Version 05.10.2019

Accreditation Management System (AMS) Guide 2019

The purpose of this guide is to support residency programs completing their program instrument in the Accreditation Management System (AMS). Instrument replaces the pre-survey questionnaire (PSQ) that programs traditionally

completed prior to a review. Program information is now entered into an online system that is managed by the Royal College. The design of the instrument was developed by a group composed of the Royal College of Physicians &

Surgeons of Canada, College of Family Physicians of Canada, and Collège des Médecins du Québec, named CanERA (Canadian Excellence in Residency Accreditation). Visit the CanERA home page at http://www.canera.ca/canrac/home-e for more information.

The benefit of this system is that rather than an intensified effort to complete PSQs a few months prior to a review,

the maintenance of program information is continual throughout the accreditation cycle (timeline between college on-site surveys). The expectation is, after the initial loading of required documents and information, the AMS will be updated regularly as changes are made to residency programs. e.g. updated academic activities, RPC meeting

agendas, committee membership, updated policies, etc.

The AMS system will be used for 2019-2020 McMaster Internal Reviews. When the AMS system becomes available programs will be asked to sign in and complete their instrument. Each question should be read carefully and answered accordingly. This document is a reflection of

the quality of the program and sets the tone of the meetings that occur during the internal review.

How to use this guide: Guide Left Column is what programs will complete in the AMS and has templates if that can be used. For

documents common to some or all programs, a link provided.

Guide Right Column provides the number of the related Accreditation Standard(s) available at

http://www.canera.ca/canrac/general-standards-e and comments, suggestions, and notes to guide program’s

responses in the left column.

If you have any questions while completing the AMS instrument, contact:

Brenda Montesanto for process questions: bmontes@mcmaster.ca

Margaret Ackerman for content questions: mackerma@mcmaster.ca

Version 05.10.2019

Page 2 of 31

Visit CanERA for training, tools & support

frequently asked questions

The Basics Click Here

Navigating CanAMS

Logging in

Changing password

The Standards Click Here

Access the standards

Documents Click Here

Access, upload & remove documents

Working with Instruments Click Here

Working with required documents (evidence)

Working with tables

Adding comments

Working with reference documents

Formatting answers & adding hyperlinks

Managing of assignees

The above links can be found at

http://www.royalcollege.ca/mssites/canera-

uprh/index.html#/

Tips When Naming Files

Try to keep file name short and consistent. Justenough to identify the files contents

Use standard abbreviations, example RPC (residencyprogram committee), ToR (terms of reference)

Use _underscore _ to_separate_words_ or elements

Don’t use spaces or other characters or unnecessarywords such as: and, as, the, at, a, to

Date all documents

Ensure file extension is displayed when saving files

(eg. Doc, .docx, pd, jpg)

Where applicable identify draft with Dft

Examples Curriculum_Plan_20190122.pdf,

Scholarship_ Faculty_20190225.pdf.ToR_RPC_20181015.pdf

Hyperlinks

Use hyperlinks to documents that are stored onlinee.g. PGME policies,

Be sure to test links in your documents periodically

Hyperlinks should take you directly to the document

and not to a site that contains the document.

Hyperlinks should not be password protected.

Templates provided by the College

If there is a template provided by the college, in somecases, you can choose to substitute your document if

it contains all the elements of the template.

1

2

4

3

Update templates-Since the release of the system it was discovered that the curriculum plan template was not made available in CanAMS. The college is currently updating this template; however, a version is available at https://pgme.mcmaster.ca/digital-accreditation-management-system/

Version 05.10.2019

Page 3 of 31

AMS Guide

Program Information Entry Completed

Date:________________

Sections of the AMS Comments, suggestions, notes

Numbers indicate the Standard

Sites

Fill out in the AMS

Site Site

Coordinator

Distribution of Residents by Site

Year

1

Year

2

Year

3

Year

4

Year 5 or

above

Clinical

Fellows

Definition: Clinical Fellows are in

programs that do NOT lead to

certification by the Royal College.

Subspecialty learners e.g. Cardiology,

Geriatric Psychiatry, Maternal Fetal

Medicine are considered to be residents

as the training leads to certification.

Recommendation: if there are clinical

fellows or AFC trainees, add a comment

in the resource section on how

competition for resources is managed or

avoided.

