Advanced Creative
                                  Maribyrnong                Western Health                                         Charles Sturt University    Training Solutions
                                  Moonee Valley                                                                     Deakin University           RMIT TAFE
                                  Wyndham                                                                           LaTrobe University          Sunraysia Institute of TAFE -
                                                                                                                    Monash University           Swan Hill
                                                                                                                    RMIT University             Victoria University (Vocational
                                                                                                                    University of Ballarat      Education)
                                                                                                                    University of Melbourne
                                                                                                                    University of Notre Dame
                                                                                                                    (Australia)
                                                                                                                    Victoria University
                                                                                                                    (Higher Education)




f
    This local government area is slightly modified, adding the area bounded by Toorak Road (north), Punt Road (east), High Street (south) and St Kilda Road (west).



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Appendix 9: Vocation Education and Training (VET) Moderation Delivery Committee (MDC)
meeting attendees
Organisation
Australian Nurses Federation
Bendigo Regional Institute of TAFE
Box Hill Institute
Care Training Australia
Chisholm Institute of TAFE
Community Services and Health Industry Training Board
East Gippsland TAFE
Flexible Advanced Creative Training Solutions Geelong
Gippsland Institute of TAFE
Goulburn Ovens Institute of TAFE Shepparton
Goulbourn Ovens Institute of TAFE Wangaratta
Goulbourn Ovens Institute of TAFE Wangaratta / Benalla
Gordon Institute of TAFE Geelong
Health Skills Australia
National Enrolled Nurses Association
RMIT TAFE
University of Ballarat (School of Mines)
Victoria University (Vocational Education)
Wodonga Institute of TAFE



Appendix 10: Eastern Metropolitan Region roundtable discussion attendees
Organisation                                             Sector
Alfred Health                                            Public health service
Austin Health                                            Public health service
Australian Catholic University                           University
Box Hill Institute                                       VET sector
CARE Training Australia                                  VET sector
Deakin University                                        University
DHS
Eastern Health                                           Public health service
Epworth Healthcare                                       Private health service
Health Skills Australia                                  VET sector
Holmesglen Institute of TAFE                             VET sector
Kangan Batman TAFE                                       VET sector
La Trobe University                                      University
Mayfield Education Centre                                VET sector
Melbourne East GP Network                                GP
Monash University                                        University
Ramsay Health Care                                       Private health care provider
RMIT University                                          University
Southern Health                                          Public health service
University of Ballarat                                   University
University of Melbourne                                  University
Victoria University (Higher Education)                   University
Victorian Metropolitan Alliance                          Regional Training Provider
Whitehorse Community Health Service                      Community health service




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Appendix 11: Barwon South-Western Region roundtable discussion attendees
Organisation                                           Sector
Australian Catholic University                         University
Australian Nursing Federation                          Nursing peak association
Barwon Health                                          Public health service
Charles Sturt University                               University
Deakin University                                      University
Deakin/DHS Partnership
DHS
Flexible Advanced Creative Training Solutions          VET sector (Private RTO)
G21 Geelong Regional Alliance                          Health & Wellbeing Pillar
Gordon Institute of TAFE                               VET sector
GP Association Geelong                                 GP
Greater Green Triangle GP Education and Training       Regional Training Provider
La Trobe University                                    University
Lyndoch Warrnambool Inc                                Aged care
Monash University                                      University
Moyne Health Services                                  Public health service (rural)
RMIT University                                        University
South West Healthcare Warrnambool                      Public health service (rural)
University of Ballarat                                 University
University of Melbourne Rural Clinical School          University
Victorian Metropolitan Alliance                        Regional Training Provider
Western District Health Service                        Public health service (rural)




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Appendix 12: Clinical Placement Regional Networks Discussion Paper

Clinical Placement Governance in Victoria:
Models for consideration and issues for discussion
1. Background
The appropriate provision of clinical education and training has become a significant focus of government
activity at both state and national levels in recent years. At a national level, the National Health
Workforce Taskforce (NHWT)7 was established in 2006, with a brief that included a role in planning,
coordinating and funding of professional entry clinical training across all disciplines. The NHWT has
recently published a discussion paper on clinical training governance and organisation that canvasses
models for how clinical placements could be organised and managed across Australia8. There is now
considerable urgency to establishing new national approaches to clinical placements, following the COAG
decision in November 2008 to allocate significant levels of funding to clinical training over the next four
years, as part of a $1.6 billion package (combined Commonwealth and state funds) targeted to health
workforce issues.

