University of ManitobaPre-Survey Meeting with
Department Heads
Date: July 4, 2013Time: 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
Repo
rts
Repo
rts
&
Resp
onse
s
Recommendation
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
Office of Education
Sarah TaberAssistant Director
Education Strategy & Accreditation
Educational Standards Unit
Sylvie LavoieSurvey Coordinator
Contact Information at theRoyal College