Policies Entry CompletedDate:________________

Resident Assessment and Promotion

Copy the following links to AMS, ‘Additional Information or reference’ column:

Evaluation, Assessment & Appeals

Policy on Assessment of Learners (PGEC 2019) Appeals Process (PGEC 2009)

5.1.1

This is a list taken from the PGME web site that are

common to all programs. Choose those appropriate to

your program.

In the AMS also Include policies that are program specific

e.g. Promotion and Appeals process used by your

program.

Version 05.10.2019

Page 4 of 31

Learning Environment

Resident Supervision

Supervision of Clinical Activities of Postgraduate Learners (PGEC

2015)

Permitted Activities for McMaster Medical Learners (2012)

5.1.1

Health & Safety

PGME Health & Personal Safety Policy (PGEC 2011)

Communicable Diseases Policy (FHS 2016)

Guidelines for the Support of Learners in Clinical Placements (FHS

2009)

5.1.2

5.1.3

If your program has specific safety issues that are not

covered in the PGME document there should a program

specific safety policy addressing these issues.

Examples:

radiation exposure

biohazards

potentially violent patients

house calls

after hours consultations

resident attending patient transfers

complaint management

fatigue management

Resident Affairs

https://pgme.mcmaster.ca/traineeaffairs/

Resident affairs provides more information & resources on learner

intranet –

https://www.medportal.ca/pg/trainee

5.1.3.2

5.1.3.4

Patient Safety

Guidelines Regarding Patient Safety

Health Records

Health Records Completion by Residents (PGEC 2013)

Health Records Handling & Disposal

Professionalism

Promoting Professionalism Policy & Procedures (PGME 2014)

Professional Behavior Code of Conduct for Learners (FHS)

Guidelines for Appropriate use of Internet Electronic Networking &

Other Media (PGME)

Guidelines for Interaction with Industry (PGEC 2013)

Update: Note that since the release of the system it was discoved that in some cases you cannot link the policy. It must be uploaded.

Version 05.10.2019

Page 5 of 31

Technology & Industry

Guidelines for Appropriate use of Internet Electronic Networking &

Other Media (PGME) this is above

Guidelines for Interaction with Industry (PGEC 2013)

Committees Entry Completed

Date:_______________

Organization Structure:

Upload to AMS your program’s organizational chart.

Residency Program Committee Entry Completed

Date:_______________

What is the function of this committee?

Suggested Introduction:

The RPC is responsible for the overall operations of the

PROGRAM NAME residency program by assisting the Program

Director in planning, organizing and supervising the residency

program, including providing the environment, mentorship, and

experience whereby each resident will have access to an

educational experience required to successfully complete the

program objectives. The RPC supports and assists the Program

Director in:

Program design

Program curriculum

Site/rotation review

Resident evaluation

Appeals and promotion

Resident selection

Resident wellness and safety

Continuous improvement

Career Planning

The RPC responsibilities, as outlined in the Program

Terms of Reference, must describe and do all of the

elements listed in

1.2

2.1

2.2

6.1.1

6.1.2

All Programs must have an effective, fair and transparent

process for the residents to choose their resident

members on the RPC. The number of resident reps must

reflect the size of the program.

Explain how the Program communicates with residents,

teaching faculty, admin staff and Division Director and/or

Chair.

Version 05.10.2019

Page 6 of 31

To whom does this committee report?

Suggestion

The RPC members report to the Program Director, who, in turn,

reports to Division/Department Chair and the Associate Dean of

Postgraduate Education.

Include the reporting structure in your RPC’s Terms of

Reference

How often does this committee meet?

Comments:

1. The Standards no longer specify a minimum meeting frequency. Element

1.2.2.3 says “Meeting frequency is sufficient for the committee to fulfil its

mandate.” Therefore, the response here should indicate not only a

frequency, but a statement about the meeting frequency being sufficient

to manage the program effectively.

2. If the minutes show there are ongoing program issues, such as, lack of

resources, harassment, supervision problems, then there should be a

sufficient number of meetings and the minutes reflect that a process is in

place and working towards resolution.

Recommendation: meetings 3-4 per year. More for large programs or when there

are program issues.

3. If the RPC meets in conjunction with a Division or Clinical Department

meeting, there must be a distinct and separately minuted RPC meeting.

