Standards › ASF Health Standards V11 › Standard 17
Standard 17 (Academic Medical Centre), PDF
ASF-HS11-S17 · Revision 01 · 1 November 2026 · 25 pages, A4. The same criteria as this page, for printing and assessors.
Where this standard applies
Standard 17 applies to academic medical centres, the teaching and research activity they carry out. It is required by default in hospitals and not applicable to the other facility types. The table shows each criterion and where it applies.
| Criterion | Hospital | Ambulatory clinic | Primary health clinic | Long-term care | Telemedicine | Home care | Fitness and wellness | Dental clinic | Aesthetic and procedure clinic |
|---|---|---|---|---|---|---|---|---|---|
| 17.1 Resident and Trainee Supervision With Verified, Graduated Autonomy | Yes | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| 17.2 Patients Are Informed of Trainee Involvement in Their Care | Yes | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| 17.3 Research Activity Operates Under Independent Ethics Review Before Enrolment | Yes | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| 17.4 Clinical Care and Research Participation Are Clearly Separated in Consent | Yes | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| 17.5 Conflicts of Interest Between Research and Clinical Care Are Disclosed and Managed | Yes | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| 17.6 Teaching Faculty Maintain Verified, Current Clinical Competency | Yes | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
Academic Medical Centre
It covers the supervision of residents and trainees, patient information on trainee involvement, independent ethics review of research, separate research consent, conflicts of interest between research and clinical care, and verified competency for faculty who teach clinical skills.
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
17.1
Resident and Trainee Supervision With Verified, Graduated Autonomy
Humanitarian settings: MustTransition and fragile: MustStandard: Must
Each resident or trainee's current scope of independent practice is explicitly defined and documented, matched to their verified competency progression, with supervising physician involvement available at the level that scope requires.
Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: ambulatory clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.
Why it matters. A trainee who operates alone before they are competent puts the patient at risk. Each trainee's independent scope, matched to verified competency, makes sure the level of supervision fits the person.
Questions the surveyor asks
- Does each trainee have a written scope of independent practice? The surveyor checks the trainee scope register (TCH-REG-001) and the scope policy (TCH-POL-001) for each trainee on the sample list.
- Is supervision available at the level the scope requires? The surveyor checks the supervision rota for each trainee's scope and confirms that a supervisor was available when the trainee acted.
How the surveyor verifies this criterion
Sample. Review the scope of independent practice record for 5 trainees, anonymised.
1. Each trainee has a written scope of independent practice.
Method. Check each sampled trainee for a recorded scope.
Evidence to show. Trainee scope and competency register ( TCH-REG-001 ).
Pass when. Every sampled trainee has a written scope recorded.
2. The scope is matched to verified competency.
Method. Check the competency verification date against the scope.
Evidence to show. Trainee scope and competency register ( TCH-REG-001 ).
Pass when. Every scope is matched to a verified competency.
3. Supervision is available at the level the scope requires.
Method. Check the supervision level recorded against the scope, and the supervision record.
Evidence to show. Trainee scope and competency register ( TCH-REG-001 ).
Pass when. Every trainee has the supervision level recorded and available.
Immediate fail (any one means the criterion is not met)
- . A first-year trainee operates alone with no record of scope.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Each trainee's scope is reviewed at each rotation and whenever competency is verified, and the trainee receives their scope in writing.
Partial because. The scope is written, but it is not updated when a trainee's competency changes.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Specialist physician ISCO 2212 |
Sets the scope and supervision level for each trainee | Must | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | — |
| Manager ISCO 1342 |
Checks the register against the scope | Must | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | TCH-REG-001 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Credentialing, Competence and the Training Matrix (T-14) (T-14-EN) GMJ Academy: English · Georgian |
Manager, Specialist physician | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| TCH-REG-001 · Trainee scope and competency register Register |
Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| TCH-POL-001 · Trainee scope of independent practice and supervision Policy |
Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
References
- WFME Global Standards for Quality Improvement: Postgraduate Medical Education (World Federation for Medical Education, 2023) https://wfme.org/?p=9697
17.2
Patients Are Informed of Trainee Involvement in Their Care
Humanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Patients are clearly informed before or at admission that a teaching facility's care model involves residents and trainees, with an opportunity to ask questions about who is involved in their care.
Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: ambulatory clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.
Why it matters. Patients in a teaching hospital are often seen by trainees. They have a right to know this before they are treated, and to ask questions about it.
Questions the surveyor asks
- How are patients told about trainee involvement? The surveyor checks the information given to patients (TCH-FRM-001) for a sample of admissions, and confirms that it was given before or at admission.
- Can patients ask questions about who is involved in their care? The surveyor checks that the form records the opportunity to ask questions, and asks a sample of patients whether they were able to ask.
How the surveyor verifies this criterion
Sample. Review the patient information on trainee involvement and 10 admission records showing it was given.
1. Patients are informed of trainee involvement before or at admission.
Method. Check each sampled admission record for the information given.
Evidence to show. Trainee involvement information and admission record ( TCH-FRM-001 ).
Pass when. At least 95% of admissions show the information given.
2. The information explains who is involved in care.
Method. Check the current patient information for the explanation.
Evidence to show. Trainee involvement information and admission record ( TCH-FRM-001 ).
Pass when. The information explains the involvement of trainees.
3. The patient has the chance to ask questions.
Method. Check each record for the questions invited and answered.
Evidence to show. Trainee involvement information and admission record ( TCH-FRM-001 ).
Pass when. At least 90% of records show questions invited and answered.
Immediate fail (any one means the criterion is not met)
- . A patient is unaware that a trainee performed the examination.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Patient information is given in the patient's own language, and each trainee introduces themselves at the start of the consultation.
Partial because. The information is given, but only in one language and it is not repeated at the bedside.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Nurse ISCO 2221 |
Gives the trainee information at admission | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | — |
| Specialist physician ISCO 2212 |
Answers the patient's questions | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | — |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Patient Identification, Informed Consent and Patient Rights (T-07) (T-07-EN) GMJ Academy: English · Georgian |
Nurse, Specialist physician | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| TCH-FRM-001 · Trainee involvement information and admission record Form (record) |
Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
References
- World Medical Association (2015). Declaration of Lisbon on the Rights of the Patient. Used for: the patient's right to be informed about who is involved in their care. https://news.gmj.ge/guideline/wma-declaration-of-lisbon-on-the-rights-of-the-patient/
17.3
Research Activity Operates Under Independent Ethics Review Before Enrolment
Humanitarian settings: MinimumTransition and fragile: MustStandard: Must
No patient is enrolled in a research study until that study has received approval from an independent ethics review board, with the approval current and the enrolled patient's participation falling within the approved protocol.
Rating: Minimum in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: ambulatory clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.
Why it matters. Research on patients must be approved by an independent ethics board before the first person is enrolled. Otherwise patients are used for research without protection.
Questions the surveyor asks
- Is each study approved by an independent ethics board before enrolment? The surveyor checks the research ethics approval register (TCH-REG-002) for each study in the sample, confirming that approval was given before the first enrolment.
- Do enrolled patients fall within the approved protocol? The surveyor checks each enrolled patient's record against the approved protocol and the expiry date of the approval.
How the surveyor verifies this criterion
Sample. Review the ethics approval for each research study, with the first enrolment date.
1. Each study has approval from an independent ethics review board before enrolment.
Method. Check each study's approval date against its first enrolment date.
Evidence to show. Research ethics approval register ( TCH-REG-002 ).
Pass when. Every study has approval before its first enrolment.
2. The approval is current.
Method. Check each approval for its expiry against the enrolment dates.
Evidence to show. Research ethics approval register ( TCH-REG-002 ).
Pass when. Every enrolment falls within a current approval.
3. Each enrolled patient's participation falls within the approved protocol.
Method. Check each enrolment against the approved protocol.
