Title of presentation

1. FACULTY OF MEDICINE • UPDATE ON ACCREDITATION • and a FOCUS ON • OUR LEARNING ENVIRONMENTS SURGERY & OB/GYN GRAND ROUNDS Dean Brian Postl, March 13, 2013 Title of presentation umanitoba.ca

2. PRESENTATION OVERVIEW • Accreditation Update – UGME • PGME Accreditation • 3. The Learning Environment, Mistreatment and Accreditation • Source Documents re: provision of a safe learning environment • Learner Feedback • Action to date • Prevention and mitigation

3. ACCREDITATION UPDATE POST UGME SURVEY – APRIL 3-6, 2011 Survey team was very impressed: • Remarkable effort • Team approach • Very well-organized survey visit • Student participation • Generous support throughout visit by faculty, staff, students • Thanks to all faculty, staff, residents, students, for past and continued commitment

4. ACCREDITATION UPDATE POST UGME SURVEY – APRIL 3-6, 2011 October 2011 – Received consolidated Liaison Committee on Medical Education (LCME) and Committee on Accreditation of Canadian Medical Schools (CACMS) letter : “…the CACMS and the LCME voted to continue accreditation of the educational program leading to the MD degree … for an unspecified term.” • October 2012 Letter following August 2012 update: continuing accreditation for unspecified term • Dec. 5 & 6, 2012 Secretariat Consult Visit for Aug.2013 report

5. ACCREDITATION UPDATE LCME/CACMS CONSOLIDATED LETTER October 2011: • 118 / 130 standards Compliant • 4 / 130 standards Compliant w Monitoring • 8 / 130 standards Non-compliant October 2012, following August 15, 2012 Update: • 119 / 130 standards Compliant • 8 / 130 standards Compliant w Monitoring • 3 / 130 standards Non-compliant CACMS/LCME expect compliance with each standard cited within two years

6. ACCREDITATION UPDATE LCME/CACMS IDENTIFIED FACULTY STRENGTHS • Re-energized leadership in Decanal team • Dean & Associate Dean, UGME supported by colleagues, students • Faculty engaged in current educational program • OPAL curriculum management system • Indepth approach to behavioral and socio-economic subjects admired by students • Clinical Learning & Simulation Facility (CLSF) • Medical students’ thoughtful, detailed analysis • Financial resources and support of WRHA and Province

7. N=8 IN COMPLIANCE W MONITORING Institutional Setting (IS) Standards IS-11 Administrative Structure: Changes in deanery in almost all major positions; new appointments effective Sept.15, 2011. Educational Standards for MD Degree (ED) ED-8 Comparability of Sites:Clerkship directors have not used outcome measures to examine/assure comparability of clinical experiences/methods of assessment of sites. ED-9Curriculum Renewal: School has initiated a 4-year curriculum renewal effort schedule to continue into 2013. ED-35 Review: Evidence of indepth reviews of individual courses, curriculum years, preclerkship or clerkship years.

8. N=8IN COMPLIANCE W MONITORING Educational Standards for MD Degree (ED) ED-37 Monitoring Content: Adequacy of monitoring and management of the content in the final year of the curriculum, particularly electives ED-47 Student Evaluation: Low student satisfaction with the MSK (musculoskeletal) course and the Public Health Course - improving Medical Students Standards (MS) MS-19 Career Counseling: Update status of system to assist in career choice, application to residency program, guide to choosing Electives. MS-31A Learning Environment: In spite of much effort, the school still struggles to ensure learning environment … promotes development of explicit, appropriate professional attributes

10. N=3 NONCOMPLIANCE Institutional Setting (IS) Standards IS-1Strategic Plan: … in the most recent strategic plan (2008) outcome measures and timelines to track progress . . . were not clearly defined. Educational Standards for MD Degree (ED) ED-31 Formative Feedback - system for ensuring timely mid-clerkship feedback . . . in two major specialties (surgery & medicine) not done for 1/3 to 1/2 of students; (medicine improved 2012) ED-33: Curriculum Management - Recurrent problems with logical sequencing of segments of the curriculum and content is not integrated within and across academic periods

