Transcript Document

University of Toronto
Pre-Survey Meeting with
Resident Representatives &
Senior Residents
Date:
September 21, 2012
Time:
9:00 – 10:30 a.m.
Room:
Queen’s Park Ballroom
Park Hyatt Hotel
Objectives of the Meeting
To review the:
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Accreditation Process
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Categories of Accreditation
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Standards of Accreditation
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Role of residents in the accreditation
process
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Pilot accreditation process
Principles of Accreditation
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Continuing quality improvement
process
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Peer-reviewed
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Based on Standards
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Categories of Accreditation
Role of the Resident in the
Accreditation Process
• Program Administration
• Member of the Residency Program Committee
• Must be elected
• Communication to and from Residency Program
Committee
• Residency programs
• Evaluation of the program
• Rotations, teachers, teaching
• Understand the Standards
Pilot Accreditation Process
The University of Toronto is one of three
universities participating in a pilot
accreditation process!
• Details for the pilot process will be
discussed later in presentation
Six Year Survey Cycle
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5
Monitoring
4
Internal Reviews
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3
Process for Pre-Survey
Questionnaires
University
Questionnaires
Specialty
Committee
Questionnaires
Comments
Royal College
Comments
Program
Director
Questionnaires &
Comments
Surveyor
The Survey Team
• Chair - Dr. Kamal Rungta
– Responsible for general conduct of survey
• Deputy chair – Dr. Anurag Saxena
– Visits teaching sites / hospitals
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Surveyors
Resident representatives – CAIR
Regulatory authorities representative – FMRAC
Teaching hospital representative – ACAHO
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 reviews
since last regular survey, if applicable
The Survey Schedule
Includes:
• Document review
(30 min)
• 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)
The Survey Schedule
Document review
(30 min)
• Residency Program Committee Minutes
• Resident Assessments
Meeting Overview
• Program director
• Overall view of program
• Evaluation of Standards
• Department chair
• Support for program
• Resources available to program
• Teaching faculty
• Involvement with residents
• Communication with program director
Meeting with ALL Residents
• Group(s) of 20 residents
(60 min)
• If off-site, tele- or video- conferencing
• Looking for balance of strengths &
challenges
• Focus on Standards
• Evaluate the learning environment
Meeting with ALL Residents
• Topics to discuss with residents
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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
Preparing for the Survey
Role of the Resident
• Complete the CAIR questionnaire
• Confidential, not given to survey team
• Meet together as a group to discuss the
strengths & challenges of your program
• 1 to 2 months before survey
• Obtain a copy of the pre-survey
questionnaires (PSQ) and the previous
survey report
• If you feel you need more time with
surveyor, request it
• Be open and honest with surveyor
• Comments in meetings are anonymous
Meeting with Residency Program
Committee
All members of RPC attend meeting,
including resident representatives
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Review Committee responsibilities
Functioning appropriately
Opportunity for surveyor to provide
feedback on information obtained
during survey
The Recommendation
• Survey team discussion
– Evening following review
• Feedback to program director
– Exit meeting with surveyor
• Morning after review
– 07:30 – 07:45
– Survey team recommendation
• Category of accreditation
• Strengths & challenges
Categories of Accreditation
New terminology
• Revised and approved by the Royal College,
CFPC and CMQ in June 2012.
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
• Accredited program with follow-up at
next regular survey
– Program demonstrates acceptable compliance
with standards.
Categories of Accreditation
Definitions
• Accredited program with follow-up by
College-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
Definitions
• Accredited program with follow-up by
external review
– Major issues identified in more than one
Standard AND concerns •
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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
Definitions
• 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 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.
