university of toronto pre-survey meeting with department / clinical chairs
DESCRIPTION
University of Toronto Pre-Survey Meeting with Department / Clinical Chairs. Date: September 21, 2012 Time: 10:45 a.m. to 12:15 p.m. Room: Queen’s Park Ballroom Park Hyatt Hotel. Objectives of the Meeting. To review the: Accreditation Process New Categories of Accreditation - PowerPoint PPT PresentationTRANSCRIPT
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University of Toronto
Pre-Survey Meeting withDepartment / Clinical Chairs
Date: September 21, 2012
Time: 10:45 a.m. to 12:15 p.m.
Room: Queen’s Park BallroomPark Hyatt Hotel
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Objectives of the Meeting
To review the:• Accreditation Process• New Categories of Accreditation• Standards of Accreditation• Pilot Accreditation Process• Role of the:
– Program director
– Department / division chairs
– Residents
– Program administrators
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• 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
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•Based on General and Specific Standards
•Based on Competency Framework•On-site regular surveys•Peer-review• Input from specialists•Categories of Accreditation
The Accreditation Process
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The University of Toronto is one of three universities participating in a pilot accreditation process!
• Details for the pilot process will be discussed later in presentation
Pilot Accreditation Process
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Internal Reviews
1
2
34
5
6
Monitoring
Six Year Survey Cycle
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Process for Pre-Survey Questionnaires
Royal CollegeComments
Questionnaires
University
Specialty Committee
Questionnaires
Questionnaires &Comments
Program Director
Comments
Surveyor
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•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
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•Voting Members (chair + 5)– Canada-wide representation
•Ex-Officio Members– Chairs of exam boards– National Specialty Society (NSS)
•Corresponding Members– ALL program directors
Composition of a Specialty Committee
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• Chair - Dr. Kamal Rungta– Responsible for general conduct of survey
• Deputy chair – Dr. Anurag Saxena– Visits teaching sites / hospitals
• Surveyors • Resident representatives – CAIR
• Regulatory authorities representative – FMRAC
•Teaching hospital representative – ACAHO
The Survey Team
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•Revised questionnaire (PSQ) and appendices– Completed by program
•Program-specific Standards (OTR/STR/SSA)
•Report of last regular survey– Reports of mandated Royal College reviews 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
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•Document review (30 min)
• Residency Program Committee minutes• Resident assessment files
•Meetings with:• Program director (75 min)
• Department chair (30 min)
• Residents (per group of 20 - 60 min)
• Teaching staff (60 min)
• Residency Program Committee (60 min)
The Survey Schedule
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•Program director• Overall view of program• Address each Standard• Time & support
•Department chair• Support for program• Concerns regarding program• Resources available to program• Research environment
•Teaching faculty• Involvement with residents• Communication with program director
Meeting Overview
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•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
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•Survey team discussion– Evening following review
•Feedback to program director– Exit meeting with surveyor
•Morning after review– 07:30 – 07:45 at the Park Hyatt Hotel
– Survey team recommendation• Category of accreditation
• Strengths & challenges
The Recommendation
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New terminology • Revised and approved by the Royal College,
CFPC and CMQ in June 2012.
Categories of Accreditation
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Accredited program• Follow-up:
– Next regular survey – Progress report within 12-18 months (Accreditation
Committee)– Internal review within 24 months– External review within 24 months
Accredited program on notice of intent to withdraw accreditation
• Follow-up:– External review conducted within 24 months
Categories of Accreditation
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• Accredited program with follow-up at next regular survey
– Program demonstrates acceptable compliance with standards.
Categories of Accreditation Definitions
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• 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
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• 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
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• 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
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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
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• 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
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•All pre-survey documentation available to surveyor
•Survey report
•Program response
•Specialty Committee recommendation
•History of the program
Information Available to the Accreditation Committee
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•Decisions
– Accreditation Committee meeting
• October 2013
• Dean & postgraduate dean attend
– Sent to• University• Specialty Committee
•Appeal process is available
The Accreditation Committee
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“A” Standards• Apply to University, specifically the PGME office
“B” Standards• Apply to EACH residency program• Updated January 2011
General Standards of Accreditation
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Standards for University & Education SitesA1 University Structure
A2 Sites for Postgraduate Medical Education
A3 Liaison between University and Participating Institutions
“A” Standards
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Standards for EACH residency programB1 Administrative Structure
B2 Goals & Objectives
B3 Structure and Organization of theProgram
B4 Resources
B5 Clinical, Academic & Scholarly Content of the Program
B6 Assessment of Resident Performance
“B” Standards
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There must be an appropriate administrative structurefor each residency program.