At a state level, the Victorian Government has allocated significant funding to clinical training and has
auspiced a number of projects examining clinical placement capacity and quality issues in medicine,
nursing and allied health disciplines9. The Department of Human Services (DHS) has developed a strategy
for clinical placements in Victoria (Clinical Placements in Victoria: Establishing a Statewide Approach;
available on the DHS website, see footnote 3) and has recently drafted an action plan (Clinical Placements
in Victoria: An action plan in the new national context; not yet available on the DHS website) that
canvasses a model for how local networks might operate in the new national system being developed by
the NHWT.

In March 2009, a Project Steering Group set up by DHS invited the Council of Victorian Health Deans
(CVHD) to lead the development of a regional cluster model for clinical placements in Victoria. The CVHD
engaged a consultant (Dr Donna Cohen, Darcy Associates10) to assist with this work, with a brief to report
on potential models of clinical placement governance by the end of May 2009.

To inform the development of a viable model that addresses current issues and achieves the desired
outcomes, the consultants have conducted interviews with stakeholders and key informants from the
following sectors and organisations:
    Universities – Australian Catholic University, Deakin University, La Trobe University, Monash
     University, RMIT University, University of Ballarat, University of Melbourne, University of Notre Dame
     Australia, Victoria University
    VET sector – group discussions with 10 VET institutions and five private RTOs represented on the
     Moderation Delivery Committee (MDC)
    Regional Training Providers – Victorian Metropolitan Alliance (VMA) and Vic Felix
    General Practice Divisions Victoria (GPDV)
    Public hospitals – Austin Health
    Private hospitals – Epworth HealthCare
    Catholic hospitals – Cabrini Health, St John of God Health Care
    Small rural hospitals – Kyneton District Health Service
    Community health – Bendigo CHS, Whitehorse CHS
    Aged and Community Care Victoria (ACCV)
    Department of Human Services

These interviews identified major issues in relation to the current system of managing and organising
clinical placements – from both the education provider and health service provider perspectives – that are


7
    See the NHWT website at: http://www.nhwt.gov.au/nhwt.asp (accessed 5 May 2009)
8
 NHWT (2009) Health Education and Training: Clinical training – governance and organisation. Available at:
http://www.nhwt.gov.au/dataproject-gov.asp (accessed 5 May 2009)
9
  See the DHS Clinical Placements in Victoria website at: http://www.health.vic.gov.au/workforce/placements
(accessed 5 May 2009)
10
  Dr Cohen and her colleague for this project, Dr Richard Huysmans (Raven Consulting Group), recently completed
work on the development of a best practice framework for clinical learning environments. The report is available at:
http://www.health.vic.gov.au/workforce/placements (accessed 5 May 2009)




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set out in Section 2. Section 3 presents three models of how regional clinical placement networks could
be established and Section 4 identifies a number of operational issues that explore how the networks
might conduct their business. The purpose of the roundtable discussion sessions being conducted with
metropolitan stakeholders and regional Victoria stakeholders (on 11 and 12 May, respectively) is to
discuss the models and operational issues presented later in this paper.

2. The Issues – An Overview
From the interviews with key informants and stakeholders across the education provider and health
service sectors, there is general consensus that the current arrangements for clinical placements work
largely because of the hard work of the individuals involved and the good will that exists between
institutions. Importantly, most informants found it easier to identify what doesn’t work in the present
arrangements, as opposed to what works well.

