University of Toronto

Pre-Survey Meeting withResident Representatives &

Senior Residents

Date: September 21, 2012

Time: 9:00 – 10:30 a.m.

Room: Queen’s Park BallroomPark Hyatt Hotel

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

• Continuing quality improvement process

• Peer-reviewed

• Based on Standards

• Categories of Accreditation

Principles of Accreditation

•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

Role of the Resident in the Accreditation Process

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

Internal Reviews

1

2

34

5

6

Monitoring

Six Year Survey Cycle

Process for Pre-Survey Questionnaires

Royal CollegeComments

Questionnaires

University

Specialty Committee

Questionnaires

Questionnaires &Comments

Program Director

Comments

Surveyor

• 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

•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 reviews

since last regular survey, if applicable

Information Given to Surveyors

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

Document review (30 min)

• Residency Program Committee Minutes• Resident Assessments

The Survey Schedule

•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 Overview

•Group(s) of 20 residents (60 min)

• If off-site, tele- or video- conferencing

•Looking for balance of strengths & challenges

•Focus on Standards

•Evaluate the learning environment

Meeting with ALL Residents

•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

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

•Meet together as a group to discuss the strengths & challenges 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

Preparing for the SurveyRole of the Resident

All members of RPC attend meeting, including resident representatives

• Review Committee responsibilities• Functioning appropriately• Opportunity for surveyor to provide

feedback on information obtained during survey

Meeting with Residency Program Committee

•Survey team discussion– Evening following review

•Feedback to program director– Exit meeting with surveyor

•Morning after review– 07:30 – 07:45

– Survey team recommendation• Category of accreditation

• Strengths & challenges

The Recommendation

New terminology • Revised and approved by the Royal College,

CFPC and CMQ in June 2012.

Categories of Accreditation

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

• Accredited program with follow-up at next regular survey

– Program demonstrates acceptable compliance with standards.

Categories of Accreditation Definitions

• 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

• 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

• 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

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

• 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

•All pre-survey documentation available to surveyor

•Survey report

•Program response

•Specialty Committee recommendation

•History of the program

Information Available to the Accreditation Committee

•Decisions

– Accreditation Committee meeting

• October 2013

• Dean & postgraduate dean attend

– Sent to• University• Specialty Committee

•Appeal process is available

The Accreditation Committee

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

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

General Standards of Accreditation

Standards for University & Education SitesA1 University Structure

A2 Sites for Postgraduate Medical Education

A3 Liaison between University and Participating Institutions

“A” Standards

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

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

B1 – Administrative Structure

•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

B1 – Administrative Structure

B2 – Goals & Objectives

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

•Medical Expert

•Communicator

•Collaborator

•Manager

•Health Advocate

•Scholar

•Professional

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

B3 – Structure & Organization

• Increasing professional responsibility•Appropriate independence as residents

progress•Supervision•Call

• Frequency• In-hospital or from home• Expectations (e.g. cross coverage)

•Service / education balance

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

B3 – Structure & Organization

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

B4 – Resources

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

B5 – Clinical, Academic & Scholarly Content of Program

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

B6 – Evaluation of Resident Performance

Scheduled from April 7 to 12, 2013 • PGME and teaching sites – A Standards

• Residency programs – B Standards

Pilot Accreditation Process

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

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

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

Criteria• Program on full approval since last regular

on-site survey

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 (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

accred@royalcollege.ca

613-730-6202

Office of Education

Margaret KennedyAssistant Director

Accreditation & Liaison

Educational Standards Unit

Lise DupéréManager

Sylvie LavoieSurvey Coordinator

Contact Information at theRoyal College