4. Programs that do not have residents every year, still must have a

functioning RPC, a suggested minimum of two meetings per year. It must

ensure the ongoing organization and quality of the clinical sites and

teachers and include new changes to curriculum, policies, etc. There must

be minutes and, if action items, documentation of implementation, etc.

Upload to the AMS as PDF documents:

Terms of Reference

Membership list

Agendas (last two years in a single PDF document)

Other documentation

Version 05.10.2019

Page 7 of 31

Competence Committee (or equivalent):

What is the function of this committee?

Suggestion:

The Program competency committee is a subcommittee of the

RPC that reviews resident progress ensuring progress in achieving

the educational objectives through the levels of training. This

includes readiness for independent practice. If a resident has

difficulty meeting objectives, then it will assist with the

development of individual learning plans. The recommendations

of the Competence Committee will be brought forth to, and

discussed by, the RPC for approval.

Having a Competence Committee is a new requirement,

reflective of the new increasing complexity of assessment

of competence with Competency Based Medicial

Education.

1.2.2.4

3.4.3.1

3.4.3.2

The function of the CC should be reflected in the Terms of

Reference. 3.2.3, 3.4.4

As the complexities of evaluation progresses with CBME

implementation, it can be helpful for residents be

assigned a formal Academic Advisor. 3.4.2.2

Even in very small programs it is helpful to have a

competence committee to assist the Program Director.

To whom does this committee report?

Suggestion:

The Chair of the competence committee is a member of the RPC

reports to RPC.

How often does this committee meet?

This will depend on the length of the program and the

number of residents.

In programs with short training periods e.g. 12 to 24

months, it can be helpful for the Program Director and/or

Academic Advisor to have a meeting with each resident at

the completion of Introduction, Foundation, Core, and

Transition to practice.

The CC should regularly review resident progress to

ensure the resident has completed the requirements of

each phase.

Version 05.10.2019

Page 8 of 31

Upload to the AMS in PDF documents:

Terms of Reference

Membership list

Agendas (from last two years in one single PDF)

Other documentation

Other Committee(s)

It is not a requirement to have other RPC

subcommittees but depending in size and needs these

subcommittees have been implemented by programs:

Wellness/Social 1.2.1.3

CaRMS/selection 1.2.2.2

Research 3.2.5.1

Simulation 3.2.2.3

QI/Patient Safety 1.2.1.4, 3.2.6.1

Narrative - Leadership and Collaboration Entry Completed

Date:_______________

Does the program director have Royal College certification? If yes, please provide the name of the

specialty/subspecialty. If no, please provide specialty qualifications.

Protected time for the program director (in FTE):

Is it adequate?

Yes No

Version 05.10.2019

Page 9 of 31

Why/why not?

1.1.1.1

If you do not have adequate protected time, provide an

explanation

Administrative support available to the program director (in FTE):

1.1.2.2

8.1.1

Is it adequate?

Yes No

Why/why not?

If you do not have adequate administrative support for

your program, provide an explanation.

Version 05.10.2019

Page 10 of 31

Please describe how the residency program collaborates with undergraduate medical education (UGME) and

continuing professional development programs.

2.1.2.3

7.1.1.4

7.1.1.6

Possible examples:

a. Undergraduate Medical Education (UME):

students and clinical clerks are members of clinical

teams and supervised by residents and teachers

resident and teachers involved in presenter/tutor

clerkship specialty teaching week, tutors for

clerkship orientation, UME clinical skills preceptors,

OSCE examination observers, Medical Foundations

(co-)tutor,

b. Resident participation in CPD opportunities e.g.

University Teaching Program

https://fhs.mcmaster.ca/facdev/events.html

Faculty member/teacher is a lead/facilitator for CPD/UME

Does the residency program collaborate with other health professions to provide educational experiences for

learners in all health professions.

Yes No

SURGICAL FOUNDATIONS (for Surgical Programs Only)

Describe how Surgical Foundations functions in this program. Specifically outline the following:

1. Your relationship with the director of Surgical Foundations?

Modify these sections to increase detail as needed

to reflect any specific issues related to your

program.

Version 05.10.2019

Page 11 of 31

2. Who determines the choice and locations of clinical rotations for your residents in Surgical Foundations?

3. Who receives the rotation evaluations for your residents during the first two years in your program?

Version 05.10.2019

Page 12 of 31

Narrative - Educational Design and Delivery

Upload your curriculum plan to the AMS. As guidance, a template has been provided in the "documents” section

of your dashboard in the “From the College – DO NOT DELETE” folder; however, an alternate format would also be

acceptable, provided it includes all information requested in the template.