The following list summarises the issues that were identified through the interviews:
  There is insufficient capacity to meet current clinical education demands.
        o It is not clear whether this a real capacity limit or a „glass ceiling‟, i.e. is there further capacity
            that can be identified but not accessed?
        o Demand is clustered at certain times of year, rather than being distributed more evenly
            across the year.
        o The problem has been exacerbated by recent large increases in student numbers.
        o It is anticipated the problem will only get worse once the higher education system is fully
            deregulated.
  There appears to be no relationship between the capacity to provide clinical education and the
   number of students enrolled.
        o This problem has been compounded by what is perceived as a push for growth within
            education providers, largely driven by senior administrators who have limited appreciation for
            the problems of insufficient capacity for clinical education.
  There is a lack of strategic direction in workforce planning, resulting in student enrolments that do not
   reflect workforce needs.
  Competition between education providers is unhelpful and greatly disadvantages the education
   providers who have less bargaining power (academic and/or financial).
        o Given that all education providers must produce graduates who are competent to work as
            practitioners in the health system, this is ultimately an unsustainable arrangement.
  There is significant variation in quality between placement sites.
  Negotiations between education providers and health service providers are characterised by lack of
   transparency, continuity and coordination.
        o The availability of placements at particular sites varies significantly in number and type from
            year to year.
        o Some education providers do not notify health services of student numbers/placement
            requests in a timely manner.
        o Education providers receive notice of actual placement numbers too late to make alternative
            arrangements at other sites.
        o The reasons for lower-than-requested placement numbers are not transparent and there is a
            perception that “back room deals” are a factor.
  The policy settings and priorities set by various government departments/branches lack consistency,
   creating perverse incentives and conflicting objectives for education providers and health service
   providers.
        o For example, education is a major export income earner for Australia and education providers
            are encouraged to increase their enrolments of international students (inadequate funding of
            the education system also encourages this). However, health services are disinclined (and
            receive no particular incentive) to provide clinical education places for international students,
            as they are not seen as representing future workforce.
  Clinical education is not adequately funded, which makes it an “unprofitable” activity for health
   services.
  Health services do not always receive adequate support from education providers, either during
   preparation for student arrival or once students are on placements.
  Differences between curricula, education models and assessment used by different education
   providers create significant problems for clinical educators at health services.
        o Many health services would like to make input to curricula, but are not given the opportunity.




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   There are currently no mechanisms to deal with these issues.

3. Finding a Solution
Although some of the issues that were identified are likely to be beyond local control, many of the issues
reflect communication and coordination problems that can be resolved. Some stakeholders expressed the
view that if the new model of governance that is developed does not result in an increase in clinical
placement capacity (values ranged from 10% to as high as 30%), then it isn‟t worth pursuing. However,
other stakeholders indicated that while increased clinical placement capacity is important (both to
accommodate current demand and provide room for growth), nominating the amount of acceptable
increased capacity is too arbitrary to be useful. Furthermore, even if a new governance model did not
deliver significant increase in identified capacity, these stakeholders commented that the current system
is so beset by inefficiencies and problems that a new process needs to be developed to avoid the system
collapsing under its own weight.

Therefore, with these stakeholder views in mind, any new model of governance for clinical placements
needs to achieve the following:
  Reveal the true level of capacity for placements and provide this information to all stakeholders. This
   includes information about:
        o Number of students that can be accommodated at each level of study.
        o Other (non-discriminatory) preferences/requirements; for example, health services in regional
            areas may have a preference for local students.
        o Timing, including shifts, days of the week and time blocks when students can be
            accommodated.
  Identify capacity development needs within health services and formulate coherent plans to meet
   them. This includes:
        o Preceptor/educator training.
        o Placement support.
        o Infrastructure needs (including simulation facilities).
  Develop quality assurance tools to create consistently high standards at all placement sites.
  Improve communication between health services and education providers (to allow greater exchange
   of ideas and discussion of placement-related decisions).
  Improve communication between education providers to create greater compatibility between
   different models.
  Develop policies for conflict/dispute resolution, equity of access, handling emergencies, access by
   „outside‟ players.
  Establish mechanisms for communication and negotiation between regions.
  Provide a platform for innovation and research.
  Provide a forum for discussing issues beyond the control of regional networks (and proposing
   solutions).
  Achieve sustainability, particularly in light of anticipated further deregulation of the education and
   training sectors. This includes ensuring that clinical education is delivered where and how health
   services are delivered (i.e. in a range of settings and with an increased focus on team-based primary
   care).

