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McGill University. Date: September 12, 2012 at 1:30 p.m. Carp Conference Room, Goodman Building. Pre-survey Meeting with Department Chairs. Objectives of the Meeting. To review the: Accreditation Process New Categories of Accreditation Standards of Accreditation

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Mcgill university

McGill University

Date: September 12, 2012 at 1:30 p.m.

Carp Conference Room, Goodman Building

Pre-survey Meeting withDepartment Chairs

Objectives of the meeting

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 chairs

    • Residents

Conjoint visit

Conjoint Visit

  • Planning

  • Organization

  • Conduct

  • Share the cost

  • One decision taken at the Royal College Accreditation Committee

Coll ge des m decins du qu bec

Collège des médecins du Québec


  • To promote quality medicine so as to protect the public and help improve the health of Quebecers.

    Since 1847

  • In Quebec, legal responsibility for the accreditation of residency programs is assigned to the CMQ pursuant to regulations made under the Loi médicale and the Code des professions.

Royal college of physicians and surgeons of canada

Royal College of Physicians and Surgeons of Canada


  • To improve the health and care of Canadians by leading in medical education, professional standards, physician competence and continuous enhancement of the health system.

    Since 1929

  • A special Act of Parliament established The Royal College of Physicians and Surgeons of Canada to oversee postgraduate medical education for medical and surgical specialties.



  • Is a processto:

    • 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

The accreditation process

The Accreditation Process

  • Based on General and Specific Standards

  • Based on Competency Framework

  • On-site regular surveys

  • Peer-review

  • Input from specialists

  • Categories of Accreditation

Pilot accreditation process

Pilot Accreditation Process

McGill University is one of three universities participating in a pilot accreditation process!

  • Survey will be conducted in two distinct parts:

    • A Standards review

    • B Standards review

  • Details for the pilot process will be discussed later in presentation

Six year survey cycle

Six-Year Survey Cycle








Internal Reviews

Process for pre survey questionnaires

Process for Pre-Survey Questionnaires



Specialty Committee


Royal College


Questionnaires &



Program Director


Role of the specialty committee

Roleof the Specialty Committee

  • 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

Composition of a specialty committee

Composition of a 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

The survey team

The Survey Team

  • Chair - Dr. Mark Walton

    • Responsible for general conduct of survey

  • Surveyors

  • Resident representatives – FMRQ

  • Regulatory authorities representative - CMQ

Information given to surveyors

Information Given to Surveyors

  • 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/CMQ reviews since last regular survey, if applicable

The survey schedule

The Survey Schedule

  • 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)

Meeting overview

Meeting Overview

  • 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 with all residents

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

The recommendation

The Recommendation

  • Survey team discussion

    • Evening following review

  • Feedback to program director

    • Exit meeting with surveyor

      • Morning after review

        • 07:30 – 07:45 at the Fairmont The Queen Elizabeth

  • Survey team recommendation

    • Category of accreditation

    • Strengths & weaknesses

Categories of accreditation

Categories of Accreditation

New terminology

  • Revised and approved by the Royal College, CFPC and CMQ in June 2012.

Categories of accreditation1

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 definitions

Categories of AccreditationDefinitions

  • Accredited program with follow-up at next regular survey

    • Program demonstrates acceptable compliance with standards.

Categories of accreditation definitions1

Categories of AccreditationDefinitions

  • Accredited program with follow-up byCollege-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 definitions2

Categories of AccreditationDefinitions

  • 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 definitions3

Categories of AccreditationDefinitions

  • Accredited program onnotice 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

      (2specialists + 1resident) within 24 months

    • At the time of the review, the program will be required to show why accreditation should not be withdrawn.

