University of Manitoba Pre-Survey Meeting with Department Heads

1. University of ManitobaPre-Survey Meeting withDepartment Heads Date: July 4, 2013 Time: 10:45 a.m. to 12:45 p.m. Room: Pharmacy Apotex, Theatre # 264

2. 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

3. Accreditation • 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

4. Principles of 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

5. Six Year Survey Cycle 1 6 Monitoring 5 2 3 4 Internal Reviews

6. Pre-Survey Process University Questionnaires Specialty Committee Questionnaires Royal College Comments Questionnaires & Comments Comments Program Director Surveyor

7. Role of 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

8. Composition of a Specialty Committee • Voting Members (chair + 5) • Canada-wide representation • Non-voting Members • Chairs of exam boards • National Specialty Society (NSS) • ALL program directors

9. The Survey Team • 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

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

11. Information Given to Surveyors • 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

12. The Survey Schedule • 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 20 - 60 min) • Teaching staff (60 min) • Residency Program Committee (60 min)

13. Meeting Overview • 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

14. 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

15. Meeting with Residency Program Committee • 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

16. 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 Winnipeg • Survey team recommendation • Category of accreditation • Strengths & weaknesses

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

18. 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

19. Categories of Accreditation Definitions • Accredited program with follow-up at next regular survey • Program demonstrates acceptable compliance with standards.

20. Categories of Accreditation Definitions • 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

21. 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

22. Categories of Accreditation Definitions • 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 (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.

23. After the Survey survey team Reports specialty committee royal college university Report & Response Reports Responses Recommendation Reports & Responses accreditation committee

24. 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)

25. Information Available to the Accreditation Committee • All pre-survey documentation available to the surveyor • Survey report • Program response • Specialty Committee recommendation • History of the program

26. The Accreditation Committee • Decisions • Accreditation Committee meeting • May/June 2014 • Dean & postgraduate dean attend • Sent to • University • Specialty Committee • Appeal process is available

27. General Standards of Accreditation “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

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

29. “B” Standards B1 Administrative Structure B2 Goals & Objectives B3 Structure and Organization of the Program B4Resources B5 Clinical, Academic & Scholarly Content of the Program B6 Assessment of Resident Performance

30. B1 – Administrative Structure 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

31. 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 head unduly influential • RPC is conducted as part of a Dept/Div meeting • No resident voice

32. 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 assessment • Distributed to residents & faculty • Reviewed regularly • At least every 2 years

33. 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

34. 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 / education balance • Resident supervision • Clearly defined role of each site / rotation • Educational environment

35. 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

36. 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, specimens and procedures • Technical resources • Ambulatory/ emergency /community resources/experiences • Educational

37. B4 – Resources “Pitfalls” • Insufficient faculty for teaching/ supervision • Insufficient clinical/technical resources • Infrastructure inadequate

38. B5 – Clinical, Academic & Scholarly Content of Program 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

39. 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

40. B6 – Assessment of Resident Performance 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

41. B6 – Assessment of Resident Performance “Pitfalls” • 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

42. University of ManitobaOn-site Survey February 23 to 28, 2014

43. Contact Information at theRoyal College accred@royalcollege.ca 613-730-6202 Office of Education Sarah Taber Assistant Director Education Strategy & Accreditation Educational Standards Unit Sylvie Lavoie Survey Coordinator