For assistance and guidance, please contact Brenda Montesanto in the PGME office.

The following is the explanation for the Program Profile Instruments provided by CanERA:

CanAMS Program Profile Instrument: Education Design and Delivery Section Guidance (Royal College Programs)

For Royal College residency programs, the Education Design and Delivery section of the program profile instrument within

CanAMS, the digital accreditation management system, requires uploading or population of two key tables: a curriculum plan

and a detailed description of educational experiences by stage/year, including their sequence, purpose/goal(s), and assessment

methods. Guidance is provided below to assist in the completion of these tables:

1) Curriculum Plan

Each residency program is asked to upload a curriculum plan, which will be evaluated to determine compliance with the

expectations detailed in requirements of Standard 31. To assist residency programs with the provision of a curriculum

plan, the Canadian Residency Accreditation Consortium (CanRAC) has developed a template available within the

documents section of the CanAMS program profile instrument. Use of the template is not mandatory; however, it is

expected that the curriculum plan captures the information in the template, at a minimum. In the future, a curriculum

plan template may be developed to enable pre-population of some details based on discipline-specific documentation.

In completing the curriculum plan, please consider the following:

Time-based vs. competency-based:

To facilitate the transition and reduce the burden on residency programs preparing for accreditation, each residency

program is expected to submit one curriculum plan, even if the residency program has both CBD and non-CBD cohorts

of residents. Whether the curriculum plan is based on competencies (i.e. the discipline’s CBD Competencies), or based

on the traditional curriculum (i.e. the discipline’s Objectives of Training Requirements (OTR)), is determined by the

discipline-specific standards that were in place 12 months in advance of an accreditation activity. For example, if a

program transitioned to CBD more than 12 months in advance of an accreditation review, the curriculum plan is

expected to be based on the discipline’s CBD Competencies. o Notwithstanding the principle of applying those standards

in place 12 months in advance of an accreditation activity, please note that to support programs in transitioning to CBD,

programs in disciplines that have transitioned to CBD less than one year may choose to submit a competency-based

curriculum plan. This

Version 05.10.2019

Page 13 of 31

option recognizes that it may work best for programs to focus their efforts during the transition period on the

development of a competence-based curriculum and that the CBD Competencies document does not represent a

significant departure from the discipline’s OTR. The submission of a competency-based plan should be clearly identified

on the program’s submission to ensure it is clear for surveyors, Specialty Committees and the Residency Accreditation

Committee.

Objectives/Competencies:

Please identify the relevant objectives/competencies associated with, and organized by, each CanMEDS Role. It is

expected that the identified objectives/competencies be based on the OTR/Competencies document for the discipline, as

applicable. It is recommended that the curriculum plan be detailed to the enabling competencies sub-level (e.g., 1.2) of

the OTR/Competences document. There may be instances where it is more appropriate to group all

objectives/competencies together in a common row or activity (e.g., all of Communicator 1), or to break down the

expectations further (e.g., 1.2.2.). Both approaches are acceptable, provided the overall curriculum plan clearly outlines

how all objectives/competencies are taught/learnt and assessed.

How Taught/Learnt and Assessed:

Please identify the various methods for how the identified objectives/competencies are taught/learnt and assessed.

Within the template provided, it is suggested that a list of all of the various methods be provided and then for each

objective/competency identified, the applicable methods be indicated by an “X”. An example is provided in the template.

In addition to this, within the CanAMS program profile instrument, there is a question that asks for examples of each

assessment method identified in the Curriculum Plan. Time-based programs will be expected to provide a

template/sample of each tool identified; however, for CBD programs, it is only expected that samples/templates be

uploaded where the assessment method(s) identified in the Curriculum Plan differ(s) the Royal College CBD suite of

assessment tools.

2) Educational Experiences (Rotations) by Year (non-CBD)/Educational Experiences by Stage (CBD)

Each residency program is asked to populate a table (or upload an equivalent document) detailing the educational

experiences by year (time-based)/by stage (CBD), including the sequence of this training, the associated purpose/goal(s)

of the educational experience, and the associated assessment methods.

