Date:
Time:
July 3, 2013
2:00 to 4:00 p.m.
Room: Pharmacy Apotex, Theatre # 264

Objectives of the Meeting
• Provide an overview of
• Accreditation Process
• Questionnaire and Appendices
• Schedule
• Standards
• Opportunity to network with colleagues

• Who has been involved in a survey process?
• Last regular survey in 2008
• External review
• Internal review

Accreditation
• Is a process to:
• Improve quality of postgraduate medical education
• Provides a means for assessment of residency programs
• Assists program director in reviewing conduct of program
• Based on Standards

5
Six Year Survey Cycle
6 1
4
Internal Reviews
3
2

Pre-Survey Process
Specialty
Committee
University
Questionnaires
Questionnaires
Comments
Royal College
Comments
Program
Director
Questionnaires &
Comments
Surveyor

Questionnaire and Appendices
• First impression of the program by the surveyor is the questionnaire and appendices
• All sections of the questionnaire are complete
• Error-free vs typos
• Neat vs sloppy
• Clear descriptions vs confusing information
• Spell out abbreviations

Questionnaire and Appendices
When submitting your questionnaire and appendices please format and name them as follows:
Questionnaire
• Each individual section (i.e. each standard) is submitted as a separate PDF file
• The files are named as:
• General_Information.pdf, Standard_B1.pdf,
Standard_B2.pdf, etc.

Questionnaire and Appendices
Appendices
• For each appendix, the name of the appendix (e.g.
Appendix A) is clearly indicated on the first page.
• Each individual appendix is submitted as a separate
PDF file.
• The files are named as: Appendix_A.pdf,
Appendix_B.pdf, etc.
• Any additional attachments are labelled/formatted as above with the name corresponding to the appendix name as listed in the General Information section of the PSQ (e.g. Appendix_K.pdf,
Appendix_L.pdf, Appendix_M.pdf, etc.)

The Survey Schedule
• Review – Length & Day
• Based on
• Number of residents in program
• Traveling to different sites
• Last schedule in 2008
• Coordinated by the Royal College and PGME office
• Inform PGME office if you foresee a scheduling conflict
• PGME office will notify the program of the day of the review
 Surgical Foundations will be reviewed on Monday morning.

The Survey Schedule
• Transportation
• Arranged by program
• Include details
• Name & contact info for person responsible
• Morning
• Pick-up at 07:45 a.m.
•
At the Fairmont Winnipeg
• To and from different sites
• When required during review
• Afternoon
• Survey must end no later than 4:00 p.m.
•
At the Fairmont Winnipeg

The Survey Schedule
• Sequence to follow
• Document review
(30 min)
• Program director
(75 min)
• Department head *
(30 min)
• Residents *
(per group of 20 - 60 min)
• Teaching faculty *
(60 min)
• Residency Program Committee
(60 min)
• Exit Meeting
(15 min)
• Morning after the review concluded
• 07:30-07:45 a.m. at the Fairmont Winnipeg
* Scheduled anytime after program director but before RPC

The Survey Schedule
Document Review
(30 min)
• Scheduled at beginning of schedule
• Available in meeting room
• Residency Program Committee minutes - last 6 years
• Resident assessment files
•
If automated, arrange access to a computer, make sure that it is easy to navigate and retrieve
•
Provide assistance/demo
• Remember surveyors have limited time to review the documents on-site

The Survey Schedule
• Program director
(75 min)
• Scheduled after document review
• To discuss
• Overall view of program
• Evaluation of Standards
• Strengths, challenges and weaknesses
• Specialty Committee Comments
−
Sent by email to program director week prior to on-site visit

The Survey Schedule
• Department head
(30 min)
• Scheduled anytime after program director but before RPC
• To discuss
• Support for program director and program
• Resources available to program

The Survey Schedule
• Residents
(60 min)
• Scheduled anytime after program director but before RPC
• Groups of 20 residents
−
Can be organized in various groups


By postgrad year
By Junior & Senior years
• Encourage residents to:
• Complete the ‘confidential’ CAIR questionnaire
• Sent by CAIR
• Meet as a group to discuss strengths & challenges prior to visit
• Send reminders – date, time, locations

The Survey Schedule
• ALL residents invited to attend/participate in their resident meeting(s)?
• Residents who cannot attend
• Arrange link by video- or tele- conferencing
• Different funding / title across Canada
• For accreditation purposes only, a resident is a person who is following the same academic program/training as a resident eligible to write College exams – funding doesn’t matter !