11. STANDARD ED-31 – MID & FINAL EVALUATIONS OPAL DATA: ACCREDITATION SURVEY APRIL 2011

13. STND ED-31 CURRENT DATA: CLASS 2013

14. STND ED-31 CURRENT DATA: CLASS 2014

15. ACCREDITATION CONCLUSION • Lots to be proud of at the Faculty of Medicine. • Tremendous number of changes over last few years. • Will continue to work on key areas defined, i.e. UGME curriculum governance, renewal, evaluation, professionalism. • ED-31 – improving, but not good enough for compliance • MS-31A– improved; ongoing management must be evident • Must make accreditation standards part of our regular, day-to-day operations; chronicity will be our downfall • Jan. 2013 – Appointment of Dr. Gary Harding Associate Dean, UGME & PGME Accreditation

16. The Learning Environment, Mistreatment,andAccreditation

17. Source Documents • Royal College of Physicians and Surgeons / College of Family Physicians of Canada: “General Standards of Accreditation” • Royal College: “Accreditation And The Issue Of Intimidation And Harassment In Postgraduate Medical Education: Guidelines For Surveyors And Programs” • LCME Accreditation Standards • Faculty of Medicine “Guidelines for Conduct in Teacher-Learner Relationships” • U of M “Respectful Work & Learning Environment” Policy • WRHA “Respectful Workplace” Policy

18. Faculty of Medicine Guidelines for Conduct in Teacher-Learner Relations • Includes: • Statement of Philosophy • Responsibilities in the Teacher-Learner Relationship • Behaviours Inappropriate to the Teacher-Learner Relationship • Avenues for Addressing Inappropriate Behaviour • Procedures for Handling Allegations • Guidelines on Professionalism & Diversity webpage

19. PGME ACCREDITATION Moved to Feb. 23-28, 2014 Canadian Association of Internes & Residents (CAIR) website:Facts about the Accreditation Process“Accreditation is singly the most important process that residents can be involved in.” “The single most critical "zero-tolerance" issue in Accreditation is intimidation and harassment.”

20. CAIR Mantras Intimidation/Harassment(Canadian Association of Interns & Residents) Intimidation / harassment include, but not limited to: • Derogatory written or verbal communication or gestures re: race, national or ethnic origin, colour, religion, age, sex, marital status, family status, disability, or sexual orientation. • Unwelcome physical contact • Physical or sexual assault

21. CAIR Mantras Intimidation/Harassment cont. Intimidation / harassment include, but not limited to: • Abuse of authority that undermines a resident’s performance or threatens a resident’s career • Patronizing or condescending behaviour intended to humiliate a resident’s performance (distinctly different from timely, constructive feedback from preceptors). • Any coercion in the accreditation process

22. FOR ROYAL COLLEGE HARASSMENT VERY SERIOUS e.g. “Harassment imperils N.L. anesthesia training”February 2011 - Residency program in Anesthesiology at Memorial University received Notice of Intent to Withdraw Accreditation due to “Ongoing allegations of intimidation which remain unresolved by the program, faculty or university processes (B3.8)”

23. “Harassment imperils N.L. anesthesia training” RE: Notice of Intent to Withdraw Accreditation: • Major and/or continuing weaknesses are identified which bring into question the ongoing program accreditation • Residents in the program, those already contracted to enter the program, and applicants to the program, must be advised immediately by the program director of the status of the program. • Within 2 years of Notice, an external review is conducted - the program must show cause why accreditation should not be withdrawn.

24. Jan. 2011/July 2012 GENERAL STANDARDS APPLICABLE TO ALL PROGRAMS STND B3: STRUCTURE AND ORGANIZATION OF THE PROGRAM 9. “Teaching and learning must take place in environments which promote resident safety and freedom from intimidation, harassment and abuse.”

25. RCPSC Position Paper: “Accreditation And The Issue Of Intimidation And Harassment In PGME: Guidelines For Surveyors & Programs” Definition of Harassment: . . . Repeated, often public, critical remarks or ridicule. Singling out for grilling or interrogation. Unjustified negative remarks or inappropriately positive remarks about appearance or dress. Unjust assignment of duties.

26. Definition of Intimidation: . . . the use of authority to influence someone to do/refrain from an action or to do something they would not do or should not do otherwise. e.g. asked to do extra work; refraining from reporting patient events; falsely positive faculty evaluations. It can also include ‘flattering’ intimidation such as “you are different than the others so I wonder if you can..”; “you’re great, you never complain and I wonder if you could take on this task for me…”

27. RCPSC: “Accreditation And Intimidation Guidelines . . . PRINCIPLES: 1. Timely identification of a concern about intimidation and harassment should be the goal of all programs. 2. Trainees should be encouraged to inform their program director or university administration of problems. 3. The initial discussion must occur in a confidential setting.