In completing the educational experiences table, please consider the following:

Time-based vs. competency-based:

Should your program be transitioning to CBD, with both time-based and CBD cohorts progressing through the program

at the time that the work begins to populate CanAMS (i.e. one year in advance of the accreditation review), please

provide content addressing the rotations/learning experiences for both time-based and CBD cohorts (i.e. populate the

table twice, or upload two documents).

Version 05.10.2019

Page 14 of 31

Purpose/Goal of Rotation:

For time-based programs/cohorts, please populate the purpose/goal of the rotation column with relevant rotation-

specific objectives. Should you wish to upload existing Rotation-Specific Objectives, rather than detailing the purpose of

each rotation in the provided table, please ensure to complete the table in the same order of experience as is listed in

your RSO document to ensure the linkage is clear. (i.e., that the link between the content of the uploaded document and

the completed columns of the table is clear). For programs/cohorts that have transitioned to CBD, please populate the

purpose/goal of experience with the competencies to be acquired/EPAs to be observed. Should you wish to upload a

document detailing these rather than detailing these within the table, please ensure that all other sections of the table

are populated in the same order as the competencies to be acquired/EPA’s to be observed.

Version 05.10.2019

Page 15 of 31

For each method of assessment identified in the curriculum plan, Upload an example (e.g. template).

- Upload in AMS

The curriculum plan should be reflected in the clinical experience and Academic Half/Full Day sessions e.g. didactic, simulation,

workshops, etc. Over a specific period of time, depending on the length of program, all components of the curriculum should be

covered.

Curriculum Plan [Template - with example]

Academ

ic C

urr

iculu

m

Mic

roscopic

sig

n-out

Rota

tion

Pre

para

tion L

ab R

ota

tion

Quality

Assura

nce R

ota

tion

Rapid

on-site e

valu

ation R

ota

tion

[Add a

ddit

ional colu

mns a

s n

eeded]

Assig

nm

ent

(re

searc

h/schola

rly p

roje

ct)

In-Tra

inin

g E

valu

ati

on R

eport

Ora

l and s

lide e

xam

s

Multis

ourc

e f

eedback t

ool

[Add a

ddit

ional colu

mns a

s n

eeded]

1.1

(Example) Demonstrate knowledge of criteria for

spiment adequacy and assessment of slides to

diagnose benign, pre-malignant and malignant

conditions.

X X X X X

[Add additional rows as needed]

[Insert applicable objectives/competencies]

[Add additional rows as needed]

[Insert applicable objectives/competencies]

[Add additional rows as needed]

[Insert applicable objectives/competencies]

[Add additional rows as needed]

[Insert applicable objectives/competencies]

[Add additional rows as needed]

[Insert applicable objectives/competencies]

[Add additional rows as needed]

[Insert applicable objectives/competencies]

[Add additional rows as needed]

Communicator

Objectives/Competencies (Based on the

specialty specific standards and

associated OTR/Competencies document,

as applicable)

CanMEDS Role

How Learned / Taught How Assessed

Medical Expert

Collaborator

Leader

Health Advocate

Scholar

Professional

Version 05.10.2019

Page 16 of 31

Educational Experiences (Rotations) by Year (non-CBD) / Educational Experiences by Stage (CBD)

Populate the table(s) in the AMS, as applicable, or Upload an equivalent document detailing all educational

experiences (eg. rotations) by year (non-CBD) and/or stage (CBD), including the associated learning sites,

rotation-specific objectives (non-CBD) or experience-specific competencies, milestones, and EPAs, as applicable

(CBD), as well as the associated methods of assessment. For residency programs with both CBD and non-CBD

cohorts, please populate both tables.

PGY Rotations Learning

Site(s)

Purpose/goal

of rotation

Assessment

Method(s)

Stage (CBD) Educational

Experience

(CBD)

Learning

Site(s)

Purpose/goal

of experience

(CBD)

Assessment

Method(s)

Describe how the program ensures that all residents are provided with increasing professional responsibility.

SUGGESTIONS:

PGY -Residents assume responsibility for teaching and mentoring

more junior residents, clerks, and medical students. Senior

residents take on the role of junior faculty and be supervised by a

staff physician and is responsible for clinical, administrative and

educational tasks under supervision.

CBD-There is a progressive increase in responsibility, as resident

move through the competency phases of transition to discipline,

foundations, core, transition to practice.

Assessment methods have been developed to inform decisions

about resident readiness to progress through these stages. During

transition to practice, residents have the opportunity to work

independently, in preparation for future practice.