Given that most of the current issues reflect the historical development of the system of handling clinical
placements and the one-to-one nature of negotiations between education providers and health services, it
is likely that improved communication, transparency and coordination will provide a framework for
sustainable solutions. However, stakeholder consultations conducted by DHS over the past year produced
a clear consensus that centralised models of governance are not desirable. Rather, stakeholders indicated
a preference for local solutions developed by regional networks, which preserve the autonomy of
institutions and support existing beneficial relationships.

The key question, therefore, is: on what basis should these networks be established?

The remainder of this section presents three models for the proposed networks. Each model results in
regional groupings, but arrives at this grouping as a first, second or third order arrangement. The models
are named according to the first order grouping that is proposed. For the purposes of this discussion, it is
assumed that the eight DHS regional boundaries will be used to delineate regions (five in regional Victoria
and three in metropolitan Melbourne), although further discussion with stakeholders may result in
different boundaries, particularly for metropolitan areas. All three models could potentially deliver against
the objectives listed above.




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Model 1: Regionally-based networks
Figure 1 depicts how a regionally-based model might work. Victoria would comprise eight (or whatever
number) regional clinical placement networks.




Figure 1: Regionally-based networks (Model 1)
Inthe first instance, the membership of each network would include:
  Education providers (university and VET institutions) that currently place students in that region
  General Practice Regional Training Providers (RTPs) based in that region
  Health services in that region (hospitals/health networks, community health services, aged care,
   clinics, etc), both public and private
  Representative bodies, such as Aged and Community Care Victoria (ACCV), Divisions of General
   Practice, Australian Nurses Foundation, Australian Physiotherapists Association, etc
  Department of Human Services

Each region would have responsibility for developing policies and principles that will serve as the
framework for negotiations between education providers and health services within that region. The
region may decide to establish an executive committee or may operate as a cooperative with all
stakeholders having a seat at the table for major decision-making. While it is very likely that each
education provider would wish to have a seat at the table for policy discussions, it is possible that some
health services would be happy to have a shared representative who speaks on behalf of specific health
care settings. For example, aged and community care services may be happy to have the local ACCV
regional officer represent their interests, and GPs may be happy to be represented by their Division of
General Practice or RTP. This arrangement will work well provided there is adequate two-way flow of
information and sufficient time is allowed in decision-making processes for representatives to discuss
issues with their constituents.

It is expected that each network would collect information about current clinical placement capacity, as
well as capacity development needs (in terms of preceptor/educator training, placement support and
infrastructure, including simulation facilities). It is recommended that a common database template
should be used across all Victorian regions to collect clinical placement capacity information (to allow for
sharing of information between and across regions). Each region would also formulate a plan for meeting
its capacity development needs, which can serve as the basis for funding and other support requests to
government.

Once the policy framework for managing the regional supply and demand of clinical placements has been
defined, it is anticipated that negotiations about placements would be handled by individual disciplines,
rather than on a whole-of-network basis. Thus, each of the regions would be expected to establish a set
of disciplinary sub-committees. Although relationships between individual health services and education




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providers would be an important ingredient of these discussions, it is anticipated that one-to-one
negotiations will not be the principal modus operandi of the network. Instead, it is most likely that
multiple stakeholders will be involved in iterative rounds of placement allocations for each discipline, to
ensure all placement needs are met as equitably as possible.

Note that a variation on this model is that regional boundaries are defined by existing health network
boundaries (e.g. Bayside Health, West Wimmera Health Service, Peninsula Health, etc). The major
problem with using such boundaries is that there are a large number of health networks in Victoria, which
will result in a large number of clinical placement networks that are actually too small to be of much
practical use in achieving the objectives of the new governance model. Furthermore, many health service
providers are not defined as being part of these health networks (aged care, community health services,
GPs and other clinics) and therefore new geographical boundaries would have to be drawn anyway to
define the clinical placement networks.

Pros of Model 1:
   Regional differences in capacity and available placement settings can be readily taken into account.
   The model provides opportunities for disciplines to learn from each other‟s experiences and
    approaches.
Cons of Model 1:
  Education providers may find they have to deal with very different policies in different regions.
  Consistency between regions may be difficult to achieve.

