Accreditation Briefing sheet
What is accreditation and why do we put ourselves through this process?
Accreditation is a voluntary process of continuous quality improvement
– not an exam
– you are provided with unbiased feedback from peers who face the same challenges in their own programs
– it is an ongoing dialogue between the programs, the College, external organizations
– it is an opportunity to promote your program’s strengths and discuss the challenges that it faces
– accreditation provides leverage to obtain missing resources
Maintaining the standards means maintaining excellent programs and producing competent family physicians
About the B-Standards
The general standards for the accreditation of postgraduate training programs = the “B standards”
They define the standards common to all postgraduate medical training in Canada
They were agreed to by the three postgraduate medical education accrediting agencies:
- The College of Family Physicians of Canada (CFPC),
- The Royal College of Physicians and Surgeons of Canada (RCPSC),
- The Collège des médecins du Québec (CMQ).
The Red Book is complementary to and consistent with the B standards and will clarify or expand on the
B standards as they relate to the education of family physicians.
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How do we begin to prepare?
The survey is a picture in time - Faculty and Residents should be prepared – all the participants need to be prepared and open - the feedback given to the accreditation team will help your program to continue to promote (work on) the areas of strength and, at the same time, focus on areas that need improvement.
To prepare the faculty and residents, ask them –
• What challenges do you want to be identified by the team?
• What strengths do you wish to highlight?
• What can accreditation do to improve your residency program? What resources do you need?
What will be the focus of the team during the visit?
General Standards of Accreditation – Redbook
Family Medicine – Scope of practice/ scope of experience / continuity
Enhanced Skills – Overarching program - Category 1 Programs/Category 2 Programs – Palliative medicine
Triple C /CanMeds-FM / Four principles of family medicine
Program Evaluation –

The process used for evaluating the program
• Internal review process
• On-going resident assessment
• Resident orientation and input
• Faculty evaluation from residents
Program Organization and Resources
• Adequate administrative structure
• Teaching practices
• Number of faculty (1 GFT per 4 residents)
• Continuity
Resident Issues
• Intimidation and Harassment – communication of protocols
• Involvement of residents in the governance structure
• Assessment/Evaluation of both resident performance and of educational experiences
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How does the Accreditation process work?
The Accreditation Committee makes a final decision on the program’s status and recommends follow-up to ensure CQI
Information about the FM program (PSQs) are sent from the
University to the CFPC
The University rectifies any factual errors and sends the report back to the Accreditation
Committee
The survey team visits the
FM program, makes a recommendation, writes a report, and sends it to the
University
Pre Survey Preparation
• This pre survey visit
• Pre survey documentation
• Preparation of Faculty and Residents
The CFPC organizes the accreditation visit
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Who comes to the accreditation survey?
• The Royal College – to visit the RC Specialty programs
• Members of the CFPC Accreditation Committee
• CFPC Survey Chair
• FM Program Directors from other universities
• Postgrad Office Reviewer
• Undergrad Office Reviewer
• Post-Grad Dean
• CAIR Representative
• FMRAC Representative
• CFPC Staff
Whom does the team meet from the University?
• Dean and Postgraduate Dean
• Department Chair and Program Director
• Chief residents in Family medicine and enhanced skills
• Key Faculty
• Teaching sites for Core FM
• Teaching Hospital Sites / Specialty teachers
• Community Practices
What about the Teaching Sites?
• Unit Director and Educational Director
• Residents
• Teachers
• Key Faculty including Non-Physician Teachers
• Unique Aspects of the Site
What about the Enhanced skills programs?
• Similar Agenda /Separate Schedule/ Surveyor(s) from the core team
• Overarching program
• FM/Emergency medicine – Care of the Elderly – FP-anesthesia - Clinician Scholar
• Palliative medicine
• All Category 1 programs and meet with the ES program committee plus residents from cat 1 and
2.
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How are we provided with the feedback?
• Team Report and Recommendations
• Program Response
• Committee decision
• Categories of Approval
• Appeal Process
The new categories of accreditation
In an effort to put stronger focus on continuous quality improvement, new terminology for the
Categories of Accreditation was recently approved by the Royal College, the CFPC, and the CMQ. A major change is the deletion of the word “provisional” from the terminology. The new terminology is:
 Accredited New Program
 Accredited Program
Follow-up of the Program will be by the following:

Regular External Survey in 6 years

Normal University-governed internal review required at mid-cycle
OR

Progress Report
OR

College-Mandated Internal Review
OR

External Review
 Accredited Program on Notice of Intent to Withdraw Accreditation
 Withdrawal of Accreditation
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Don’t forget –
• Family Medicine evolves and develops
• Resources Come and Go
• Guidelines change and develop between visits in response to many factors
• The guidelines and the programs change and adapt in response to one another.
But most importantly: the Accreditation Team is coming to help you improve your program………………
Sunday
Monday
Tuesday
Morning
Doc Review and Program Overview
Group 1 –Site Visit
Group 2 - Site Visit
Group 3 - Site Visit
Wednesday Group 1- Site Visit
Group 2 ES - Group 3
Group 3 - Site Visit
Thursday Group 1
Friday
Group 2
Group 3
All – Residency Training Committee (11am-
12pm)
Lunch with Program Director and Dept Chair
Exit FM
Conjoint Exit
Afternoon
RCPSC and CFPC Meetings
Doc Review and Program Overview
Group 1 – Site Visit
Group 2 - Site Visit
Group 3 - Site Visit
Group 1 - Site Visit
Group 2 ES – Category 2 Programs
Group 3 - Site Visit
CFPC Team together for Deliberation
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