University of Manitoba

Pre-Survey Meeting withDepartment Heads

Date: July 4, 2013

Time: 10:45 a.m. to 12:45 p.m.

Room: Pharmacy Apotex, Theatre # 264

Objectives of the Meeting

To review the:• Accreditation Process• Categories of Accreditation - New• Standards of Accreditation• Role of the:

– Program directors

– Department heads

– Residents

– Program administrators

• Is a process to:– Improve the quality of postgraduate medical

education– Provide a means of objective assessment of

residency programs for the purpose of Royal College accreditation

– Assist program directors in reviewing conduct of their program

•Based on Standards

Accreditation

•Based on General and Specific Standards

•Based on Competency Framework•On-site regular surveys•Peer-review• Input from specialists•Categories of Accreditation

Principles of the Accreditation Process

Internal Reviews

1

2

34

5

6

Monitoring

Six Year Survey Cycle

Pre-Survey Process

Royal CollegeComments

Questionnaires

University

Specialty Committee

Questionnaires

Questionnaires &Comments

Program Director

Comments

Surveyor

•Prescribe requirements for specialty education

– Program standards– Objectives of training– Specialty training requirements– Examination processes– FITER

• Evaluates program resources, structure and content for each accreditation review

•Recommends a category of accreditation to the Accreditation Committee

Role of the Specialty Committee

•Voting Members (chair + 5)– Canada-wide representation

•Non-voting Members– Chairs of exam boards– National Specialty Society (NSS)– ALL program directors

Composition of a Specialty Committee

• Chair - Dr. Sarkis Meterissian– Responsible for general conduct of survey

• Deputy chair – Dr. Maureen Topps– Visits teaching sites / hospitals

• Surveyors • Resident representatives – CAIR

• Regulatory authorities representative – FMRAC

•Teaching hospital representative – ACAHO

The Survey Team

• Assess how the program is meeting standards at the time of survey

• Looking for ‘evidence’

Role of the Surveyor

•Questionnaires and appendices– Completed by program

•Program-specific Standards (OTR/STR/SSA)

•Report of last regular survey– Plus report of mandated Royal College review since last

regular survey, if applicable

•Specialty Committee comments– Also sent to PGD / PD prior to visit

•Exam results for last six years

Information Given to Surveyors

•Document review (30 min)

• Residency Program Committee minutes• Resident assessment files

•Meetings with:• Program director (75 min)

• Department head (30 min)

• Residents (per group of 20 - 60 min)

• Teaching staff (60 min)

• Residency Program Committee (60 min)

The Survey Schedule

•Program director• Overall view of program, strengths, challenges &

weaknesses• Address each Standard• Resources to support program director & program

•Department head• Support for program director & program• Concerns regarding program• Resources available to program• Research environment

•Teaching faculty• Involvement with residents• Communication with program director

Meeting Overview

•Topics to discuss with residents– Objectives– Educational experiences– Service /education balance– Increasing professional responsibility– Academic program / protected time– Supervision– Assessments of resident performance– Evaluation of program / assessment of faculty– Career counseling– Educational environment– Safety

Meeting with ALL Residents

•Program director attends first half of meeting

•All members of RPC attend meeting, including resident representatives

•Review of responsibilities of Committee

•Functioning appropriately

•Opportunity for surveyor to provide feedback on information obtained during previous meetings

Meeting with Residency Program Committee

•Survey team discussion– Evening following review

•Feedback to program director– Exit meeting with surveyor

•Morning after review– 07:30 – 07:45 at the Fairmont Winnipeg

– Survey team recommendation• Category of accreditation

• Strengths & weaknesses

The Recommendation

New terminology – June 2012• Revised and approved by the Royal College,

CFPC and CMQ.

Categories of Accreditation

Accredited program• Follow-up:

– Next regular survey – Progress report (Accreditation Committee)– Internal review– External review

Accredited program on notice of intent to withdraw accreditation

• Follow-up:– External review

Categories of Accreditation

• Accredited program with follow-up at next regular survey

– Program demonstrates acceptable compliance with standards.

Categories of Accreditation Definitions

• Accredited program with follow-up by College-mandated internal review

– Major issues identified in more than one Standard

– Internal review of program required and conducted by University

– Internal review due within 24 months

Categories of Accreditation Definitions

• Accredited program with follow-up by external review

– Major issues identified in more than one Standard AND concerns -• are specialty-specific and best evaluated by a

reviewer from the discipline, OR• have been persistent, OR• are strongly influenced by non-educational issues

and can best be evaluated by a reviewer from outside the University

– External review conducted within 24 months– College appoints a 2-3 member review team – Same format as regular survey

Categories of Accreditation Definitions

• Accredited program on notice of intent to withdraw accreditation

– Major and/or continuing non-compliance with one or more Standards which calls into question the educational environment and/or integrity of the program

– External review conducted by 3 people (2 specialists + 1 resident) within 24 months

– At the time of the review, the program will be required to show why accreditation should not be withdrawn.

