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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 Presentation
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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
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
• 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
•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
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
•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
•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
• 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
•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
•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
•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
•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
•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
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.
• 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
•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”
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
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
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
•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”
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
• Insufficient faculty for teaching/ supervision
• Insufficient clinical/technical resources• Infrastructure inadequate
B4 – Resources “Pitfalls”
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
•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”
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
• 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”
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
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
613-730-6202
Office of Education
Margaret KennedyAssistant Director
Accreditation & Liaison
Educational Standards Unit
Lise DupéréManager
Sylvie LavoieSurvey Coordinator
Contact Information at theRoyal College