University of Manitoba Pre-Survey Meeting with Department Heads Date: July 4, 2013 Time: 10:45 a.m. to 12:45 p.m. Room: Pharmacy Apotex, Theatre # 264

Objectives of the Meeting To review the: Accreditation Process Categories of Accreditation - New Standards of Accreditation Role of the: –Program directors –Department heads –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 Principles of the Accreditation Process

Internal Reviews Monitoring Six Year Survey Cycle

Pre-Survey Process Royal College Comments 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 Non-voting Members –Chairs of exam boards –National Specialty Society (NSS) –ALL program directors Composition of a Specialty Committee

Chair - Dr. Sarkis Meterissian –Responsible for general conduct of survey Deputy chair – Dr. Maureen Topps –Visits teaching sites / hospitals Surveyors Resident representatives – CAIR Regulatory authorities representative – FMRAC Teaching hospital representative – ACAHO The Survey Team

Assess how the program is meeting standards at the time of survey Looking for ‘evidence’ Role of the Surveyor

Questionnaires and appendices –Completed by program Program-specific Standards (OTR/STR/SSA) Report of last regular survey –Plus report of mandated Royal College review 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 head (30 min) Residents (per group of min) Teaching staff (60 min) Residency Program Committee (60 min) The Survey Schedule

Program director Overall view of program, strengths, challenges & weaknesses Address each Standard Resources to support program director & program Department head Support for program director & 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

Program director attends first half of meeting All members of RPC attend meeting, including resident representatives Review of responsibilities of Committee Functioning appropriately Opportunity for surveyor to provide feedback on information obtained during previous meetings 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 at the Fairmont Winnipeg –Survey team recommendation Category of accreditation Strengths & weaknesses The Recommendation

New terminology – June 2012 Revised and approved by the Royal College, CFPC and CMQ. Categories of Accreditation

Accredited program Follow-up: –Next regular survey –Progress report (Accreditation Committee) –Internal review –External review Accredited program on notice of intent to withdraw accreditation Follow-up: –External review 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 COLLEGE SPECIALTY COMMITTEE ACCREDITATION COMMITTEE Reports Reports & Responses Recommendation Reports Responses After the Survey Report & Response UNIVERSITY

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 the surveyor Survey report Program response Specialty Committee recommendation History of the program Information Available to the Accreditation Committee

Decisions –Accreditation Committee meeting May/June 2014 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 “C” Standards Apply to Areas of Focused Competence (AFC) programs General Standards of Accreditation

A1University Structure A2Sites for Postgraduate Medical Education A3Liaison between University and Participating Institutions “A” Standards

B1Administrative Structure B2Goals & Objectives B3Structure and Organization of the Program B4Resources B5Clinical, Academic & Scholarly Content of the Program B6Assessment of Resident Performance “B” Standards

There must be an appropriate administrative structure for each residency program. Program director Time & support Acceptable qualifications Residency Program Committee Operation of the program Program & resident evaluations Appeal process Selection & promotions of residents Process for teaching & assessment of competencies Research Regular review of program Faculty assessments 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 head 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 assessment Distributed to residents & faculty Reviewed regularly At least every 2 years 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 assessment 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 / 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, specimens and procedures Technical resources Ambulatory/ emergency /community resources/experiences Educational 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 the Roles of the specialist. Educational program Organized curriculum - Content specific areas defined by Specialty Committee CanMEDS Roles Teaching of the individual competencies 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 assessment data on each resident. Based on objectives Include multiple assessment techniques Regular, timely, formal Face-to-face B6 – Assessment of Resident Performance

Mechanism to monitor, promote, remediate residents lacking Formative feedback not provided and/or documented Assessments not timely, not face to face Summative evaluation (ITER) inconsistent with formative feedback, unclearly documents concerns/ challenges B6 – Assessment of Resident Performance “Pitfalls”

University of Manitoba On-site Survey February 23 to 28,

Office of Education Sarah Taber Assistant Director Education Strategy & Accreditation Educational Standards Unit Sylvie Lavoie Survey Coordinator Contact Information at the Royal College