Model 2: Health setting-based networks
Figure 2 depicts how a network based on health care settings might work. In this model, the
responsibility for developing policies and principles that will serve as the framework for negotiations
between education providers and health services is determined for each different type of health care
setting. The initial decision-making process would involve discussions between the following stakeholders:
   All Victorian health services in that category of setting
   Education providers (university and VET institutions) that currently place students in that health care
    setting
   Regional Training Providers, where appropriate
   Representative bodies or peak associations, as appropriate
   Department of Human Services




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Figure 2: Health care setting-based networks (Model 2)

It is expected that each health care setting would collect information about current clinical placement
capacity, as well as capacity development needs (in terms of preceptor/educator training, placement
support and infrastructure, including simulation facilities) for that sector. This information could be
collated (or sorted) on a regional basis to facilitate the preparation of funding and other support requests
to government.

Once the policy framework for managing placements in each category of setting has been defined, it is
anticipated there would need to be further refinement of policies based on regional groupings (since
issues in regional and metropolitan areas are likely to be different). Once this is accomplished, as with
Model 1, negotiations about placements would be handled by individual disciplines, rather than on a
whole-of-region basis.

Pros of Model 2:
   Consistent approach within health service settings.
   Builds on the work already done in some settings (such as GPs) to coordinate placement activities on
    a region-by-region basis.
   Better representation for health service stakeholders, by comparing like with like.
   Allows a voice for individual organisations (rather than being represented en masse).
Cons of Model 2:
   Requires three layers of committees and negotiations.
   Places the emphasis on the setting rather than the purpose of the placement.
   Education providers may find they have to deal with very different policies in different settings.
   Consistency within disciplines (within education providers) may be difficult to achieve.
   This model works against the established domains of health networks, which usually include a range
    of health care settings.

Model 3: Discipline-based networks
Figure 3 depicts how a model based on disciplines might work. In this model, the responsibility for
developing policies and principles that will serve as the framework for negotiations between education
providers and health services is determined for each discipline. This will result in a consistent set of
guidelines across the whole state for a given discipline and will reduce the likelihood of a Galapagos
Islands effect, whereby different policies and practices evolve in each region, creating a complex maze
across the state for education providers to negotiate.




Figure3: Discipline-based networks (Model 3)

The initial decision-making process would involve discussions between the following stakeholders:
  Victorian health services that offer placements for that discipline




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   Education providers (university and VET institutions) that offer courses in that discipline
   Regional Training Providers, where appropriate
   Representative bodies or peak associations, as appropriate
   Department of Human Services

Because of the large number of health service providers involved, it might be considered appropriate for
health service providers to organise themselves into relevant groupings and nominate representatives to
speak on their behalf during the initial discussions.

It is expected that each discipline would collect information about current clinical placement capacity, as
well as capacity development needs (in terms of preceptor/educator training, placement support and
infrastructure) for that discipline. Once the policy framework for managing placements in each discipline
has been defined, it is anticipated that negotiations about placements would be handled on a regional
basis (if necessary), rather than on a whole-of-discipline basis.

Pros of Model 3:
   Consistency across the state (and potentially nationally) for each discipline.
   Disciplines can determine if it is appropriate to organise on a regional basis.
   Provides a platform for discipline-based strategic workforce planning.
   Builds on the work already done in some disciplines (such as Social Work) to coordinate placement
    activities across the state.
Cons of Model 3:
   There is likely to be little cross-talk between disciplines.
   The number of stakeholders in each discipline may be unmanageable and smaller organisations may
    find it difficult to be heard.

One of the possible outcomes of Model 3 is that the system ends up as a collection of regional discipline-
based networks. On the one hand, this might be precisely what is needed (at the micro level) for the
system to operate effectively and efficiently overall. However, such a model does not really provide a
mechanism for learning between professional disciplines, sharing of resources (particularly simulation
facilities) between disciplines, or development of interprofessional education initiatives and research
projects. For this reason, a modified version of Model 3 is suggested (see Figure 4).




Figure4: Model 3 - extended version

In this extended version of Model 3, all the discipline-based networks for a particular region are grouped




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together in a regional clinical academy. Although this would represent a third level of organisation, this
virtual academy would provide a mechanism for information sharing and coordination between disciplines
(where required or desired), developing regional priorities for capacity building and infrastructure, and a
platform for innovation and research. Importantly, this model would be most conducive to addressing the
objectives of interprofessional learning and preparing students for work in multi-disciplinary settings.