Comment:

The content of this answer will vary if the program is

traditional or CBME.

The answer must provide information that

demonstrates increasing responsibility. The

suggestions provided in the left column are just to get

you started and should be elaborated as appropriate.

Version 05.10.2019

Page 17 of 31

Describe how community and societal needs served by the discipline are considered in designing the residency

program.

SUGGESTIONS:

-Programs with residents at community sites are helping provide

clinical service, introduces residents to the benefits of community

practice and potential recruitment

-Partnering with community services to meet patient needs

3.1.1.4

3.2.3.1

4.1.1.2

What changes have been made in your program, or

provide examples, where needs of the community or

region have been considered in your program’s design.

CBME curriculum is about socially accountable medical

education.

Describe how individual residents’ educational experiences are tailored to accommodate learning needs and future

career aspirations.

SUGGESTIONS:

Selectives/electives

Special projects

Choice of learning sites

3.2.3.1

3.3.1.2

Elaborate on the experience.

Describe how the program ensures residents' clinical responsibilities do not interfere with their ability to

participate in academic activities.

3.2.5.2

When residents are participating in protected academic

activities/AHD:

who covers for the resident

how are pages/calls diverted from resident

call schedules and AHD attendance post call

how does the program ensure work is not just left

for the residents after AHD.

Version 05.10.2019

Page 18 of 31

Describe the scholarship and research activities available to residents.

Resources to consider:

Program

AHD curriculum

Faculty member responsible for resident research,

reports to RPC

Division/Department

Faculty research and scholarly activity open to

participation of residents

Faculty mentors/research supervisors

PGME

CIP

MAD day (there is only one this year)

FHS

Program for Faculty Development

McMaster Education Research, Innovation and

Theory (MERIT)

HRM

Master of Science in Health Science Education

Clinical Educator Program Area of Focused

Competence

FHS Health Research Services

RMA grants

PSI grants

Version 05.10.2019

Page 19 of 31

Populate the text box below and/or Upload a document listing resident contributions to scholarship (e.g.

Publications, presentations, etc) since the last regular accreditation review.

3.2.5

4.2.1.3

4.2.1.4

Note Change:

In the past, the program listed the number of resident

publications in the past 5 years. The new accreditation

cycle will be 8 years. The last McMaster on-site

accreditation review was 2012.

The new expectation is documentation of all scholarly

activities.

Narrative – Clinical Learning Environment Entry Completed

Date:_______________

How does the Residency Program Committee stay informed of issues related to resident wellness and safety?

5.1.2

Suggestions:

PD membership on PGME PD committee where issues

pertaining to all programs would be disseminated.

At program level,

concerns brought to RPC meeting by a member,

faculty or resident representative;

residents speaking to PD

Program could have a faculty member responsible

for resident wellness. 1.2.1.3 and possibly a RPC

subcommittee

Program could have QI member responsible for

safety issues 1.2.1.3

Version 05.10.2019

Page 20 of 31

How does the Residency Program Committee stay informed of issues related to quality of care and patient safety

at learning sites?

1.2.1.1

Suggestion:

Include this as part of the job description of the site

coordinators who would report on these issues at the RPC

meeting. Or the QI member of the RPC.

Are there hospital committees providing reports to

Division/Department with issues that inform the RPC?

Narrative - Resident Assessment and Promotion Entry Completed

Date:_______________

Describe the residency program’s program of assessment, including roles, tools, and frequency.

3.4.1

3.4.2

Describe how decisions regarding resident progress are made, including data/information considered, frequency,

process, etc.

3.4.3

Provide a list of data/information considered by the Competence Committee (or equivalent).

Resident names or identifiers should be removed.

Version 05.10.2019

Page 21 of 31

Describe the support provided to residents who are not attaining required competencies as expected including

support provided to those residents who require formal remediation.

Elaborate on support resources:

https://fhs.mcmaster.ca/postgrad/trainee_well_being.html

In addition to PGME resources, describe program specific

support and process.

Describe the process for appeals.

3.4.4

6.1.1.1

Describe program level and précis PGME process with

links to Appeals Policy

Have there been any appeals in the last two years?

Yes No

Version 05.10.2019

Page 22 of 31

Narrative - Resource Allocation Entry Completed

Date:_______________

Please describe how the Residency Program Committee identifies and advocates for the resources needed by the

residency program.