28. RCPSC: “Accreditation And Intimidation Guidelines . . . PRINCIPLES: 4. There should be a process to clarify the facts concerning the allegation. 5. The process of clarification must occur in an atmosphere free of retribution. 6. There should be a process to address and resolve allegations in a timely manner.

29. UGME STNDS- The Learning Environment MS-31: there should be no discrimination on the basis of age, creed, gender identity, national origin, race, sex, or sexual orientation in any of the program’s activities. MS-31A Annotation: . . . the school … should regularly assess the learning environment to identify positive and negative influences on the maintenance of professional standards and conduct, and develop appropriate strategies to enhance positive/mitigate negative influences. MS-32 Annotation: Mechanisms for reporting violations -- such as incidents of harassment or abuse -- should assure that they can be registered and investigated without fear of retaliation.

30. Student Feedback

31. Canadian Medical School Graduation Questionnaire (CGQ) • Since 2001, comprehensive, national survey re: graduates’ 4 years • 38 questions, many with subsets. • 89% U of MB graduates completed 2010 • 86.5% U of MB graduates completed 2011 • 89.7% U of MB graduates completed 2012 (75.4% Average ALL Schools 2012) • Three 2012 Reports received: • U of M data • Comparative data for “All Schools” • U of M narrative comments

32. CGQ – Key Component on Mistreatment Asks Students about: • Awareness of, and satisfaction with mistreatment policy • Witnessed and experienced mistreatment. • Reporting of mistreatment • Source of mistreatment • i.e. Faculty, residents, nurses, administrators, students, patients or patients’ family. • Type of mistreatment: • i.e. General mistreatment (public belittlement, humiliation); sexual mistreatment; racial/ethnic mistreatment; sexual orientation mistreatment.

33. CGQ 2012, 2011 & 2010 #29. Awareness of a mistreatment policy:

34. CGQ 2012, 2011 & 2010 #30. Did you witness mistreatment of another learner, patient or other health care professional?

35. CGQ 2012, 2011, & 2010 (All = 17 Med Schools) #30a. Source of witnessedmistreatment:

36. #31. PERSONAL MISTREATMENT 2012 CHANGE IN SCALE - Includes ALL Students, i.e. “For each of the types of mistreatment, indicate frequency you personally experienced

37. Source of personal mistreatment: (ALL = 17 Med Schools)

38. Nature of personal,GENERAL mistreatment (Mistx): • Public belittlement or humiliation • Threatened with harm or physically harmed • Required to perform services (shopping, babysitting) 2011– 17 of 23 of those who reported mistreatment 2010 – 17 of 21 of those who reported mistreatment

44. CGQ 2012, 2011 & 2010 #31c. Did you report the incident(s) to a designated faculty member or member of the medical school administration? YES20122011 2010 U of M: 10.3% of 58 26.1% of 23 28.6% of 21 (N=6) (N=6) (N=6) ALL Schools: 15.5% 26.9% 25.4%

45. CGQ 2012, 2011 & 2010 #31d. If yes, to whom did you report mistx experience(s)?

46. Action • Distribution of CGQ report to: • Dean’s Council • Department Heads • Curriculum Committees • Faculty via Dean’s presentations at Grand Rounds 2. Ongoing Scanning of Environment via: • PreClerkship course evaluations • Clerkship rotation evaluations • Electives evaluations • PARIM survey

47. Action 3. Meetings with: • Clinical Departments / grand rounds • Individual departments identified by residents and students in Accreditation reports and internal reviews • WRHA leadership including Nursing • PARIM and residents • HSC leadership 4. Core/required presentations by Dean/Associate Deans during medical students’ and residents’ orientations and during “Introduction to Clerkship”

48. Prevention 1. Education of learners : • Curricular components: • PreClerkship • Introduction to Clerkship (ITC) • Introduction to Residency in renewed curriculum • Education of teachers including residents, faculty • Policy development / entrenchment – Faculty & Program • Ongoing management of compliance with standards of the Royal College and LCME/CACMS

49. Mitigation • Surveillance of learning environment • Share information on learning environments through existing liaison committees • Encourage a culture of disclosure and support • Move to Zero tolerance