Accreditation Workshop University of Manitoba January 8, 2013 Dr. Joanne Todesco Ms. Margaret Kennedy
Agenda Introductions Principles of Accreditation Accreditation Process Standards of Accreditation Pitfalls Categories of Accreditation Evaluation of a residency program Break out session
Objectives of the Workshop At the end of the workshop you will be able to: Understand the standards of accreditation Evaluate a residency program using the Standards of Accreditation Determine the category of accreditation for a residency program Know the role of a program reviewer
Introductions Who we are Who you are Name, program Involvement in accreditation Myths about accreditation 4
Accreditation Is a process for evaluating residency programs including the educational environment to determine if the program is meeting the Standards
Principles of Accreditation Continuing quality improvement General and Specialty-specific Standards A competency framework Peer review Surveyor from different specialty Specialist input Specialty Committee Regular cycle of review Regular 6 year Royal College survey Internal review in year 3 Categories of Accreditation
Accreditation College does NOT accredit: Excellence of departments Excellence and reputation of research Quality and expertise of clinical faculty Moral worth of program directors College does evaluate: How programs meet published Standards of Accreditation
General Standards of Accreditation A Standards Apply to University and education sites B Standards Apply to EACH residency program musts vs shoulds C Standards Apply to AFC (Areas of Focused Competence) programs
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 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 1.1 Program Director Overall responsibility for program Acceptable qualifications Royal College certification - should Sufficient time & support Generally interpreted as non-clinical time for program administration Impact to operation of program
B1 Administrative Structure 1.2 Residency Program Committee (RPC) Representative from each site & major component Resident member of Committee At least one elected by the residents Accountability Meets 4 times/year; keeps minutes Communicates regularly with members of program, department, residents
B1 Administrative Structure 1.3 Responsibilities of RPC Planning and operation of program Opportunities for residents to attain competencies Selection of residents Assessment & promotion of residents Appeal mechanism Career planning & counselling Manage stress
B1 Administrative Structure 1.3 Responsibilities of RPC Ongoing program review Clinical and academic components Resources and facilities Teachers Feedback mechanisms Learning environment Anonymous Resident safety Written policy
B1 Administrative Structure 1.4 Site Coordinator Active liaison 1.5 Research coordinator 1.6 Environment of inquiry and scholarship
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 RPC is conducted as part of a Dept/Div meeting No resident voice
B2 Goals & Objectives 2.1 Overall statement 2.2 Structured to reflect the CanMEDS competencies Used in planning & assessment of residents 2.3 Rotation specific Used in planning & assessment of residents 2.4 Resident & staff have copies Used in teaching, learning, assessment Learning strategies developed at start of rotation 2.5 Regular review At least every 2 years
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 rotation specific Goals and objectives not used by faculty and/or residents Goals and objectives dysfunctional does not inform assessment Goals and objectives not reviewed regularly
B3 Structure & Organization 3.1 Program provides all components of training as outlined in the specialtyspecific documents 3.2 Appropriate supervision According to level of training, ability/competence and experience 3.3 Increasing professional responsibility 3.4 Senior resident role 3.5 Balance of service and education Ability to follow academic sessions
B3 Structure & Organization 3.6 Equivalent opportunity for each resident 3.7 Opportunity for electives 3.8 Role of each site clearly defined 3.9 Safe learning/educational environment Free from intimidation, harassment or abuse Promotes resident safety 3.10 Collaboration with other programs whose residents need to develop expertise in the specialty
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 4.1 Sufficient teaching staff From appropriate health professions 4.2 Appropriate number and variety of patients, specimens and procedures Refer to specialty-specific documents 4.3 Clinical services organized to achieve educational objectives Training in collaboration with other disciplines Inpatient, emergency, ambulatory, community Age, gender, culture, ethnicity
B4 Resources 4.4 Adequate educational resources Access to computers, on-line references Close proximity to patient care areas 4.5 Access to physical and technical resources in the setting where they are working Direct observation/privacy for confidential discussions Adequate space for residents 4.6 Adequate supporting facilities ICU, diagnostic, laboratory
B4 Resources pitfalls Insufficient faculty for teaching/supervision Insufficient clinical/technical resources Infrastructure inadequate
B5 Clinical, Academic & Scholarly Content of Program Evidence of teaching each of the CanMEDS roles Medical Expert Communicator Collaborator Manager Health Advocate Scholar Professional 25
B5 Clinical, Academic & Scholarly Content of Program Academic program Organized curriculum Organized teaching in basic & clinical sciences
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 6.1 Based on Goals & Objectives Identified methods of assessment Level of performance expected 6.2 Assessment consistent with characteristic being assessed Based on specialty-specific requirements 6.3 Timely, regular, documented feedback Face-to-face meetings 6.4 Residents informed of serious concerns
B6 Assessment of Resident Performance pitfalls Mechanism to monitor, promote, remediate residents lacking Assessments not timely, not face to face Summative assessment (ITER) inconsistent with formative feedback, unclearly documents concerns/weaknesses Assessment of CanMEDS competencies is lacking
The Accreditation Process
Six Year Survey Cycle 6 1 5 Monitoring 2 4 Internal Reviews 3
Responsibility for PGME at the Royal College COUNCIL EDUCATION COMMITTEE
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
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 Chair Deputy chair Surveyors Medical educators from other disciplines Resident representatives CAIR Regulatory authorities representative FMRAC Teaching hospital representative ACAHO
Role of the Surveyor Assess how the program is meeting standards at the time of review/survey Looking for evidence
Information Given to Surveyors Program questionnaires (PSQ) and appendices Completed by program Program-specific Standards (OTR/STR/SSA) Report of last regular survey Plus reports of mandated Royal College reviews since last regular survey, if applicable Specialty Committee comments Also sent to PGD / PD prior to visit Exam results for last six years
The Survey Schedule Includes: Document review (30 min) Minutes, Residency Program Committee Resident Assessments Meetings with: Program director (75 min) Department chairs (30 min) Residents per group of 20 (60 min) Teaching staff (60 min) Residency Program Committee (60 min)
After the Survey SURVEY TEAM Reports SPECIALTY COMMITTEE Report & Response ROYAL COLLEGE Reports Responses UNIVERSITY Reports & Responses 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 All pre-survey documentation available to surveyor Survey report Program response Specialty Committee recommendation History of the program
Categories of Accreditation
Categories of Accreditation Accredited new program 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 Withdrawal of Accreditation
Accredited new program An acceptable application for a residency program Internal review to be conducted within 24 months of resident being enrolled
Accredited program with follow-up at next regular survey Program demonstrates acceptable compliance with standards University internal review conducted at mid-cycle
Accredited program with follow-up by internal review Major issues identified in more than one Standard Internal review of program required and conducted by University Review of program Internal review conducted within 24 months
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 noneducational 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
Accredited program on notice 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 within 24 months College appoints a 2-3 member review team At the time of the review, the program will be required to show why accreditation should not be withdrawn 50
The Accreditation Committee Decisions Accreditation Committee meeting Dean & postgraduate dean attend Sent to University Specialty Committee Appeal process is available