Evidence to show. Research ethics approval register ( TCH-REG-002 ).
Pass when. Every enrolment falls within the approved protocol.
Immediate fail (any one means the criterion is not met)
- . A study enrols patients with no ethics approval.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. An ethics board member who is independent of the study team reviews each protocol amendment before enrolment resumes.
Partial because. Approval is obtained, but protocol changes are not sent back to the ethics board.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Manager ISCO 1342 |
Checks approval before enrolment | Must | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | TCH-REG-002 |
| Secretary ISCO 3344 |
Keeps the approval register | Must | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | TCH-REG-002 |
E-learning: who must take each course.
No course is required for this criterion.
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| TCH-REG-002 · Research ethics approval register Register |
Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
References
- Pan American Health Organization (2020). Guidance for Ethics Oversight of COVID-19 Research in Response to Emerging Evidence. Used for: ethics review committee oversight of research before and during enrolment (COVID-era). https://news.gmj.ge/guideline/guidance-for-ethics-oversight-of-covid-19-research-in-response-to-emerging-evidence/
- Pan American Health Organization (2020). Ethics guidance on issues raised by the novel coronavirus disease (COVID-19) pandemic. Used for: research ethics, consent and review committee guidance (COVID-era). https://news.gmj.ge/guideline/ethics-guidance-on-issues-raised-by-the-novel-coronavirus-disease-covid-19-pandemic/
- Pan American Health Organization (2020). Considerations for Regulatory Oversight of Clinical Trials in the COVID-19 Pandemic. Used for: regulatory approval of clinical trials before enrolment (COVID-era). https://news.gmj.ge/guideline/considerations-for-regulatory-oversight-of-clinical-trials-in-the-covid-19-pandemic/
17.4
Clinical Care and Research Participation Are Clearly Separated in Consent
Humanitarian settings: MinimumTransition and fragile: MediumStandard: Must
A patient understands which elements of their care are standard clinical treatment and which are research participation, with declining research participation never affecting the standard care they receive.
Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: ambulatory clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.
Why it matters. A patient who agrees to care may not know that part of it is research. Separating the two in the consent, and letting the patient refuse research without losing standard care, protects their choice.
Questions the surveyor asks
- Is research consent taken on a separate form? The surveyor checks the research participation consent form (TCH-FRM-002) and confirms that it is separate from the standard care consent.
- Does declining research affect standard care? The surveyor checks the records of patients who declined research and confirms that their standard care was unchanged.
How the surveyor verifies this criterion
Sample. Review the separate consent forms for standard care and research, and 5 signed forms.
1. Research participation is consented on a form separate from standard care.
Method. Check the consent forms for two separate forms.
Evidence to show. Research participation consent form ( TCH-FRM-002 ).
Pass when. Research and standard care consent are separate forms.
2. The patient understands which care is research.
Method. Check each signed form for the explanation of research and standard care.
Evidence to show. Research participation consent form ( TCH-FRM-002 ).
Pass when. Every signed form shows the explanation.
3. Declining research does not affect standard care.
Method. Check the form statement and the care recorded for a patient who declined.
Evidence to show. Research participation consent form ( TCH-FRM-002 ).
Pass when. Every form states declining does not affect standard care.
Immediate fail (any one means the criterion is not met)
- . A patient is enrolled in research without knowing it.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. The consent discussion is held in a private room, and the patient is given time and a copy of the form.
Partial because. The forms are separate, but the patient is not told that declining research does not affect their care.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Specialist physician ISCO 2212 |
Explains research and standard care to the patient | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | — |
| Nurse ISCO 2221 |
Witnesses the signed form | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | — |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Patient Identification, Informed Consent and Patient Rights (T-07) (T-07-EN) GMJ Academy: English · Georgian |
Nurse, Specialist physician | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| TCH-FRM-002 · Research participation consent form Form (record) |
Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
References
- Pan American Health Organization (2020). Ethics guidance on issues raised by the novel coronavirus disease (COVID-19) pandemic. Used for: research ethics, consent and review committee guidance (COVID-era). https://news.gmj.ge/guideline/ethics-guidance-on-issues-raised-by-the-novel-coronavirus-disease-covid-19-pandemic/
17.5
Conflicts of Interest Between Research and Clinical Care Are Disclosed and Managed
Humanitarian settings: MinimumTransition and fragile: MediumStandard: Must
A clinician's financial or other significant interest connected to a research study is disclosed through a defined process and managed, such as separating the clinician's research role from their direct clinical decision-making for enrolled patients.
Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: ambulatory clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.
Why it matters. A clinician who is paid by a company that sponsors a study may be biased in their clinical choices. Declaring the interest and managing it protects the patient and the research.
Questions the surveyor asks
- Are conflicts of interest disclosed and managed? The surveyor checks the conflict of interest register (TCH-REG-003) and the management record for each disclosed interest (TCH-FRM-003).
- Is the clinician's research role kept separate from decisions for their enrolled patients? The surveyor checks the management record for the separation of roles and the clinician's decisions for an enrolled patient.
How the surveyor verifies this criterion
Sample. Review the research conflict of interest register and the management record for each study.
1. A clinician's significant interest connected to a study is disclosed through a defined process.
Method. Check the register for a declaration for each clinician on each study.
Evidence to show. Research conflict of interest register ( TCH-REG-003 ).
Pass when. Every interest is disclosed for each study.
2. Each disclosed interest has a management action.
Method. Check each declaration for the management action.
Evidence to show. Study conflict management record ( TCH-FRM-003 ).
Pass when. Every declared interest has a management action recorded.
3. The clinician's research role is separated from direct decisions for enrolled patients.
Method. Check the role separation for each study.
Evidence to show. Study conflict management record ( TCH-FRM-003 ).
Pass when. Every declared interest has role separation recorded where it applies.
Immediate fail (any one means the criterion is not met)
- . A clinician enrols patients in a study paid by a drug company with no declaration.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. The conflict register is shared with the ethics board each year, and a clinician with an interest in a study does not recruit patients for it.
Partial because. Interests are declared, but no management action is recorded for them.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Specialist physician ISCO 2212 |
Declares significant interests | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | — |
| Manager ISCO 1342 |
Manages each declared interest | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | TCH-REG-003 TCH-FRM-003 |
E-learning: who must take each course.
No course is required for this criterion.
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| TCH-REG-003 · Research conflict of interest register Register |
Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| TCH-FRM-003 · Study conflict management record Form (record) |
Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
References
- WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Participants (World Medical Association, 2024, amended October 2024) https://www.wma.net/policies-post/wma-declaration-of-helsinki
17.6
Teaching Faculty Maintain Verified, Current Clinical Competency
Humanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Faculty teaching clinical skills maintain active, verified clinical competency in the skill being taught, confirmed through a defined process.
Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: ambulatory clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.
Why it matters. Trainees learn skills from the people who teach them. A faculty member who has not practised a skill for years may teach an old or unsafe method.
Questions the surveyor asks
- Do faculty who teach clinical skills hold active, verified competency? The surveyor checks the faculty clinical competency register (TCH-REG-004) for each faculty member who teaches clinical skills.
- Is the verification current, and done through a defined process? The surveyor checks the date of the last verification against the defined interval, and the process used to verify.
How the surveyor verifies this criterion
Sample. Review the faculty competency register, with the verification records for the teachers of clinical skills.
1. Faculty teaching clinical skills have active, verified clinical competency in the skill taught.
Method. Check each teacher for the verification record for each skill taught.
Evidence to show. Faculty clinical competency register ( TCH-REG-004 ).
Pass when. Every teacher of a clinical skill has a verified competency recorded.
2. Verification is current.
Method. Check each verification date against the due date.
Evidence to show. Faculty clinical competency register ( TCH-REG-004 ).
Pass when. Every verification is within its due date.
3. The verification is through a defined process.
Method. Check the process used and the record for each verification.
