mcgill university
Skip this Video
Download Presentation
McGill University

Loading in 2 Seconds...

play fullscreen
1 / 52

McGill University - PowerPoint PPT Presentation

  • Uploaded on

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

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'McGill University' - elke

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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

A1 University Structure

A2 Sites for Postgraduate Medical Education

A3 Liaison between University and Participating Institutions

b standards
“B” Standards

Standards for EACH residency program

B1 Administrative Structure

B2 Goals & Objectives

B3 Structure and Organization of the Program

B4 Resources

B5 Clinical, Academic & Scholarly Content of the Program

B6 Assessment 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


[email protected]


Office of Education

Margaret Kennedy

Assistant Director

Accreditation & Liaison

Lise Dupéré

Manager, Educational Standards Unit

Sylvie Lavoie

Survey Coordinator


[email protected]


Direction des étudesmédicales

Dr. Anne-Marie MacLellan


Marjolaine Lamer


Mélanie Caron

Accreditation Agent