Describe the process that your RPC uses for identifying

the current and future needs of the program.

What is the mechanism by which the educational experts

within a department can identify what lies ahead for

residency training, how are these issues flagged for the

department or PGE office, and what strategize they use

to acquire the resource(s) e.g. advocating at the hospital

level for ultrasound machines needed for patient care.

In the AMS: List by teaching site the teachers who have a major role in this program, including members from

other departments. In indicating a subspecialty, use as a criterion whether he or she is considered by colleagues

as a subspecialist and functions academically and professionally as one.

Teaching Site Name University

Rank

Specialty

Qualifications

Subspecialty

(if any)

Nature of

interaction

with

Residents

Describe the process to select, organize, and review the residency program’s learning sites.

See requirements: 2.2.1, 2.2.2, 2.2.3

Element 2.2 and Element 9 (9.1.1 and 9.1.2) link direct

to the mandate of the RPC and should be in the Terms of

Reference. The minutes of the RPC should demonstrate

that there is a process with a timetable, so all elements

are reviewed, evaluated, and changes/revisions made on

an ongoing basis.

Resident input must be sought and documented in the

minutes. This can include and not limited to: information

from Resident Retreats, Chief Residents, RPC resident

representatives, exit surveys.

Version 05.10.2019

Page 23 of 31

In the AMS when given permission by PGME, please Upload any Inter-Institution Affiliation Agreements relevant

to the residency program.

Do residents have free 24/7 access to online libraries, journals, and other educational resources?

Yes No Partially

Do residents have adequate space to carry out their daily work?

Yes No Partially

Are technical resources required for patient care duties located in the work setting?

Yes No Partially

Do facilities allow resident skills to be observed?

Yes No Partially

Do facilities allow for confidential feedback/discussions?

Yes No Partially

Describe other technical resources, including simulation facilities, teaching space, etc. available to the residency

program.

Program specific information.

FHS and Hospital Simulation resources

Examples:

McMaster Centre for Simulation-based Learning

https://simulation.mcmaster.ca

Program Specific Simulation Resources

-Critical Care

-Emergency Medicine

Centre for Minimal Access Surgery (CMAS)

With which programs does the residency program collaborate to share educational resources and provide

educational experiences in other disciplines? Please describe.

Version 05.10.2019

Page 24 of 31

Narrative - Resident Wellness and Support Entry Completed

Date:_______________

Please describe the career planning and counselling available to residents in the program.

Program Specific

PGME central programs

-?MAD

CMPA

3.2.3

6.1.2

The RPC must oversee/monitor this process. The key is it

must happen throughout the program, and for each

resident. Document the discussions at semi- or annual

reviews so there is evidence of purposeful meetings.

Ad hoc meetings with ‘willing faculty members’ or during

clinical ‘downtime’ are not enough.

Demonstrate that the program can be tailored to

resident’s future interests, based on career discussions.

Examples: formal mentor program, annual/twice a year

meetings with Program Director, resident meetings with

their Academic Advisor, annual retreats, lectures or

seminars in half-day, career fairs.

Is there a mentorship program available to residents in the program?

Yes No

Describe or upload in the AMS: A list of leadership opportunities for residents.

Examples

Program:

RPC resident rep

Chief Resident

President/Executive of resident group/organization

University:

PARO, RDoC

PGEM Committees

Internal review resident member

Version 05.10.2019

Page 25 of 31

Narrative - Teacher Support and Development Entry Completed

Date:_______________

Describe how teachers in the program are assessed.

7.1.1

7.1.2

System of teacher evaluation, regular

Recognition of teaching excellence

Includes resident input

Teachers receive recognition for contributions outside of

residency: exam boards, specialty committees,

accreditation committees, medical advisory boards, peer

reviewer.

Contributions to medical scholarship

Describe how any unprofessional behaviour by teachers is identified, documented and addressed.

Outline process:

Poor assessment is received what process is followed

who speaks with teacher e.g. Program Director, DEC,

Division Director or Chair

time lines

how is intimidation or harassment addressed

when a designated supervisor is not available or

responding to the resident, etc.

Version 05.10.2019

Page 26 of 31

Please describe faculty development provided to teachers in the residency program.

How are needs and priorities identified and addressed?

