Pre-survey Meeting withResident Representatives &

Senior Residents

Date: September 12, 2012 at 10:30 a.m.Osler Amphitheatre

McGill University

Objectives of the Meeting

To review the:• Accreditation Process• Categories of Accreditation• Standards of Accreditation• Role of residents in the accreditation

process• Pilot accreditation process

Conjoint Visit

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•Planning•Organization•Conduct•Share the cost•One decision taken at the Royal College

Accreditation Committee

Collège des médecins du Québec

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Mission• To promote quality medicine so as to protect the public

and help improve the health of Quebecers.Since 1847• In Quebec, legal responsibility for the accreditation of

residency programs is assigned to the CMQ pursuant to regulations made under the Loi médicale and the Code des professions.

Royal College of Physicians and Surgeons of Canada

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Mission• To improve the health and care of Canadians by leading in

medical education, professional standards, physician competence and continuous enhancement of the health system.

Since 1929• A special Act of Parliament established The Royal College

of Physicians and Surgeons of Canada to oversee postgraduate medical education for medical and surgical specialties.

What is Accreditation

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Accreditation is a mechanism for evaluating residency programs and institutions in order to ensure the quality of

postgraduate medical education.

• It makes it possible to verify:• That appropriate objectives are set• That resources necessary to the attainment

of objectives are available• That objectives are effectively attained and

will continue to be attained

Principles of Accreditation

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• Continuing quality improvement process• Peer-reviewed• Based on Standards• Categories of Accreditation

Pilot Accreditation Process

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McGill University is one of three universities participating in a pilot accreditation process!

• Survey will be conducted in two distinct parts:

– A Standards review– B Standards review

• Details for the pilot process will be discussed later in presentation

Six-Year Survey Cycle

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2

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5

6

Monitoring

Internal Reviews

Process for Pre-Survey Questionnaires

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Royal CollegeComments

Questionnaires

University

Specialty Committee

Questionnaires

Questionnaires &Comments

Program Director

Comments

Surveyor

The Survey Team

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• Chair - Dr. Mark Walton– Responsible for general conduct of survey

• Surveyors • Resident representatives – FMRQ• Regulatory authorities representative -

CMQ

Information Given to Surveyors

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•Questionnaire (PSQ) and appendices– Completed by program

•Program-specific Standards (OTR/STR/SSA)

•Report of last regular survey•Specialty Committee comments

– Also sent to PGD / PD prior to visit•Exam results for last six years•Reports of mandated Royal College/CMQ

reviews since last regular survey, if applicable

The Survey Schedule

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Includes:• Document review (30 min)

• Meetings with:– Program director (75 min)– Department chairs (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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Document review (30 min)• Residency Program Committee Minutes• Resident Assessments

Meeting Overview

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•Program director• Overall view of program• Evaluation of Standards

•Department chair• Support for program• Resources available to program

•Teaching faculty• Involvement with residents• Communication with program director

Meeting with ALL Residents

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•Group(s) of 20 residents (60 min)

• If off-site, tele- or video- conferencing•Looking for balance of strengths &

weaknesses•Focus on Standards•Evaluate the learning environment

Meeting with ALL Residents

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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 Residency Program Committee

Resident representative(s) to attend• Review Committee responsibilities• Functioning appropriately• Opportunity for surveyor to provide

feedback on information obtained during survey

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The Recommendation

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•Survey team discussion– Evening following review

•Feedback to program director– Exit meeting with surveyor

•Morning after review– Between 07:30 – 07:45

– Survey team recommendation• Category of accreditation• Strengths & weaknesses

Categories of Accreditation

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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 AccreditationDefinitions

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• Accredited program with follow-up at next regular survey

– Program demonstrates acceptable compliance with standards.

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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 AccreditationDefinitions

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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 AccreditationDefinitions

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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 AccreditationDefinitions

After the Survey

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SURVEY TEAM

ROYAL COLLEGESPECIALTY COMMITTEE

UNIVERSITY

ACCREDITATION COMMITTEE

Repo

rts

Repo

rts

&

Resp

onse

s

Recommendation

Reports

Responses

Report &Response

The Accreditation Committee

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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)

Information Available to 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

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•Decisions– Accreditation Committee meeting

• June 2013• Dean & postgraduate dean attend

– Sent to• University• Specialty Committee

•Appeal process is available

The Accreditation Committee

Preparing for the Survey Role of the Resident

• Complete the FMRQ questionnaire • Confidential, not given to survey team

•Meet together as a group to discuss the strengths & weaknesses of your program • 1 to 2 months before survey

•Obtain a copy of the pre-survey questionnaires (PSQ) and the previous survey report

