accreditation information session
TRANSCRIPT
Accreditation Information Session
Mr. Denis LalibertéTeam Lead, Survey Deployment
Royal College of Physicians and Surgeons of Canada
Dr. Michael GousseauBoard Member, Canadian Association of Internes & Residents
PGY 3 Otolaryngology Head and Neck Surgery
University of Manitoba
Ms. Judith ScottAccreditation Manager
College of Family Physicians of Canada
Provincial Association of Resident Physicians of Alberta
Assembly Meeting
August 26, 2014
• What is accreditation?
• The accreditation process of postgraduate medical
education (PGME)
• The role of residents in the accreditation process
• What happens before, during and after the accreditation
visit?
• How can we prepare?
Accreditation of Family Medicine and Royal
College residency programs will take place at
the University of Calgary, February 22-27,
2015.
• A peer-reviewed process of continuous quality
improvement
• Based on Standards common to all postgraduate medical
training programs in Canada
Residents play an integral role in the Accreditation
process in Canada
• An opportunity to promote your program’s strengths and
identify areas for improvement
…meant to improve the quality of residency
education by seeking to ensure that all necessary
resources are available and utilized efficiently and
effectively to enable residents to meet the training
requirements of their specialty, subspecialty or area
of focused competence
Accreditation is NOT a test
Accreditation has no bearing on your FITER
A resident would not lose their position due to
accreditation status
Internal Reviews
1
2
34
5
6
Ongoing
Monitoring
The PGME accreditation process in Canada is based on a system of
regular formal full University survey visits that occur every six years
“A” Standards
◦ Apply to University, specifically the office of the
Postgraduate Dean and Educational sites
“B” Standards
◦ Apply to EACH residency program
“C” Standards
◦ Apply to Areas of Focused Competence (AFC)
programs (Royal College only)
Pre-Survey visit - the Colleges meet with the Programs
and chief residents in September 2014.
Pre-Survey documentation for the Survey Team is
prepared. These include:
◦ Pre-survey questionnaires (PSQs) completed by the programs
◦ Program-specific Standards (OTR/STR/SSA)
◦ Report of last regular survey
◦ Exam results for last six years
◦ Reports of mandated CFPC and Royal College reviews since last
regular survey, if applicable.
As part of the accreditation process, PARA will send the CAIR
pre-accreditation questionnaire in the Fall to residents in a Royal
College or Family Medicine program at the University of Calgary.
This questionnaire is specifically designed to obtain your
perspective on your training. Results are confidential,
anonymous and NOT given to the survey team, your program or
faculty.
PARA collates the results and the report is provided ONLY to the
resident representatives on the Royal College and CFPC Survey
teams.
Recommendations:
• Create a Resident Team at PARA with responsibility for
finalizing the Pre-accreditation report that will be made
available to the resident surveyors
• Publicize accreditation EARLY & provide CAIR
Accreditation Manual to members
• Survey on-line and send multiple reminders
• Offer to meet with residents by program or during half-
days.
Composition of the Royal College and CFPC Survey Teams:
• Chair/Deputy Chair
• Surveyors (Specialists from a variety of disciplines)
• Resident Representatives (CAIR)
• Regulatory Authority Representative (FMRAC)
• Teaching Hospital Representative (HealthCareCAN,
formerly ACAHO)
Survey Team reviews documents (Residency Program
Committee Minutes, Pre-Survey Documentation etc.)
Survey Team meets with:
1. Program Director
2. Department head
3. Teaching faculty
4. Residents
5. Residency Program Committee
Program director
◦ Overall view of program
◦ Evidence on how program is meeting the Standards
◦ Response to previous challenges
Department head
◦ Support for program
◦ Resources available to program
Teaching faculty
◦ Involvement with residents
◦ Communication with program director
• Group(s) of 20 residents [Tele-or video- conferencing options if
off-site]
• Looking for balance of strengths & challenges; focus on
Standards
• Of all the meetings, the time with the residents has perhaps the greatest influence on the surveyors
One caution is to ensure that there are no significant surprises for surveyors. Serious concerns should have been raised previously (Residency Program Committee, University-led Internal Review, or the pre-accreditation questionnaire).