• Qualifications of, and support for program director• Membership = resident(s) + faculty
• Responsibilities• Operation of program• Program & resident evaluations• Appeal process• Selection of candidates• Process for teaching & evaluating competencies• Research
B1 – Administrative Structure
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•Program director autocratic•Residency Program Committee
dysfunctional– Unclear Terms of Reference (membership,
tasks and responsibilities)• Agenda and minutes poorly structured• Poor attendance
– Department chair unduly influential– RPC is conducted as part of a Dept/Div
meeting
•No resident voice
B1 – Administrative Structure“Pitfalls”
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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 evaluation
• Distributed to residents & faculty
B2 – Goals and Objectives
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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 evaluation
•Goals and objectives not reviewed regularly
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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 responsibilities, service /
education balance• Resident supervision• Clearly defined role of each site /
rotation• Educational environment
B3 – Structure & Organization
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•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”
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There must be sufficient resources –Specialty-specific components as identified by
the Specialty Committee.
• Number of teaching faculty• Number of variety of patients and
operative procedures• Technical resources• Resident complement• Ambulatory/ emergency /community
resources/experiences
B4 - Resources
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• Insufficient faculty for teaching/ supervision
• Insufficient clinical/technical resources• Infrastructure inadequate
B4 – Resources “Pitfalls”
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The clinical, academic and scholarly content of the program must prepare residents to fulfill all Roles of the specialist.
• Educational program• Curriculum / structure
- Content specific areas defined by Specialty Committee
• CanMEDS Roles• Teaching of the individual
competencies• Resident / faculty participation in
conferences
B5 – Clinical, Academic & Scholarly Content of Program
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•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”
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There must be mechanisms in place to ensure the systematic collection and interpretation of evaluation
data on each resident.
• Assessment must be -• Regular, timely, formal• Face-to-face• Based on objectives• Include multiple evaluation techniques
B6 – Assessment of Resident Performance
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• Mechanism to monitor, promote, remediate residents lacking
• Formative feedback not provided and/or documented
• Evaluations not timely (particularly when serious concerns identified), not face to face
• Summative evaluation (ITER) inconsistent with formative feedback, unclearly documents concerns/ challenges
B6 – Evaluation of Resident Performance “Pitfalls”
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What are the processes in place to resolve problems / issues?
Appropriate faculty / resident interaction and communication must take place in an open and collegial atmosphere so
that a free discussion of the strengths and challenges of the program can
occur without hindrance.
Learning Environment
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Scheduled from April 7 to 12, 2013 • PGME and teaching sites – A Standards
• Residency programs – B Standards
Pilot Accreditation Process
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ALL residency programs• Complete PSQ• Undergo a review, either by
– On-site survey, or– PSQ/documentation review, and input from various
stakeholders
Process varies depending on group• Mandated for on-site survey• Eligible for exemption from on-site survey• Selected for on-site survey
Pilot Accreditation Process
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Scheduled for On-site Reviewin April 2013
Criteria• Core specialties
– General Surgery, Internal Medicine, Obstetrics & Gynecology Pediatrics, Psychiatry
• Palliative Medicine– Conjoint Royal College/CFPC program
• Program Status– Not on full approval since last regular survey– New program which has not had a mandated internal
review conducted
Programs Mandated for On-site Survey
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Process remains the same• PSQ Review
– Specialty Committee
• On-site survey by surveyor• Survey team recommendation• Survey report• Specialty Committee• Final decision by Accreditation Committee
– Meeting in October 2013– Dean & postgraduate dean attend
Process for Programs Mandated for On-site Review
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Criteria• Program on full approval since last regular
on-site survey
Programs Eligible forExemption from On-site Review
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• PSQ and documentation review– Accreditation Committee reviewer– Specialty Committee
• Recommendations to exempt– Accreditation Committee reviewer– Specialty Committee– Postgraduate dean– Resident organization (CAIR)
• Steering Committee (AC) Decision– Review of recommendations
•Exempted: on-site survey not required•Not exempted: program scheduled for on-site survey in April
– Selected program (random)– University notified in January 2013
Process for Programs Eligible for Exemption
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613-730-6202
Office of Education
Margaret KennedyAssistant Director
Accreditation & Liaison
Educational Standards Unit
Lise DupéréManager
Sylvie LavoieSurvey Coordinator
Contact Information at theRoyal College
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