Waikato District Health Board has been put on notice over the training of junior doctors in orthopaedics because of a serious imbalance in the types of surgeries they are learning.
The DHB has 15 months to correct the situation, where registrars are not performing enough elective surgeries to meet training requirements, or face losing accreditation in orthopaedics.
Accreditation has already been lost in another service, obstetrics and gynaecology in November 2015, but a cancelled accreditation in orthopaedics would plunge the tertiary and major trauma hospital into crisis.
It would mean the departure of at least eight 24/7 registrars who are in advanced training in the five-year orthopaedic programme, so that they could continue training at other accredited hospitals around the country.
Without accreditation, which can take years to get back, senior doctors would face more pressure including longer hours in a department where staff shortages were a concern late last year.
Assessors from the New Zealand Orthopaedic Association visited Waikato Hospital earlier this year for a five-yearly review of its training.
Association president Dr Richard Keddell said all aspects of the training were good except for the significant imbalance which is now under review.
"Waikato is a major trauma hospital so the guys there are getting fantastic trauma training but because of the amount of trauma they're doing they're not getting to do enough elective surgeries."
Keddell said it would be a "major blow" and a "shame" if Waikato DHB lost its accreditation.
"It's a significant thing for a hospital to lose accreditation and it doesn't happen often. But they have shown a willingness to address the situation. They need to confront it and the surgeons there will want to confront it."
Waikato Hospital services executive director Brett Paradine said the situation came about because acute trauma took precedence and there had been a reduction in elective procedures because of a shortage of specialist staff.
Also impacting the situation was the fact some theatres had been unusable while air conditioning in them was fixed, Paradine said.
The DHB was working to increase the amount of theatre time for registrars not just at Waikato Hospital, but with any elective surgeries outsourced to other providers, he said.
"We are arranging for registrars to attend the other hospitals and work alongside the surgeons there."
Paradine said the DHB's elective services commissioner was working with operational managers to ensure sufficient access was available.
"We have recruited more specialist staff and the air conditioning and lighting issues in the theatres have all been addressed."
The DHB was also on track to regain its Women's Health Services registrar training accreditation later this year, he added.
Paradine said NZOA's accreditation team was otherwise complimentary of the DHB's orthopaedic training programme.
"[It] said we had a culture of respect for patients and staff and that we were very focused on patient safety.
"[It] said our education facilities were excellent and the quality of education, training and learning is also excellent with good supervisor support from the consultants."
The report comes at a time when the Government is considering a proposal by Waikato DHB and the University of Waikato to create a third medical school based in Hamilton.
It also follows a letter from 13 orthopaedic surgeons at Waikato Hospital lambasting managers in November last year for stopping them from seeing patients to meet another health target.
Association of Salaried Medical Specialists executive director Ian Powell said it would be "concerning and alarming" if the DHB lost accreditation.
"It undermines the credibility of the hospital in respect of orthopaedics - it will be a body blow for recruitment.
Resident Doctors Association national secretary Dr Deborah Powell [no relation], said a loss of accreditation would be "massive".
"Accreditation by the colleges is an independent marker of standards. If we lose accreditation then we've got standards issues and that goes to the heart of clinical care."
If not enough elective surgeries were being performed, junior doctors could not learn, she said.
"There is a provision in our contract that training cannot be interrupted so if a district health board loses accreditation the registrars in the training programme have to be moved to another place."