• If you feel you need more time with surveyor, request it

•Be open and honest with surveyor• Comments in meetings are anonymous

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Role of the Resident in the Accreditation Process

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•Program Administration• Member of the Residency Program Committee• Must be elected• Communication to and from Residency Program Committee

• Residency programs• Evaluation of the program• Rotations, teachers, teaching

• Understand the Standards

General Standards of Accreditation

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“A” Standards• Apply to University, specifically the PGME office

“B” Standards• Apply to EACH residency program• Updated January 2011

“B” Standards

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Standards for EACH residency programB1 Administrative StructureB2 Goals & ObjectivesB3 Structure and Organization of the

ProgramB4 ResourcesB5 Clinical, Academic & Scholarly

Content of the ProgramB6 Assessment of Resident Performance

B1 – Administrative Structure

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There must be an appropriate administrative structurefor each residency program.

• Program director• Time & support

• Residency Program Committee• Representative from each site and major

component• Resident member(s)

- Must include at least ONE elected resident• Meets regularly, four times a year

- Minutes

•Responsibilities of the Residency Program Committee• Selection, evaluation & promotion of residents• Ongoing review of program• Assessment of program / teachers / rotations• Research environment• Appeal mechanism• Career & stress counseling• Resident safety

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B1 – Administrative Structure

B2 – Goals and Objectives

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There must be a clearly worded statement outlining the goals of the residency program and the educational objectives of the

residents.

• Rotation-specific• Structure to reflect CanMEDS Roles• Circulated to residents & teaching staff• Used in planning and assessment of

residents

CanMEDS Roles

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•Medical Expert•Communicator•Collaborator•Manager•Health Advocate•Scholar•Professional

B3 – Structure & Organization

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There must be an organized program of rotations and other educational experiences, both mandatory and elective,

designed to fulfill the educational requirements and allow residents to achieve competence in the specialty.

• Include all components of specialty• Equal opportunity

• Increasing professional responsibility•Appropriate independence as residents

progress•Supervision•Call•Service / education balance•Educational environment

• Promote resident safety• Free from intimidation, harassment or abuse

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B3 – Structure & Organization

B4 – Resources

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There must be sufficient resources to provide the opportunity for all residents to achieve the educational objectives.

• Teaching faculty• Variety & number of patients• Physical and technical facilities• Inpatient, ambulatory, emergency, ICU• Organized• Supervised

B5 – Clinical, Academic & Scholarly Content of Program

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There must be a clinical, academic and scholarly program that prepares residents to fulfill all the roles of the specialist.

• Organized academic program• Academic half-day, journal club

• Address the CanMEDS competencies• Attendance

• Staff, residents• Provide teaching

• Something more than observation and role modeling is expected

B6 – Assessment of Resident Performance

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There must be mechanisms to ensure systematic assessment of each resident.

• Based on goals & objectives• Uses appropriate and varied assessment

methods• Feedback

• Formal, timely, appropriate• Face-to-face• Adequately documented

PilotAccreditation Process

Conducted in two separate visits • PGME and teaching sites – A Standards

– November 25-27, 2012• Residency programs – B Standards

– March 17-22, 2013

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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

stakeholdersProcess varies depending on group• Mandated for on-site survey• Eligible for exemption from on-site survey• Selected for on-site survey

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PilotAccreditation Process

Scheduled for On-site Reviewin March 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

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Programs Mandated for On-site Survey

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 June 2013– Dean & postgraduate dean attend

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Process for Programs Mandated for On-site Review

Criteria• Program on full approval since last regular on-site

survey

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Programs Eligible forExemption from On-site Review

• PSQ and documentation review– Accreditation Committee reviewer– Specialty Committee

• Recommendations to exempt– Accreditation Committee reviewer– Specialty Committee– Postgraduate dean– Resident organization (FMRQ)

• Steering Committee (AC) Decision– Review of recommendations

•Exempted: on-site survey not required•Not exempted: program scheduled for on-site survey in March

– Selected program (random)– University notified in December 2012

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Process for Programs Eligible for Exemption

Contact Information

ROYAL COLLEGE

accred@royalcollege.ca613-730-6202

Office of EducationMargaret KennedyAssistant DirectorAccreditation & LiaisonLise DupéréManager, Educational Standards UnitSylvie LavoieSurvey Coordinator

COLLÈGE DES MÉDECINS DU QUÉBEC

mlamer@cmq.org514-933-4441

Direction des études médicalesDr. Anne-Marie MacLellanDirector

Marjolaine LamerCoordinatorMélanie CaronAccreditation Agent

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