Categories of Accreditation Definitions

SURVEY TEAM

ROYAL COLLEGESPECIALTY

COMMITTEE

ACCREDITATION COMMITTEE

Rep

ort

sR

ep

ort

s &

R

esp

on

ses

Recom

mendation

Reports

Responses

After the Survey

Report &Response UNIVERSI

TY

• Chair + 16 members• Ex-officio voting members (6)

– Collège des médecins du Québec (1)

– Medical Schools (2)

– Resident Associations (2)

– Regulatory Authorities (1)

•Observers (9)– Collège des médecins du Québec (1)

– Resident Associations (2)

– College of Family Physicians of Canada (1)

– Regulatory Authorities (1)

– Teaching Hospitals (1)

– Resident Matching Service (1)

– Accreditation Council for Graduate Medical Education (2)

The Accreditation Committee

•All pre-survey documentation available to the surveyor

•Survey report

•Program response

•Specialty Committee recommendation

•History of the program

Information Available to the Accreditation Committee

•Decisions

– Accreditation Committee meeting

• May/June 2014

• Dean & postgraduate dean attend

– Sent to• University• Specialty Committee

•Appeal process is available

The Accreditation Committee

“A” Standards• Apply to University, specifically the PGME office

“B” Standards• Apply to EACH residency program• Updated January 2011

“C” Standards• Apply to Areas of Focused Competence (AFC)

programs

General Standards of Accreditation

A1 University StructureA2 Sites for Postgraduate Medical

EducationA3 Liaison between University and

Participating Institutions

“A” Standards

B1 Administrative StructureB2 Goals & ObjectivesB3 Structure and Organization of the

ProgramB4 ResourcesB5 Clinical, Academic & Scholarly

Content of the ProgramB6 Assessment of Resident

Performance

“B” Standards

There must be an appropriate administrative structurefor each residency program.

• Program director• Time & support• Acceptable qualifications

• Residency Program Committee• Operation of the program• Program & resident evaluations• Appeal process• Selection & promotions of residents• Process for teaching & assessment of competencies• Research• Regular review of program• Faculty assessments

B1 – Administrative Structure

•Program director autocratic•Residency Program Committee

dysfunctional– Unclear Terms of Reference (membership, tasks

and responsibilities)• Agenda and minutes poorly structured• Poor attendance

– Department head unduly influential– RPC is conducted as part of a Dept/Div meeting

•No resident voice

B1 – Administrative Structure“Pitfalls”

There must be a clearly worded statement outlining the Goals & Objectives of the residency program.

• Rotation-specific• Address all CanMEDS Roles• Functional / used in:• Planning• Resident assessment

• Distributed to residents & faculty• Reviewed regularly• At least every 2 years

B2 – Goals and Objectives

B2 – Goals & Objectives“Pitfalls”

•Missing CanMEDS roles in overall structure

– Okay to have rotations in which all CanMEDS roles may not apply (research, certain electives)

•Goals and objectives not used by faculty/residents

•Goals and objectives dysfunctional – does not inform assessment

•Goals and objectives not reviewed regularly

There must be an organized program of rotations and other educational experiences to cover the educational

requirements of the specialty.

• Increasing professional responsibility• Senior residency• Service / education balance• Resident supervision• Clearly defined role of each site /

rotation• Educational environment

B3 – Structure & Organization

•Graded responsibility absent•Service/education imbalance

– Service provision by residents should have a defined educational component including evaluation

•Educational environment poor

B3 – Structure & Organization “Pitfalls”

There must be sufficient resources –Specialty-specific components as identified by

the Specialty Committee.

• Number of teaching faculty• Number of variety of patients,

specimens and procedures• Technical resources• Ambulatory/ emergency /community

resources/experiences• Educational

B4 - Resources

• Insufficient faculty for teaching/ supervision

• Insufficient clinical/technical resources• Infrastructure inadequate

B4 – Resources “Pitfalls”

The clinical, academic and scholarly content of the program must prepare residents to fulfill all the Roles of the

specialist.

• Educational program• Organized curriculum

- Content specific areas defined by Specialty Committee

• CanMEDS Roles• Teaching of the individual competencies

B5 – Clinical, Academic & Scholarly Content of Program

•Organized academic curriculum lacking or entirely resident driven

– Poor attendance by residents and faculty

•Teaching of essential CanMEDS roles missing

•Role modelling is the only teaching modality

B5 – Clinical, Academic & Scholarly Content of Program “Pitfalls”

There must be mechanisms in place to ensure the systematic collection and interpretation of assessment

data on each resident.

•Based on objectives

•Include multiple assessment techniques

•Regular, timely, formal

•Face-to-face

B6 – Assessment of Resident Performance

• Mechanism to monitor, promote, remediate residents lacking

• Formative feedback not provided and/or documented

• Assessments not timely, not face to face

• Summative evaluation (ITER) inconsistent with formative feedback, unclearly documents concerns/ challenges

B6 – Assessment of Resident Performance “Pitfalls”

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University of ManitobaOn-site Survey

February 23 to 28, 2014

accred@royalcollege.ca

613-730-6202

Office of Education

Sarah TaberAssistant Director

Education Strategy & Accreditation

Educational Standards Unit

Sylvie LavoieSurvey Coordinator

Contact Information at theRoyal College