Resources available at McMaster University

Faculty of Health Sciences

Program for Faculty Development

https://fhs.mcmaster.ca/facdev/events.html

Academic Development: interprofessional workshops and

sessions

Teaching & Learning Certificates

University Teaching Program

Peer Observation of Teaching (POT) Project

Practice Based Small Group-Education: Series on Medical

Education for Clinical Teachers

PGME

Clinical Educator AFC

School of Graduate Studies

Masters in Health Sciences Education (MSc)

https://hsed.mcmaster.ca

or other University MEd

Department

Does your Department host faculty Workshops, etc.

Please describe the opportunities and support for teachers to contribute to scholarly activity, including research.

MSc. PhD Program in Health Research Methodology

http://hrm.mcmaster.ca/index.html

Graduate Diploma in Clinical Epidemiology (Online)

http://hrm.mcmaster.ca/gdce.html

identify funding agencies, Department awards,

collaboration

protected time

Version 05.10.2019

Page 27 of 31

Please list or upload a list of teachers’ contributions to scholarship activity, including research.

Add to Table in AMS or Upload your own file to AMS

Version 05.10.2019

Page 28 of 31

Narrative - Program Administrative Support and Development

Entry Completed

Date:_______________

Upload in the AMS: The program administrator job description.

Describe the process to provide program administrative personnel with feedback about their performance.

8.1.1

This is new, so programs need to implement.

Describe the professional development opportunities available to the program's administrative personnel. How are

learning needs identified?

PGME workshops

support to attend ICRE

member of ICRE organizing/planning committee

Version 05.10.2019

Page 29 of 31

Narrative - Program Evaluation and Improvement Entry Completed

Date:_______________

Describe the process to review and improve the residency program.

Suggested Program Initiatives:

-annual or every second year all rotations are reviewed

-resident evaluations of rotations

-resident exit surveys

PGME provides an Internal Review Process.

Internal reviews of each residency program are

conducted between on-site accreditation site visits from

the RCPSC and the CFPC. Internal reviews are intended

to support continuous quality improvement within all

programs, to assist the University in maintaining the

quality of its residency programs, and to provide the

Postgraduate Medical Education Committee and Program

Directors with valuable information about the strengths

and weaknesses of their programs. Internal reviews

may also serve as an important trigger for corrective

measures to be taken, where appropriate, before the

next on-site survey.

Internal reviews are conducted by teams of 3 surveyors;

each team includes a faculty Chair, a faculty member,

and a resident representative. Many of the faculty

members who serve as surveyors for the internal review

process are current or past program directors. Every

program director is required to undertake at least one

internal review of another program. Survey teams

review each program against the General Standards of

Accreditation for Residency Programs, using a review

format identical to that used by the RCPSC and CFPC

during on-site visits.

Programs complete the AMS, identical to that which will

be used at a regular on-site survey, and this instrument

is made available to the surveyors in advance of the

internal review. Surveyors are provided with a checklist

to guide and facilitate the review. After the review, the

Version 05.10.2019

Page 30 of 31

survey team prepares a report using the same report

template used by the RCPSC or the CFPC. Strengths and

weaknesses of the program are listed in the report, each

one linked to specific standards of accreditation.

Surveyors are instructed to describe any weaknesses -

especially those of sufficient importance to affect the

accreditation status of the program - fully and clearly.

Each report is reviewed by the PGME Internal Review

Committee. This subcommittee functions in a similar

fashion to the RCPSC Residency Accreditation

Committee: each report is assigned to two reviewers

from the subcommittee, who present the findings to the

full subcommittee. Based on these presentations and

the ensuing discussion, the subcommittee votes on a

proposed status of accreditation, which is intended to

represent a best guess about the accreditation status

that would have been assigned had the report arisen

from an on-site survey. The program then receives a

transmittal letter from the PG Dean summarizing the

strengths and weaknesses and the proposed status,

along with a copy of the full report.

The Internal Review Committee presents a summary of

its findings at least annually to the PGME Committee.

A follow up chart with the list of weaknesses found by

the internal review team and a space for reporting a

timetable of work planned to document progress on this

specific area is provided to each program. The PGME

Office and the Internal Review Committee monitors

progress of these areas of the program at the 6 and 12

month mark following the internal review.

Version 05.10.2019

Page 31 of 31

Provide a list or description of the data and information used to review and improve the residency program.

New

Describe how strengths and areas for improvement, and resulting action plans, are shared with the residency

program's stakeholders.

New