Environment for residency education
• Service to education balance
• Educational environment
• Supervision
• Resident orientation and input
How program supports residents to achieve
competencies
• Objectives of training
• On-going assessments of resident performance
• Increasing professional responsibility
• Academic program / protected time
• Program evaluation
• Career counseling; Safety; Intimidation and harassment
Survey team discussions occur every evening following meetings.
Feedback is provided to the program director
o Exit meeting with surveyors
o Survey team recommendation• Category of accreditation
• Strengths & weaknesses
1. Accreditation is your opportunity to openly and honestly evaluate,
and help improve the quality of your residency program with
complete anonymity.
2. The feedback given to the survey team will help your program to
continue to promote areas of strength and at the same time,
focus on areas that need improvement.
3. Be prepared to answer key questions during the survey team visit:
o What program strengths do you wish to highlight?
o What are the areas that need improvement?
o What can accreditation do to improve your residency program?
o What resources do you need?
4. Concerns about a training program should be identified by
residents prior to the survey visit (for example, Residency
Program Committee, University-led Internal Review, the pre-
accreditation questionnaire).
5. The survey team will meet with every resident (in small groups)
during the survey visit in February.
6. Residents should meet as a group prior to the survey visit in
February to set priorities for discussion with the accreditors,
establish speakers, and provide examples and documentation.
7. Complete the CAIR pre-accreditation questionnaire!
SURVEY TEAM
ROYAL COLLEGE
ROYAL COLLEGE
SPECIALTY
COMMITTEE
ROYAL COLLEGE
ACCREDITATION COMMITTEE
{DECISION}
Reports
Reports
Responses
Report &
Response UNIVERSITY
Reports &
Responses
SURVEY TEAMCOLLEGE OF FAMILY
PHYSICIANS OF CANADA
CFPC ACCREDITATION
COMMITTEE {DECISION}
Reports
Reports &
Responses
Reports
ResponsesUNIVERSITY
How are we provided with the feedback?
• Survey Team Report and Recommendations
• Program Response
• Accreditation Committee deliberation and decision [Dean &
postgraduate dean attend]
• Categories of Approval
• Appeal Process is available
Reports sent to
• University
• Specialty Committee (Royal College)
• Survey report
• All documentation available to the surveyor
• Program response
• Specialty Committee recommendation
• History of the program
• Discussion with the Dean and the Postgraduate
Dean
New terminology –
Approved by the Royal College, CFPC and CMQ,
June 2012
Accredited program
• Follow-up:
o Next regular survey
o Progress report (Accreditation Committee)
o Internal review
o External review
Accredited program on notice of intent to withdraw
accreditation
• Follow-up:
o External review
Accredited program with follow-up at next regular
survey
o Program demonstrates acceptable compliance with
standards.
Accredited program with follow-up by College-
mandated internal review
o Major issues identified in more than one Standard
o Internal review of program required and conducted
by University
o Internal review due within 24 months.
Accredited program with follow-up by external reviewo 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.
o External review conducted within 24 months
o College appoints a three-member review team (2
specialists + 1 resident)
o Same format as regular survey
Accredited program on notice of intent to withdraw
accreditation
o Major and/or continuing non-compliance with one or more
Standards which calls into question the educational
environment and/or integrity of the program
o External review conducted by three people (2 specialists + 1
resident) within 24 months
o At the time of the review, the program will be required to
show why accreditation should not be withdrawn.
Residents are critical to the process, and your input is
highly valued.
Accreditation is an ongoing dialogue between the
programs, the College, external organizations.
Maintaining the standards means maintaining excellent
programs and producing physicians who are ready for
practice.
Accreditation provides residents the mechanism to effect
positive changes on their residency programs that in many
situations will result in significant long-term benefits.
Dr. Michael Gousseau
CAIR Board Member
PGY 3 Otolaryngology Head and Neck Surgery
University of Manitoba
Mr. Denis Laliberté
Team Lead, Survey Deployment
Royal College of Physicians and Surgeons of Canada
Ms. Judith Scott
Accreditation Manager
College of Family Physicians of Canada
Any questions?