Accreditation Information Session Provincial Association of Resident Physicians of Alberta Assembly Meeting August 26, 2014 Mr. Denis Laliberté Team Lead, Survey Deployment Royal College of Physicians and Surgeons of Canada Ms. Judith Scott Accreditation Manager College of Family Physicians of Canada Dr. Michael Gousseau Board Member, Canadian Association of Internes & Residents PGY 3 Otolaryngology Head and Neck Surgery University of Manitoba
What is accreditation? The accreditation process of postgraduate medical education (PGME) The role of residents in the accreditation process What happens before, during and after the accreditation visit? How can we prepare?
Accreditation of Family Medicine and Royal College residency programs will take place at the University of Calgary, February 22-27, 2015.
A peer-reviewed process of continuous quality improvement Based on Standards common to all postgraduate medical training programs in Canada An opportunity to promote your program s strengths and identify areas for improvement Residents play an integral role in the Accreditation process in Canada
meant to improve the quality of residency education by seeking to ensure that all necessary resources are available and utilized efficiently and effectively to enable residents to meet the training requirements of their specialty, subspecialty or area of focused competence
Accreditation is NOT a test Accreditation has no bearing on your FITER A resident would not lose their position due to accreditation status
Internal Reviews The PGME accreditation process in Canada is based on a system of regular formal full University survey visits that occur every six years 6 1 5 Ongoing Monitoring 2 4 3
A Standards Apply to University, specifically the office of the Postgraduate Dean and Educational sites B Standards Apply to EACH residency program C Standards Apply to Areas of Focused Competence (AFC) programs (Royal College only)
Pre-Survey visit - the Colleges meet with the Programs and chief residents in September 2014. Pre-Survey documentation for the Survey Team is prepared. These include: Pre-survey questionnaires (PSQs) completed by the programs Program-specific Standards (OTR/STR/SSA) Report of last regular survey Exam results for last six years Reports of mandated CFPC and Royal College reviews since last regular survey, if applicable.
As part of the accreditation process, PARA will send the CAIR pre-accreditation questionnaire in the Fall to residents in a Royal College or Family Medicine program at the University of Calgary. This questionnaire is specifically designed to obtain your perspective on your training. Results are confidential, anonymous and NOT given to the survey team, your program or faculty. PARA collates the results and the report is provided ONLY to the resident representatives on the Royal College and CFPC Survey teams.
Recommendations: Create a Resident Team at PARA with responsibility for finalizing the Pre-accreditation report that will be made available to the resident surveyors Publicize accreditation EARLY & provide CAIR Accreditation Manual to members Survey on-line and send multiple reminders Offer to meet with residents by program or during halfdays.
Composition of the Royal College and CFPC Survey Teams: Chair/Deputy Chair Surveyors (Specialists from a variety of disciplines) Resident Representatives (CAIR) Regulatory Authority Representative (FMRAC) Teaching Hospital Representative (HealthCareCAN, formerly ACAHO)
Survey Team reviews documents (Residency Program Committee Minutes, Pre-Survey Documentation etc.) Survey Team meets with: 1. Program Director 2. Department head 3. Teaching faculty 4. Residents 5. Residency Program Committee
Program director Overall view of program Evidence on how program is meeting the Standards Response to previous challenges Department head Support for program Resources available to program Teaching faculty Involvement with residents Communication with program director
Group(s) of 20 residents [Tele-or video- conferencing options if off-site] Looking for balance of strengths & challenges; focus on Standards Of all the meetings, the time with the residents has perhaps the greatest influence on the surveyors One caution is to ensure that there are no significant surprises for surveyors. Serious concerns should have been raised previously (Residency Program Committee, University-led Internal Review, or the pre-accreditation questionnaire).
Environment for residency education Service to education balance Educational environment Supervision Resident orientation and input
How program supports residents to achieve competencies Objectives of training On-going assessments of resident performance Increasing professional responsibility Academic program / protected time Program evaluation Career counseling; Safety; Intimidation and harassment
Survey team discussions occur every evening following meetings. Feedback is provided to the program director o o Exit meeting with surveyors Survey team recommendation Category of accreditation Strengths & weaknesses
1. Accreditation is your opportunity to openly and honestly evaluate, and help improve the quality of your residency program with complete anonymity. 2. The feedback given to the survey team will help your program to continue to promote areas of strength and at the same time, focus on areas that need improvement. 3. Be prepared to answer key questions during the survey team visit: o What program strengths do you wish to highlight? o What are the areas that need improvement? o What can accreditation do to improve your residency program? o What resources do you need?
4. Concerns about a training program should be identified by residents prior to the survey visit (for example, Residency Program Committee, University-led Internal Review, the preaccreditation questionnaire). 5. The survey team will meet with every resident (in small groups) during the survey visit in February. 6. Residents should meet as a group prior to the survey visit in February to set priorities for discussion with the accreditors, establish speakers, and provide examples and documentation. 7. Complete the CAIR pre-accreditation questionnaire!
SURVEY TEAM Reports ROYAL COLLEGE SPECIALTY COMMITTEE Report & Response ROYAL COLLEGE Reports Responses UNIVERSITY Reports & Responses ROYAL COLLEGE ACCREDITATION COMMITTEE {DECISION}
SURVEY TEAM Reports COLLEGE OF FAMILY PHYSICIANS OF CANADA Reports Responses UNIVERSITY Reports & Responses CFPC ACCREDITATION COMMITTEE {DECISION}
How are we provided with the feedback? Survey Team Report and Recommendations Program Response Accreditation Committee deliberation and decision [Dean & postgraduate dean attend] Categories of Approval Appeal Process is available Reports sent to University Specialty Committee (Royal College)
Survey report All documentation available to the surveyor Program response Specialty Committee recommendation History of the program Discussion with the Dean and the Postgraduate Dean
New terminology Approved by the Royal College, CFPC and CMQ, June 2012
Accredited program Follow-up: o Next regular survey o Progress report (Accreditation Committee) o Internal review o External review Accredited program on notice of intent to withdraw accreditation Follow-up: o External review
Accredited program with follow-up at next regular survey o Program demonstrates acceptable compliance with standards. Accredited program with follow-up by Collegemandated internal review o Major issues identified in more than one Standard o Internal review of program required and conducted by University o Internal review due within 24 months.
Accredited program with follow-up by external review o 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. o External review conducted within 24 months o College appoints a three-member review team (2 specialists + 1 resident) o Same format as regular survey
Accredited program on notice of intent to withdraw accreditation o Major and/or continuing non-compliance with one or more Standards which calls into question the educational environment and/or integrity of the program o External review conducted by three people (2 specialists + 1 resident) within 24 months o At the time of the review, the program will be required to show why accreditation should not be withdrawn.
Residents are critical to the process, and your input is highly valued. Accreditation is an ongoing dialogue between the programs, the College, external organizations. Maintaining the standards means maintaining excellent programs and producing physicians who are ready for practice. Accreditation provides residents the mechanism to effect positive changes on their residency programs that in many situations will result in significant long-term benefits.
Dr. Michael Gousseau CAIR Board Member PGY 3 Otolaryngology Head and Neck Surgery University of Manitoba cair@cair.ca Mr. Denis Laliberté Team Lead, Survey Deployment Royal College of Physicians and Surgeons of Canada accred@royalcollege.ca Ms. Judith Scott Accreditation Manager College of Family Physicians of Canada jg@cfpc.ca
Any questions?