Evidence to show. Faculty clinical competency register ( TCH-REG-004 ).
Pass when. Every verification follows the defined process.
Immediate fail (any one means the criterion is not met)
- . A teacher demonstrates a procedure they have not done for ten years.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Faculty teach from a shared skills checklist and are observed teaching at least once a year.
Partial because. Competency is verified once, but the verification is not repeated on its due date.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Manager ISCO 1342 |
Verifies faculty competency on schedule | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | TCH-REG-004 |
| Specialist physician ISCO 2212 |
Confirms their own clinical skill | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | — |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Credentialing, Competence and the Training Matrix (T-14) (T-14-EN) GMJ Academy: English · Georgian |
Manager, Specialist physician | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| TCH-REG-004 · Faculty clinical competency register Register |
Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
References
- WFME Global Standards for Quality Improvement: Postgraduate Medical Education (World Federation for Medical Education, 2023) https://wfme.org/?p=9697
Role details: reporting, supervision and training
Each role links to its own terms of reference, which holds the full reporting line, supervision, training and competency record.
| Role | Reports to | Supervises | Core training |
|---|---|---|---|
| Manager ISCO 1342 | The chief operating officer or chief nursing officer. | Nurses and specialist physicians in the unit. | No course is required for this role in this standard. |
| Specialist physician ISCO 2212 | The head of department (per specialty). | Residents and trainees under supervision. | No course is required for this role in this standard. |
| Nurse ISCO 2221 | The head nurse or ward manager. | No direct reports. | No course is required for this role in this standard. |
| Secretary ISCO 3344 | The head of department (per specialty). | No direct reports. | No course is required for this role in this standard. |
Who is responsible for Standard 17
Each criterion below names the positions responsible for it.
| Criterion | Positions responsible or involved | |
|---|---|---|
| 17.1 | Resident and Trainee Supervision With Verified, Graduated Autonomy | Specialist physician · Manager |
| 17.2 | Patients Are Informed of Trainee Involvement in Their Care | Nurse · Specialist physician |
| 17.3 | Research Activity Operates Under Independent Ethics Review Before Enrolment | Manager · Secretary |
| 17.4 | Clinical Care and Research Participation Are Clearly Separated in Consent | Specialist physician · Nurse |
| 17.5 | Conflicts of Interest Between Research and Clinical Care Are Disclosed and Managed | Specialist physician · Manager |
| 17.6 | Teaching Faculty Maintain Verified, Current Clinical Competency | Manager · Specialist physician |
Quality oversight
The quality chain keeps this standard under review, from the governing body down to the teams that run each process.
Related courses in the GMJ Academy
These courses cover the same subjects in more depth or for a specific type of facility. They are optional. They are not required by the criteria.
| Course | Subject | Criteria |
|---|---|---|
| Credentialing, Competence and the Training Matrix (T-14) GMJ Academy: English · Georgian |
Credentialing and competence | 17.1 |
| Patient Identification, Informed Consent and Patient Rights (T-07) GMJ Academy: English · Georgian |
Patient identification and consent | 17.2 |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 17 apply to?
It applies to academic medical centres, the teaching and research activity they carry out. It is required by default in hospitals and not applicable to the other facility types. Section 4 shows the detail.
What do the colours mean for this standard?
Red means Must, required in every setting. Yellow means Medium, required and adapted to what a transition setting can realistically do. Green means Minimum, the lowest acceptable level in a humanitarian setting.
Can a trainee act alone?
Only within a written scope of independent practice that is matched to verified competency. Supervision must be available at the level the scope requires (criterion 17.1).
Must patients be told when trainees are involved?
Yes. Patients are informed before or at admission who is involved in their care, and they have the chance to ask questions (criterion 17.2).
Can research start before ethics approval?
No. Each study has approval from an independent ethics review board before enrolment, and the approval is current (criterion 17.3).
Can declining research affect standard care?
