the site visit - :// · the report findings are confidential preparation of the report begins...

THE SITE VISIT

SHEIK N. HASSAN, M.D., FCCP

OBJECTIVES

Discuss

Reasons for a site visit

Preparation for a site visit

The survey

Response to team members requests

The team’ report

PURPOSE OF ACCREDITATION

To determine if an institution or programme is in substantial compliance with accreditation standards

To promote institutional improvement and renewal

To determine if the program has clearly established its mission and institutional learning objectives

Are the program’s curriculum and resources organized to meet its mission and objectives

What is the evidence that the program is currently achieving its mission and objectives and is likely to continue to meet them in the future

STANDARD FOR ACCREDITATION AGENCY

10.3: The agency team evaluates the quality of the school’s facilities and resources at the main campus, branch campuses or additional locations and a representative sample of clinical core clerkship rotation sites affiliated with the school, as appropriate.

10.4: During the site visit, the agency team gathers information by a variety of methods, including but not limited to: documents and statistics;; individual and group interviews with a representative sample of staff and students;; and by direct observation

PURPOSE OF SITE VISIT

Obtain first hand information by meeting with administrators, faculty, and students; and survey the environment and facilities for learning to

Verify information in the school's database

Update information in the school's database

Clarify any issues

TYPES OF VSIT

Full

Limited

Secretariat

PREPARATION

New applicants – begin preparation as soon as the school decides to seek accreditation but no later than 2 years before the visit

Reaccreditation – almost immediately following conclusion of a visit – i.e. continuous quality improvement

PREPARATION

Complete database at least 6 months before the CAAM-HP visit

Conduct a mock survey six months before the CAAM-HP visit

Engage those with experience in accreditation

Mock survey should be conducted as an actual site visit

SITE VISIT TEAM

Appointed by the CAAM-HP Secretariat

Knowledgeable about medical education

Experienced surveyors are included

Selected from a pool of Administrators

Basic scientists

Clinical scientists

Educators

Researchers

CAAM-HP member or of the Secretariat

A chair and a secretary are appointed

TEAM

Dean of the school will have the opportunity to review the names proposed to survey the school for potential issues

TEAM MEMBERS

Receive database with appendices

Members are assigned specific areas for review

Review the submitted information

May request additional information prior to the visit

Arrange the schedule for the visit in collaboration with CAAM-HP and the school

Assign lead member for each session on the agenda

Identify some questions that will be asked

AGENDA

Secretariat proposes a prototype schedule

See Guidelines for Accreditation Survey Visits

Grouped differently from the CAAM-HP standards for accreditation

Can be modified

Team members are assigned to lead discussions for specific sections

SCHOOL’S CONSTITUENTS

Dean proposes members who will meet with the team for each section

Submit names and position that qualifies them to represent the school for that sectionDr. Jean Doe, Chair of the Curriculum Committee

Dr. John Harris, member of the Admissions Committee

Team and school agree on school’s constituents to meet for each sessionBroad representation of administrators, faculty, and

students

Dean informs those selected to meet with the team

PRE-VISIT PREPARATION

Ensure administrators, faculty, and students understand the information provided in the database

E.g. – members of the curriculum committee must demonstrate understanding of the entire curriculum

E.g. – faculty and students must demonstrate understanding of relevant policies

There should be no contradictions

PRE-VISIT PREPARATION

Dean and survey coordinator meet with those selected

Do not instruct them what to say except -

“Speak the truth, the whole truth, and nothing but the truth”

“Whatever you say can be and will be taken against you”

TEAM

Caucus on day one of the visit

Meet with Dean on day one to get his/her perspectives on accomplishments, goals, challenges

Team meets every evening and morning during the visit

Team visit selected areas on the main campus

Team visit selected clinical sites

MEETING

Professionally attired

Be present and be on time

Turn off cell phones

Be honest

Answer questions asked – do not ramble

Ask for clarification of question if necessary

Understand that the team is looking to verify

identify

clarify

VISIT

Dean must be intimately involved in preparation, but his/her role will be limited during the visit

Be prepared to show evidence of what you indicate (in the database and on interviews during the visit) you have done

Team may ask for additional documents on site Minutes

Additional data on students and faculty

Additional data on finances

Policies

Students self-select who will meet with the team

Faculty and administrators are not permitted in the room when meeting with students

VISIT

Gather information from reading, listening, and looking

the database and appendices

additional documents submitted

answers to questions asked

Information school’s constituents volunteer

physical facilities

electronic facilities

VISIT

Facilities

Space – classrooms, conference rooms, rooms for small group discussions, faculty office space, study space, R&R space

Safety and security

Access to virtual library

Laboratories

On-call rooms

VISIT

Clinical sites

Clinical teaching materials

Safety and security

Conference rooms

On-call rooms

Lockers

Student services

TEAM MEMBERS

Do not offer consultation

Independent of biases

Report findings and not decision on accreditation

EXIT MEETING

Team provides an oral report to institutional executives on

programme’s strengths

programme’s weaknesses and or areas of partial or substantial non-compliance

This is not a decision on accreditation

Additional information not presented in the database/appendices or during the site visit will not be accepted

THE REPORT

Findings are confidential

Preparation of the report begins before the visit or on site and completed shortly after the visit

Team secretary compile reports from team members

Draft report (approved by team) is forwarded to the Dean for correction of factual errors or of tone

If differences cannot be resolved, the Dean may write a letter to CAAM-HP ED for inclusion

THE REPORT

“Factual errors” will be corrected only if the errors were made based on information already presented and not on information that were not presented

The school will be notified of the decision on accreditation by CAAM-HP