1. Accreditation and Internal Reviews

2. Objectives
Upon completion of the session participants will be able to:
Understand how document management and preparation fit into the internal review process
Identify what elements need to be prepared for the on-site visit
Describe the overall process and timelines for internal reviews

3. Agenda What’s New in accreditation Accreditation Cycle We have a date!
Documents
On-site visit
What next?
Timelines

4. Introductions
depositphotos.com

5. What’s new in Accreditation
CanMEDS 2015
Outcomes based
LLM
Clinical teaching and assessment emphasized
Leader
Patient Safety
Moving towards evidence and data collection
canmeds.royalcollege.ca

6. Accreditation Cycle 5 Onsite survey 2013 Internal review Follow-up
PSQs for next on-site survey 2018
Onsite Survey 2019 5

7. Internal review cycle Staggered starts
January 2015
RC Internal Reviews - those w/o onsite survey in 2013
September 2015
RC Internal Reviews - those w/ onsite survey in 2013
January 2016
Family Medicine Internal Reviews
September 2016
Follow-up Internal Reviews & Update reports
September 2017
Preparations for 2019 begin
LLM 6

8. We have a date 7 Kim Brainstorm – In pairs
Take it up on writing sheets
powerpictures.crystalgraphics.com 7

9. Start Planning Book space Circulate widely “Save the Date” Catering
Review lists of documents
Kim
Brainstorm – In pairs
Take it up on writing sheets
Book Space
Tips: 1) Large enough for your “Faculty” or “Residents” -
2) Boardroom style is best. (if possible)
3) Speaker phone - may be required.
4) Best that people come to Review Team.
Circulate the date widely – who needs to know???
Tips: 1) Remind Residents to inform supervisors, especially if off service. Ask that they plan VAC around IR date.
2) Ensure Chairs, Heads, Faculty Educators & RPC block in schedules.
- Faculty may need to rearrange their clinics or OR’s schedules.
3) draft schedule as soon as possible
3. Catering
Tips: 1) Ask your budget is for this event.
2) PGME office will inform you of dietary restrictions – about 2 weeks prior.
4. Review Lists of Documents Required
Tips: 1) Review the 2 lists, what’s required for the PSQ & what will be needed for the on-site visit.
2) What they are & where to find them – nice to be familiar early.
Copyright Shutterstock.com 8

10. Documents – Worksheet 1 9 Worksheet Respond to worksheet 9

11. PSQ Documents 00: General Information
The RCPSC PSQ is 7 separate documents
The CFPC PSQ is divided up by standards but is one document
00: General Information
B1: Administrative Structure & Support
B2: Goals and Objectives
B3: Structure and Organization of the Program / The Learning Environment
B4: Resources
B5: Clinical, Academic and Scholarly Content of the Program
B6: Assessment of Resident Performance
Pre-survey questionnaire yes, but there are lots of parts to it and some new questions
Organization and Funding –
Teaching and assessment of leadership and patient safety –
Resident promotions tracking 10

12. PSQ Appendices - RCPSC A: Agendas - (past 2 years)
B: Program Policy on Resident Safety
C: Research Grants of Faculty (past 12 months)
D: Faculty Publications (past 12 months)
E: Rotation Specific Goals & Objectives
F: Overall Goals of Residency Program
G: Interuniversity affiliation agreement
H: Formal Academic Curriculum (past 2 years)
I: Other Educational Activities (past 2 years)
J: Resident Publications (past 6 years)
See PSQ Tip Sheet for appendix specific information
Headers and page numbering v. important
Table of contents v. helpful to review team.
A: Agendas-past 2 years, minutes will be required for on site visit only
B: Program Policy on Resident Safety
C: Research Grants-past 12 months, source of funding, amount funded & name of faculty are key
D: Faculty Publications-past 12 months, helps to put in Alpha order to remove duplications, submitted and inpress. ONLY peer reviewed and non-peer reviewed.
E: Rotation-Specific Goals and Objectives, table of contents v. helpful
F: Overall Goals of Residency Program
G: Interuniversity affiliation agreement, no U of T program requires one of these
H: Formal Academic curriculum (past 2 years)
I: Other Educational Activities (past 2 years)
J: Resident Publications (past 6 years) – Not required in alpha order, duplications allowed, include poster presentations. 11

13. PSQ Appendices - CFPC
Appendix 1: Outline of the clinical curriculum at
this site for each year level
Appendix 2: Outline of the academic program at
Appendix 3: Outline of a typical week in the family
medicine experience for each year level
Appendix 4: Typical schedules for a first and
second year experience
See PSQ Tip Sheet for appendix specific information
Headers and page numbering v. important
Table of contents v. helpful to review team. 12

14. On-site visit The schedule Catering
Resident files – paper vs. electronic
Food – no nuts, no seafood, no pork
Food – feeding three people
Electronic vs. paper resident files – but not in POWER
flickrhivemind.net 13

15. Document review - Worksheet 2
Outcomes
What are they really getting at?
Evidence
What are we already doing that can demonstrate this standard is being met?
Focus for standards 14

16. Document review - Worksheet 2
Standard
Outcome of the standard
Evidence
There must be a sufficient number of qualified teaching staff from a variety of medical disciplines and other health professions to provide appropriate teaching and supervision of residents
Effective teaching
Trainees are learning and progressing through stages of competence
Assessment of learners over time
Evals from learners
Evals from colleagues (MSF)
Long term performance of learners
Focus for standards 15

17. What next? Review team writes report
What’s Next
Review team writes report
Report is sent to Program (+4 weeks)
Program Director / Site Director responds
IRC / FM-IRSC reviews at monthly meeting (end of month)
IRC / FM-IRSC letter sent to program
No further action
Written report
Follow-up internal review
akiwood.com 3

18. Internal Review Reporting Structure
LLM 16

19. Timelines
Handout - JM 17

20. Documents
JM - New way of passing docs back and forth – ShareFile – If you are having trouble sending us the stuff we can send you a link to upload your documents too.
You do not need an account 18

21.
Questions?
izzyreadson.wordpress.com 19