No. Research consent is taken on a form separate from standard care, and declining research does not affect the care a patient receives (criterion 17.4).
What is a conflict of interest in this standard?
A clinician’s significant interest connected to a study. It must be disclosed, each disclosed interest must have a management action, and the clinician’s research role must be separated from direct decisions for enrolled patients (criterion 17.5).
How is faculty competency kept current?
Faculty who teach clinical skills hold active, verified competency. The verification is current and done through a defined process (criterion 17.6).
Which e-learning courses are required?
Credentialing, Competence and the Training Matrix (T-14) is required for the manager and specialist physician. Patient Identification, Informed Consent and Patient Rights (T-07) is required for the nurse and specialist physician.
Who is the specialist physician?
The specialist physician is the physician responsible for a specialty in the teaching setting. The role is linked to the consultant physician terms of reference on france-asf.fr.
Does the standard apply to other facility types?
No. Academic medical centre is not applicable to the other facility types.
What does In development mean?
The course is named in the criteria and may still be in preparation. Where a course is published, the English or Georgian version is linked.
Who is responsible for each criterion?
The criteria assign responsibility to the manager, the nurse, the secretary and the specialist physician. Each record should show who wrote and who reviewed it.
How is evidence shown to the surveyor?
The records named in each criterion’s documents table, covering the period stated in the criterion.
Is the reference cited in a criterion mandatory?
No. A cited guideline is a reference for the criterion, not a requirement. A facility may use other guidance that meets the same criterion.
Do I have to use the forms on this page?
No. They are reference drafts. Adapt them, write your own, or upload your own, provided the same criterion is met and the evidence can be shown.
E-learning by standard
These are the GMJ Academy courses named in the criteria of this standard. Each course name opens the course page in the academy. Where a course is published in English and in Georgian, both versions are linked. Evidence of completion is a verified micro-credential in the GMJ Academy micro-credential portfolio, or a training certificate in the staff file.
| E-learning course | Who must take | Who is recommended | Criteria |
|---|---|---|---|
| Credentialing, Competence and the Training Matrix (T-14) (T-14-EN) GMJ Academy: English · Georgian |
Manager, Specialist physician | None | 17.1, 17.6 |
| Patient Identification, Informed Consent and Patient Rights (T-07) (T-07-EN) GMJ Academy: English · Georgian |
Nurse, Specialist physician | None | 17.2, 17.4 |
References and guidelines for this standard
The guidelines and references cited in the criteria above are listed here. Each link opens the full text.
- WFME Global Standards for Quality Improvement: Postgraduate Medical Education (World Federation for Medical Education, 2023) https://wfme.org/?p=9697
- World Medical Association (2015). Declaration of Lisbon on the Rights of the Patient. Used for: the patient's right to be informed about who is involved in their care. https://news.gmj.ge/guideline/wma-declaration-of-lisbon-on-the-rights-of-the-patient/
- Pan American Health Organization (2020). Guidance for Ethics Oversight of COVID-19 Research in Response to Emerging Evidence. Used for: ethics review committee oversight of research before and during enrolment (COVID-era). https://news.gmj.ge/guideline/guidance-for-ethics-oversight-of-covid-19-research-in-response-to-emerging-evidence/
- Pan American Health Organization (2020). Ethics guidance on issues raised by the novel coronavirus disease (COVID-19) pandemic. Used for: research ethics, consent and review committee guidance (COVID-era). https://news.gmj.ge/guideline/ethics-guidance-on-issues-raised-by-the-novel-coronavirus-disease-covid-19-pandemic/
- Pan American Health Organization (2020). Considerations for Regulatory Oversight of Clinical Trials in the COVID-19 Pandemic. Used for: regulatory approval of clinical trials before enrolment (COVID-era). https://news.gmj.ge/guideline/considerations-for-regulatory-oversight-of-clinical-trials-in-the-covid-19-pandemic/
- WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Participants (World Medical Association, 2024, amended October 2024) https://www.wma.net/policies-post/wma-declaration-of-helsinki
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