Purpose  

Accreditation ensures that the University, the Faculty of Medicine, the PGME office,  as well as every residency and AFC program meets the standards as determined receive the training to equip them with the knowledge, skills, and behaviours for success in their certification examinations and excellence in the practice of their discipline in a supportive learning environment 

It provides the framework for continuous improvement in all aspects of the delivery of outstanding quality  and AFC programs. 

Process  

Monitoring and oversight of the accreditation standards for everyprogram are conducted by the PGME Accreditation Subcommittee, led by the Director of PGME Accreditation and supported by the Vice and Assistant Deans (PGME).  Committee membership includes a representative from each of the Medicine, Surgery, Pediatrics, Laboratory Medicine and Family Medicine departments, and  rotating membership from other departments to ensure a diversity of perspectives.  Local resident PARO representatives also sit on this committee 

What Happens During an Accreditation Visit? 

Physicians and surgeons from across Canada are appointed  by the  two Colleges to come to Ottawa to complete a full review of accreditation standards at both the program and institutional levels, to ensure that we are meeting and/or exceeding standards.  These volunteers are called surveyors.  

In advance of the onsite visit, PG training programs and the PGME office complete their reports in the CanAMS tool and gather appropriate documentation, 3-4 months in advance of the scheduled onsite visit. Programs and the PGME office are required to report on their activity on addressing new and the current state of previously identified areas for improvement (AFIs).  Surveyors  access the documents to prepare for the visit to determine what questions to ask key stakeholder groups. Surveyors meet all stakeholders, including: 

At the Program level: 

Learners: Residents 

Program teams: Program Directors, Residency Program Committees, Competence Committees 

Faculty : all teachers engaged with the program 

Administrators: Program Administrators 

Leadership: Division Heads, Department Chairs 

At the Institution level: 

University leadership:

President and Vice Chancellor; Dean of the Faculty of Medicine; Senior Vice-Dean  Medical Education; Vice-Dean, PGME; Assistant Dean, PGME 

PGME Committees:

PGEC, Accreditation, CBME, Evaluation & Professionalism 

Hospital Leadership:

Hospital liaisons; Department Chairs; Program Directors; Vice-Chairs Education 

Administrative Teams:

PGME Office; Program Administrators 

Surveyors cite specific standards in their report., A summary report is provided the day after the site visit is completed, followed by an official report from the respective Colleges within a few months. Areas for improvement identified are expected to be addressed throughout the ensuing 8-year accreditation survey cycle. 

What to Expect During an Accreditation Visit 

The PGME Accreditation Director and the PGME office Accreditation Coordinator will work closely with the Colleges to structure the timing of visits in the programs. This will be communicated to programs by the PGME office. 

Program Administrators will complete a templated schedule indicating when and where it will take place on the review day with the survey team  

You must meet with the reviewers of your program – please be on time to attend the meeting at the scheduled time and make sure to keep your answers clear and concise, to allow time for questions and fruitful discussion. Trainees MUST be released from clinical duties to attend accreditation meetings with the survey team. Trainees who are not required to attend accreditation meetings include those on vacation, other approved leave or those unable to attend due to illness. 

Meetings will be held in the strictest of confidence, without any other stakeholder group present. In the final report, concerns and issues raised will remain completely anonymous. However, all information gathered during the review process must be done openly within the assigned groups during their scheduled meetings. No private communication can occur with the survey team outside  the scheduled meeting time.  

The Canadian Residency Accreditation Consortium (CanRAC) is comprised of the three Canadian medical education accrediting bodies:  the RCPSC, the CFPC and the Collège des médecins du Québec (CMQ).  This partnership developed CanERA (Canadian Excellence in Residency Accreditation).  The CanERA conjoint accreditation process is built on robust standards that set high and uniform expectations of the objective evaluation and continuous improvement of Canadian institutions, residency and fellowship programs. The terminology used for the standards is important and is provided below. 

CanERA

The CanERA suite of general standards, rolled out in 2019, consists of 

• General Standards of Accreditation for Institutions with Residency Programs 
• General Standards of Accreditation in Residency Programs 

Each accredited program must meet the CanERA general standards as well as additional accreditation expectations specific to the discipline, including required educational experiences and content, assessment and resources. 

Documentation of how a program meets the required standards is found on CanAMS (Canadian Accreditation Monitoring System), the platform constructed and maintained by the Colleges, including updates of any changes of accreditation standards.  Every program director and program administrator has access to maintain their program’s profile on this digital platform.   

Accredited Specialty Residency Program

Discipline-specific standards for Royal College residency programs incorporate the General Standards as well as discipline-specific expectations.  Access to accreditation standards for each discipline can be found on the Royal College website.  