The Survey Schedule
• Teaching faculty
(60 min)
• Scheduled anytime after program director but before RPC
• To discuss
• Involvement with residents
• Communication with program director
• Teaching faculty who sit on RPC need only attend RPC meeting

The Survey Schedule
• Tours
(15 min)
• Optional
• Tours of wards/clinics not necessary
• Is there something special to showcase?
• MUST be scheduled before RPC

The Survey Schedule
• Residency Program Committee
(60 min)
• Program director attends first half of meeting
• Resident representative(s) attend the meeting
• Smaller programs
• Often faculty all sit on RPC
• Can combine faculty & RPC together into one meeting
• MUST be scheduled as LAST meeting of review

The Survey Schedule
• Survey Team Discussion
• Your program will be discussed the evening of the day that your review ends
• Identify the strengths & weaknesses
• Provide a recommendation

The Survey Team
• 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 Schedule
• Approved by the Royal College, CFPC and CMQ.
• Recommendation
• 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

The Survey Schedule
• Exit Meeting
(15 min)
• Morning after review
• 07:30 – 07:45 a.m.
• At the Fairmont Winnipeg
• Program director will be informed
• Survey team recommendation
• Strengths & weaknesses of program

The Survey Schedule
BE PROACTIVE
• Start early
• Share the information with your program director
• Make a plan and set timelines
• Create and use your own checklist
• Consult with the PGME office
• In doubt: ask questions

Day of the Survey
• Be available to assist the surveyors as needed.
• ‘Do Not Disturb – Meeting in Progress’ sign on door.
• Ensure that the surveyors are comfortable (i.e.: private room, water, a layout of the area, etc.)
• Arrange for beverages, healthy snacks for breaks and a lunch, when appropriate.
• Organize all the required documents in the room and ensure that there is a computer with internet access available to the reviewers.
• Retrieve all confidential documents from the room(s) at the end of the day.

After the Survey
• Final exit with University
• Friday, February 28, 2014 between 9:00 and 10:00 a.m.
• CFPC/Royal College Chairs present a summary of survey week
• Survey reports sent to PGME
• 6 to 8 weeks post-survey
• Program response sent to College
• Report any errors of fact only
• Accreditation Committee Decisions
• May/June 2014
• Dean & postgraduate dean attend
• Appeal process is available

General Standards of
Accreditation
“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

“A” Standards
• Applicable to the University
• Reviewed by chair’s team
(Team A)
• Schedule organized by PGME office
• Looking at
• Structure in place
• Training sites
• Liaison with hospitals

“B” Standards
• Applicable to ALL programs
• Reviewed by surveyors
• Looking at
B1 Administrative Structure
B2 Goals & Objectives
B3 Structure and Organization
B4 Resources
B5 Clinical, Academic & Scholarly Content
B6 Assessment of Resident http://www.royalcollege.ca/portal/page/portal/rc/common/documents/accreditation/ac creditation_blue_book_b_standards_e.pdf

B1 – Administrative Structure
•
•
There must be an appropriate administrative structure for each residency program.
•
Program director
Time & support
•
•
•
•
•
•
•
•
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
“Pitfalls”
• 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

B2 – Goals and Objectives
There must be a clearly worded statement outlining the
Goals & Objectives of the residency program.
•
•
•
•
•
•
•
Planning
Resident assessment
•
At least every 2 years

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

B3 – Structure & Organization
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
“Pitfalls”
• Graded responsibility absent
• Service/education imbalance
– Service provision by residents should have a defined educational component including evaluation
• Educational environment poor

B4 - Resources
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 “Pitfalls”
• Insufficient faculty for teaching/ supervision
• Insufficient clinical/technical resources
• Infrastructure inadequate

B5 – Clinical, Academic &
Scholarly Content of Program
The clinical, academic and scholarly content of the program must prepare residents to fulfill all the Roles of the
specialist.
•
•
•
Organized curriculum
-
Content specific areas defined by Specialty Committee
•
Teaching of the individual competencies

B5 – Clinical, Academic & Scholarly
Content of Program “Pitfalls”
• 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
• The surveyor will be verifying that the content of the academic curriculum covers all the of the CanMEDS Roles.

B6 – Assessment of Resident
Performance
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 “Pitfalls”
• 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

44

Contact Information at the
Royal College accred@royalcollege.ca
613-730-6202
Office of Education
Sarah Taber
Assistant Director
Education Strategy & Accreditation
Educational Standards Unit
Sylvie Lavoie
Survey Coordinator