After the Survey
Reports
SURVEY TEAM
COMMITTEE
Report &
Response
ROYAL COLLEGE
Reports &
Responses
SPECIALTY
ACCREDITATION
COMMITTEE
Reports
Responses
UNIVERSITY
The Accreditation Committee
• Chair + 16 members
• Ex-officio voting members (6)
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Collège des médecins du Québec (1)
Medical Schools (2)
Resident Associations (2)
Regulatory Authorities (1)
• Observers (9)
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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
The Accreditation Committee
• Decisions
– Accreditation Committee meeting
• October 2013
• Dean & postgraduate dean attend
– Sent to
• University
• Specialty Committee
• Appeal process is available
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
Standards for University & Education Sites
A1
A2
A3
University Structure
Sites for Postgraduate Medical
Education
Liaison between University and
Participating Institutions
“B” Standards
Standards for EACH residency program
B1
B2
B3
B4
B5
B6
Administrative Structure
Goals & Objectives
Structure and Organization of the
Program
Resources
Clinical, Academic & Scholarly
Content of the Program
Assessment of Resident Performance
B1 – Administrative Structure
There must be an appropriate administrative structure
for each residency program.
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Program director
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Time & support
Residency Program Committee
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Representative from each site and
major component
Resident member(s)
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Must include at least ONE elected resident
Meets regularly, four times a year
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Minutes
B1 – Administrative Structure
• Responsibilities of the Residency Program
Committee
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Selection, evaluation & promotion of residents
Ongoing review of program
Assessment of program / teachers / rotations
Research environment
Appeal mechanism
Career & stress counseling
Resident safety
B2 – Goals & Objectives
There must be a clearly worded statement outlining the
goals of the residency program and the educational
objectives of the residents.
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Rotation-specific
Structure to reflect CanMEDS Roles
Circulated to residents & teaching
staff
Used in planning and assessment
of residents
CanMEDS Roles
• Medical Expert
• Communicator
• Collaborator
• Manager
• Health Advocate
• Scholar
• Professional
B3 – Structure & Organization
There must be an organized program of rotations and
other educational experiences, both mandatory and
elective, designed to fulfill the educational
requirements and allow residents to achieve
competence in the specialty.
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Include all components of specialty
Equal opportunity
B3 – Structure & Organization
• Increasing professional responsibility
• Appropriate independence as residents
progress
• Supervision
• Call
• Frequency
• In-hospital or from home
• Expectations (e.g. cross coverage)
• Service / education balance
• Educational environment
• Promote resident safety
• Free from intimidation, harassment or abuse
B4 – Resources
There must be sufficient resources to provide the opportunity for
all residents to achieve the educational objectives.
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Teaching faculty
Variety & number of patients
Physical and technical facilities
Inpatient, ambulatory, emergency, ICU
Organized
Supervised
B5 – Clinical, Academic &
Scholarly Content of Program
There must be a clinical, academic and scholarly program
that prepares residents to fulfill all the roles of the
specialist.
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Organized academic program
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Address the CanMEDS competencies
Attendance
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Academic half-day, journal club
Staff, residents
Provide teaching
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Something more than observation and role
modeling is expected
B6 – Evaluation of Resident
Performance
There must be mechanisms to ensure systematic
assessment of each resident.
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Based on goals & objectives
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Uses appropriate and varied assessment
methods
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Feedback
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Formal, timely, appropriate
Face-to-face
Adequately documented
Pilot Accreditation Process
Scheduled from April 7 to 12, 2013
• PGME and teaching sites – A Standards
• Residency programs – B Standards
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
Scheduled for On-site Review
in April 2013
Criteria
• 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 remains the same
• PSQ Review
– Specialty Committee
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On-site survey by surveyor
Survey team recommendation
Survey report
Specialty Committee
Final decision by Accreditation Committee
– Meeting in October 2013
– Dean & postgraduate dean attend
Programs Eligible for
Exemption from On-site Review
Criteria
• Program on full approval since last regular onsite survey
Process for Programs Eligible for
Exemption
• PSQ and documentation review
– Accreditation Committee reviewer
– Specialty Committee
• Recommendations to exempt
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Accreditation Committee reviewer
Specialty Committee
Postgraduate dean
Resident organization (CAIR)
• Steering Committee (AC) Decision
– Review of recommendations
• Exempted: on-site survey not required
• Not exempted: program scheduled for on-site survey in April
– Selected program (random)
– University notified in January 2013
Contact Information at the
Royal College
[email protected]
613-730-6202
Office of Education
Margaret Kennedy
Assistant Director
Accreditation & Liaison
Educational Standards Unit
Lise Dupéré
Manager
Sylvie Lavoie
Survey Coordinator