Questions for consideration:

1. Which model do you consider the most appropriate as the basis for establishing regional networks to
   organise and manage clinical placements?

2. For your preferred model, are there issues not canvassed in this paper that might impact on the
   successful implementation of the model?
   These issues may be region-specific, discipline-specific, health care setting-specific or general issues.

3. What resourcing (particularly personnel) will be required to allow your preferred model to work
   effectively?

4. What templates and other administrative resources do you think need to be common at each level?
   For example, a common database template for collecting information about placement capacity.



4. Operational issues
Once the preferred model for establishing regional networks has been identified, it is important to
consider some of the logistical questions of how the networks will conduct their business and achieve the
overall objectives of the new governance arrangements (as discussed in Section 3, see page 3).

   Regional boundaries
For the purposes of this discussion paper, it has been assumed that the DHS regional boundaries will
serve as the basis of defining the regional networks, regardless of whether regional divisions are applied
as a first, second or third order arrangement.
Questions for consideration:

5. Are DHS regional boundaries an acceptable basis for defining regional clinical placement networks
        - in regional Victoria?
        - in metropolitan Melbourne?

6. What alternative boundaries could be used?

   Policies and principles
In this paper, it has been assumed that the first order grouping would have responsibility for determining
the policies and principles that will serve as the framework for negotiations between education providers
and health services. These policies and principles need to provide consistency where it is desirable, but
also allow second and third order groupings sufficient flexibility to meet their specific needs.

For example, if Model 3 is the preferred model, then discipline groupings might develop a policy
concerning the placement allocation process such that two or three rounds of request/ offer negotiations
occur each year, with fixed, common dates for each round applied across the discipline.

Question for consideration:

7. What common policies, principles or practices need to be set by the first order grouping in your
   preferred model?

   Membership
In Section 3 of this paper, each model included a suggestion about the organisations that would be
involved in the discussions of policies and principles that will serve as the framework for negotiations
between education providers and health services.

Questions for consideration:




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8. Who should have a seat at the table for the initial discussions of policies and principles?

           - What level of representation (i.e. individual organisations versus collective representation) is
           workable?

           - What level of representation is acceptable?

9. How will membership be weighted?

           - One organisation = one vote versus weighting proportional to placement capacity (health
           services) or student numbers (education providers).

           - If proportional weighting is used, how will smaller players have a voice in negotiations and how
           will new players be dealt with?

10. Should education providers who currently place only a few students in a region (perhaps in response
    to special students needs or requests) have a seat at the table for discussions about policies and
    principles?

11. For interstate education providers who currently place students in Victoria (e.g. Charles Sturt
    University, Flinders University and University of South Australia), will they have full membership of
    relevant networks, or some kind of associate membership with reduced voting rights?

12. What role (if any) would regional networks have in recruiting health services that are not currently
    involved in clinical education to becoming providers of clinical education (and thereby becoming
    members of the network)?

13. Should the networks include student representatives?

      Budget issues
Current thinking is that funding for clinical education in the new national context (both Commonwealth
and state funding) would follow the student. The practicalities of this have not yet been defined, but this
might indicate that, once the system has been bedded down and is running routinely, funds will be paid to
health services based on the number of student placement days delivered in a given period. If this is the
case, funds could be paid to health services from the Commonwealth government either directly, or
through a Victorian agency, for example, through the proposed Victorian Clinical Placement Council,
VCPC.

The VCPC is described in the DHS draft action plan document (Clinical Placements in Victoria: An action
plan in the new national context). According to that paper:
“It is proposed that representation of networks and statewide governance be provided through a Victorian
Clinical Placement Council. The VCPC membership would include representation of public and private
health, community services, and education and training stakeholders, and be drawn from the
geographical networks proposed below.
The purpose of the VCPC will be to provide statewide strategic leadership for clinical placements and to
oversee clinical placement projects that have an impact at a statewide level. The VCPC will oversee
statewide specific activity in the five action streams of capacity building, targeted funding, innovation,
better data and evidence, and improved governance with a view to achieving an increase in quality of and
capacity for clinical placements across Victoria. Importantly, the VCPC will be stakeholder-owned and
driven, with membership including education providers and health services, and with a rotating chair.
Government will participate, provide policy priorities and facilitate but not lead the agenda.”11