Accredited Family Medicine Residency Programs

The CFPC accredits residency training programs in Family Medicine and Enhanced Skills at all medical schools in Canada.  Discipline-specific standards for Family Medicine and Enhanced Skills programs are set out in the Standards of Accreditation for Residency Programs In Family Medicine. This document comprehensively includes expectations specific to Family Medicine residency programs as well as those set out in the General Standards applicable to all residency programs. 

Accredited Areas of Focused Competence (AFC) (Diploma) Programs 

Accredited AFC programs sponsored by a university follow a separate set of CanERA Standards that are modified to meet the Royal College AFC accreditation requirements.  These standards were revised and rolled out in 2021.  General AFC Standards and discipline specific standards can be found on the Royal College website.  

Accreditation categories

The Colleges determine a category of accreditation for each program at the time of a full review and with each mandated report submitted to the College:

• Accredited program, Follow up next Regular Survey - current process is an 8-year cycle 
• Accredited program, Follow-up with Action Plan Outcomes Report (APOR) in 18-24 months which can be either a: 
  • Written program APOR submitted on CanAMS
  • Mandated Internal Review with APOR submitted on CanAMS
• Accredited program, Follow up with External Review in 18-24 months
• Accredited program on Notice of Intent to Withdraw, Follow up by External Review in 18-24 months

To ensure that PGME programs always strive for excellence and make progress towards addressing AFI’s identified at the most recent accreditation visit, the accreditation office conducts reviews periodically during the eight-year cycle: 

Internal Preparatory Review 

This review is considered a quality assurance survey, conducted by the PGME Accreditation Subcommittee by a team of two faculty members and one resident over a full day.  Reviews are conducted in the same manner as would be expected in a full accreditation survey visit, with review team members granted temporary access to the program’s CanAMS profile as well as documents from the program (e.g., meeting minutes;  access to trainee confidential assessment information (with learner consent)). This team conducts interviews with each stakeholder group of the training program.   The resulting internal review report summarizes  information according to the discipline-specific standards and is submitted to the PGME Accreditation Committee.  Finalized reports are returned to the program director and residency program committee  to find solutions for any identified areas for improvement (AFIs) and allow for  reflection.   

The goals of an internal preparatory review are: 

1. To provide a regular cycle of program quality assurance  between full accreditation survey visits.  This equips PGME and programs with an understanding of  programs’ progress addressing identified AFIs prior to the next regular survey visit. 

2. For programs requiring Action Plan Outcome Reports, to conduct preparatory reviews  prior to the formal mandated 18–24-month reporting period to the College. 

3. To allow PGME to understand how the program is performing against accreditation standards and to deploy support where required.  If any signals indicate problems, further internal reviews will be conducted as decided by the Accreditation Subcommittee. 

4. To allow common AFI themes across multiple programs to be identified and addressed centrally through creation of policy or educational resources. 

5. To notify programs as to any new or existing  AFIs requiring action  

6. To prepare programs for any upcoming mandated internal or external review or for an upcoming regularly scheduled accreditation visit.  

Preparatory review follow-up occurs within 18-24 months and may include a written report from the program to the PGME Accreditation Subcommittee on the progress/resolution of any identified AFIs, or another full team review conducted by PGME.  Information from written reports is reviewed by the Director of Accreditation and Committee representative(s), and may be forwarded to Departmental Vice-Chairs of Education and/or Chairs as appropriate. 

Mandated Internal 

This type of review is carried out by three reviewers (2 faculty and 1 resident) over a full day . uOttawa reviewers approved by the Director of Accreditation conduct these reviews.  A report is produced and reviewed by the Accreditation Subcommittee.  The Director of Accreditation completes the Action Plan Outcomes Report (APOR) on CanAMS and submits to the respective College before the required deadline.  Programs may review the report generated by the review team but must wait for a decision letter from the College regarding the final determination of accreditation status.  Depending on the timing of the APOR review as relates to the standard meeting times of the Royal College Residency Accreditation Committee(Res-AC), or CFPC Accreditation Committee, a final decision (Transmittal) letter may take months to be Issued to the PG Deans. 

External Review 

Reviewers for a mandated external review are appointed by the responsible accrediting College (RCPSC or CFPC).  The composition of this team include a specialist in the discipline under review, a specialist in another discipline and a resident member. All are external persons. The PGME office will facilitate communication to the program and access to the documents as required.  At the end of this review, the surveyors will transmit to the Program Director and PG Deans a recommendation to the relevant College’s Accreditation Committee. That College’s Accreditation Committee will at its next meeting issue the final accreditation status in a decision letter to the PG Deans. Depending on the timing of the external review as relates to the standard meeting times of the Royal College Residency Accreditation Committee (Res-AC)/the CFPC Accreditation Committeea final decision letter may take months to be Issued to the PG Deans. 

Further information about accreditation process and residency program status can be obtain by contacting the Postgraduate Medical Education Office.