After the survey

After the Survey

survey team



specialty committee

royal college


Report &




Reports & Responses

accreditation committee

The accreditation committee

The Accreditation Committee

  • 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)

Information available to the accreditation committee

Information Available to the Accreditation Committee

  • All pre-survey documentation available to surveyor

  • Survey report

  • Program response

  • Specialty Committee recommendation

  • History of the program

The accreditation committee1

The Accreditation Committee

  • Decisions

    • Accreditation Committee meeting

      • June 2013

      • Dean & postgraduate dean attend

    • Sent to

      • University

      • Specialty Committee

  • Appeal process is available

General standards of accreditation

General Standards of Accreditation

“A” Standards

  • Apply to University, specifically the PGME office

    “B” Standards

  • Apply to EACH residency program

  • Updated January 2011

A standards

“A” Standards

Standards for University & Education Sites

A1University Structure

A2Sites for Postgraduate Medical Education

A3Liaison between University and Participating Institutions

B standards

“B” Standards

Standards for EACH residency program

B1Administrative Structure

B2Goals & Objectives

B3Structure and Organization of theProgram


B5Clinical, Academic & Scholarly Content of the Program

B6Assessment of Resident Performance

B1 administrative structure

B1 – Administrative Structure

There must be an appropriate administrative structure

for 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 pitfalls

B1 – Administrative Structure “Pitfalls”

  • 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

B2 goals and objectives

B2 – Goals and Objectives

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 pitfalls

B2 – Goals and 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

B3 structure organization

B3 – Structure & Organization

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 pitfalls

B3 – Structure & Organization “Pitfalls”

  • Graded responsibility absent

  • Service/education imbalance

    • Service provision by residents should have a defined educational component including evaluation

  • Educational environment poor

B4 resources

B4 – Resources

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 pitfalls

B4 – Resources“Pitfalls”

  • Insufficient faculty for teaching/supervision

  • Insufficient clinical/technical resources

  • Infrastructure inadequate

B5 clinical academic scholarly content of program

B5 – Clinical, Academic & Scholarly Content of Program

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 pitfalls

B5 – Clinical, Academic & Scholarly Content of Program “Pitfalls”

  • 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

B6 assessment of resident performance

B6 – Assessment of Resident Performance

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 pitfalls

B6 – Assessment of Resident Performance “Pitfalls”

  • 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/weaknesses

Learning environment

Learning Environment

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 weaknesses

of the program can occur

without hindrance.

Pilot accreditation process1

PilotAccreditation Process

Conducted in two separate visits

  • PGME and teaching sites – A Standards

    • November 25-27, 2012

  • Residency programs – B Standards

    • March 17-22, 2013

  • Pilot accreditation process2

    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

    Programs mandated for on site survey

    Programs Mandated for On-site Survey

    Scheduled for On-site Reviewin March 2013


    • 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

    Process for programs mandated for on site review

    Process for Programs Mandated for On-site Review

    Process remains the same

    • PSQ Review

      • Specialty Committee

    • On-site survey by surveyor

    • Survey team recommendation

    • Survey report

    • Specialty Committee

    • Final decisionby Accreditation Committee

      • Meeting in June 2013

      • Dean & postgraduate dean attend

    Programs eligible for exemption from on site review

    Programs Eligible forExemption from On-site Review


    • Program on full approval since last regular on-site survey

    Process for programs eligible for exemption

    Process for Programs Eligible for Exemption

    • PSQ and documentation review

      • Accreditation Committee reviewer

      • Specialty Committee

    • Recommendations to exempt

      • Accreditation Committee reviewer

      • Specialty Committee

      • Postgraduate dean

      • Resident organization (FMRQ)

    • Steering Committee (AC) Decision

      • Review of recommendations

        • Exempted: on-site survey not required

        • Not exempted: program scheduled for on-site survey in March

      • Selected program (random)

      • University notified in December 2012

    Contact information

    Contact Information



    Office of Education

    Margaret Kennedy

    Assistant Director

    Accreditation & Liaison

    Lise Dupéré

    Manager, Educational Standards Unit

    Sylvie Lavoie

    Survey Coordinator



    Direction des étudesmédicales

    Dr. Anne-Marie MacLellan


    Marjolaine Lamer


    Mélanie Caron

    Accreditation Agent

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