One issue that arises from an arrangement whereby funding follows the student is the potential to
(perversely) drive clinical placements back towards large health services, working against the trend to
more distributed, ambulatory health care settings (where patients are increasingly being treated). The
more distributed the clinical placements, the fewer students in any single setting and the more distributed
the funding. It may be difficult to get health services to pool the funding they receive to create economies
of scale, in terms of shared resources and infrastructure, so education providers may find it more
attractive to minimise their use of distributed settings.

One way to avoid such an outcome might be to have the funding follow the students to the regional
networks (for example, if Model 3 were the preferred model, the funding could go to the regional clinical
academies). The networks could agree on an off-the-top amount that is used to fund communal goods,

11
     DHS (2009) Clinical Placements in Victoria: An action plan in the new national context. Draft document. pp. 7-8.




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such as administrative personnel who conduct the business of the network, educator training programmes
and other ongoing capacity building, new infrastructure or maintenance and staffing of existing
infrastructure12, etc. The remaining funds would then flow to the health services, pro-rated for the
number of student placement days. There would be issues that would need to be resolved about how the
payments would actually be handled (since the monies would be Commonwealth and state funds that
have to be accounted for and reported against), but the concept is of some type of pro-rated contribution
to a regional fund that pays for communal assets and activities.

Questions for consideration:

14. As a general principle, should there be some mechanism for [effective] off-the-top funding of
    communal goods at a regional network level to pay for assets and activities?

15. How will funding allocated by individual education providers (particularly universities) – for example,
    for shared research facilities or joint education provider/health service appointments (e.g.
    Professor/Director positions) – work in the context of your preferred model?

    Negotiations
One of the major problems identified for the present system is that placement allocation is a non-
transparent, inequitable process that works better for education providers that have some bargaining
power (academic and/or financial). Therefore, a key criterion by which the new governance model will be
evaluated is whether the new arrangements produce a more equitable outcome.

Questions for consideration:

16. How will placement capacity, once determined, be equitably distributed between competing education
    providers?

17. Would all placements be handled under the auspices of the network, or might some private
    arrangements also be used?

         - How will “emergencies” be handled?

18. How will non-members negotiate placements in a region?



    Relationships

Most stakeholders nominated the importance of existing relationships as a key issue to be factored into
the development of any new clinical placement governance model. At the same time, many education
providers noted that the present system of bilateral negotiations based on established relationships that
exclude new players is inherently unfair and needs to be modified to a more transparent system.

Question for consideration:

19. What role will established relationships have in a new system of transparent, multi-lateral
    negotiations?

    Inter-regional negotiations
Although most stakeholders favour (in principle) a regional model for managing clinical placements, the
reality is that all the Victorian universities and the majority (about 65%) of Victorian VET institutions
place students in more than one DHS region. Therefore, whatever new model of governance is developed,
there must be provisions for inter-regional communication and negotiation and some consistency of
approaches between different regions. If this is not the case, education providers will find they are
dealing with a more complex system than currently exists.

Questions for consideration:

20. How will regions work with each other?

21. On what issues will this be necessary?


12
  It is understood the new funding package includes specific allocations for infrastructure and capacity building, but
the regional networks may require some mechanism for funding further capital purchases and ongoing capacity
building activities.




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22. How will the Victorian system interact with interstate systems (particularly NSW and SA)?

23. What role should the proposed statewide council (Victorian Clinical Placement Council) have in setting
    policy and driving inter-regional information exchange?

   Miscellaneous issues

Questions for consideration:

24. How should simulation facilities be handled in the context of your preferred model?

25. Would a database that provides real-time information on available capacity be a useful tool for
    organising clinical placements?

       - If so, would an automated computer-matching placement system be an appropriate downstream
       development?

26. What barriers do you think may impact on the successful implementation of your preferred model?

27. Do you think your preferred model is scalable, both in terms of national implementation and
    potentially for vertical integration of education and training?




Darcy Associates Consulting Services                                                                   92