Terms of Reference

General Provisions 

This committee is a subcommittee of the Postgraduate Medical Education (PGME) Committee with the option of appointing additional members representing an affiliated hospital(s) or a non-hospital teaching or research site(s) (henceforth referred to as “non-hospital site”). The committee’s mandate is to investigate professionalism complaints involving a resident or fellow, as per the Faculty of Medicine Professionalism Policy. The Postgraduate Professionalism Committee (henceforth referred to as the “Committee”) reports to the Vice Dean, PGME, or their delegate, on the cases and the decisions. The decisions of this committee may be appealed to the Faculty Council according to the policies and procedures of the PGME office and the Faculty of Medicine.

SECTION 1: MEMBERSHIP

​​​​​​1.1 Committee membership shall consist of:

1. Chair, appointed by the Postgraduate Medical Education Committee (three years, renewable once after review);
2. Assistant Dean, PGME (ex-officio – non-voting);
3. One Faculty Member, appointed by the Vice Dean, Postgraduate Medical Education (PGME) who is FRCPC certified (three years, renewable once);
4. One Faculty Member appointed by the Vice Dean, Postgraduate Medical Education (PGME) who is CCFP certified (three years, renewable once);
5. Two Faculty Members appointed by the Vice Dean, Postgraduate Medical Education (three years, renewable once);
6. One resident representative elected by PARO (one year);
7. One Faculty Member nominated by the respective Chief of Staff or other senior medical administrator of an affiliated hospital or the Medical Director of a non-hospital site and appointed by the Chair of the Professionalism Committee on a case by case basis, usually when a joint investigation is conducted with an affiliated hospital or a non-hospital site (non-voting).

1.2 It is expected that committee members will attend at least 75% of scheduled meetings.  Inability to attend the required percentage of meetings will result in removal from the committee.

SECTION 2: MEETINGS

2.1 The Committee will meet to oversee matters related to residents and fellows as respondents to professionalism complaints; when a professionalism complaint(s) is investigated; when a hearing on a professionalism complaint is conducted; or at the prerogative of the Chair.

2.2 Quorum will be four (4) members, one of which must be the Chair.
 

SECTION 3: CONFLICT OF INTEREST

3.1 A member of the Committee should recuse him/herself when dealing with an investigation where the member was materially involved in the completion of an evaluation and/or made a recommendation and/or rendered a decision in the matter which is the subject of the complaint. Prior to considering any case, the Chair will disclose any conflict they have and require committee members to do the same.  The Chair will also invite committee members to raise any potential conflicts of interest they feel have not been declared by others.  All potential conflicts will be reviewed by the committee who will decide if the declarations should result in the member recusing themselves from discussion.  These declarations and decisions will be noted in the official minutes of the committee.
 

SECTION 4: FUNCTIONS OF THE COMMITTEE  

4.1 On behalf of the Vice Dean PGME, in relation to a resident or fellow responding to professionalism complaints deemed at Level 2 or higher as per the Faculty of Medicine Professionalism Policy, the Committee:

• When applicable, reviews and renders a decision on the appropriateness of information sharing regarding a complaint between affiliated hospitals and the Faculty of Medicine.
• Reviews and renders a decision on an investigation process, including the appropriateness of involving the affiliated hospital(s) or non-hospital site(s) in the investigation.
• Renders a decision regarding the validity of a Level 2 or 3 complaint.
• Reviews and renders a decision on the violation of a Level 2 or 3 complaint, if applicable, as per the Faculty of Medicine Professionalism Policy.
• Recommends a course of intervention and follow-up to the Vice Dean, PGME.
   

SECTION 5: PROCESSES OF THE COMMITTEE

5.1 Professionalism database. The particulars of complaints deemed at Level 2 or higher will be tracked in a central database as per the Faculty of Medicine Professionalism Policy. Any complaint resulting in a formal investigational process, or considered potentially egregious are considered as Level 3 as well. During the investigation of a Level 2 complaint, new information or context may result in escalating the complaint to Level 3.

5.2 Framework for Investigations of Complaints. The approach to investigation of a professionalism complaint will include, but is not limited to, the following elements: a) confirm the lapse; b) understand the context; c) communicate and discuss in a mutually respectful manner; d) encourage self-reflection; e) agree on a plan for remediation, especially at Level 2; f) document the interventions; and g) construct a plan for follow-up. Confidentiality is paramount although it is understood that the necessary processes may make anonymity a challenge.

5.3 Sharing of Information with affiliated hospitals or non-hospital sites. The sharing of details of the complaint between institutions will be considered. Complaints deemed at Level 2 or higher will be reviewed using criteria outlined in the Professionalism Policy, section 7.3.4, and a decision will be made on the appropriateness of such sharing of details between institutions. The resident or fellow and the Program Director responsible will be notified of the decision in writing.  Consent is not required for sharing of information with these parties.

5.4 Investigation of a complaint. The Committee is responsible for conducting the investigation of a complaint deemed at Level 3, and has oversight on the investigation of complaints deemed at Level 2, which may be investigated by the Program Director responsible for the resident or fellow. The Committee may retain the advice or assistance of a third party in its investigations. If the sharing of details of the complaint between the resident or fellow and the affiliated hospital(s) or non-hospital site(s) is deemed appropriate as per above, the Committee then makes a decision on a process of investigation as per the Professionalism Policy, section 7.3.7, including inviting a representative to sit on the Committee or nominating a representative from the Committee to participate in the hospital or non-hospital site process of investigation. The resident or fellow and the Program Director responsible will be notified of the process in writing.

5.5 Determining the validity of a complaint. Level 2 complaints are considered formative, with “guided intervention by authority”¹, and a formal investigation is not always conducted. As such, the validity of a complaint as per legal standards is not always possible. For Level 3 complaints, a formal investigation is conducted and the Committee will determine the validity of the complaint. Validity of a complaint speaks to the alleged events having occurred or not; it does not speak to the lapse or violation of policies or procedures of the Faculty of Medicine.

5.6 Determining the violation. For Level 2 complaints, an area of potential violation or lapse should be identified as per section 5.2. For Level 3 complaints, the violation as per the Faculty of Medicine Professionalism Policy should be identified. Since the bylaws, policies, and procedures differ somewhat between the Faculty of Medicine and affiliated hospital(s) or non-hospital site(s), a valid complaint may trigger different lapses or violations in the different institutions.

5.7 Determining the intervention. The range of interventions is outlined in the Faculty of Medicine Professionalism Policy, section 6.2. For Level 2 complaints, the Committee and the Program Director/Residency Program Committee responsible for the resident or fellow will jointly create a plan for intervention and follow-up. For Level 3 complaints, the Committee recommends a plan of intervention and follow-up, taking into consideration past cases, stakeholder input, the complainant’s input and the respondent’s input.

5.8 Report to the Dean. For Level 2 complaints, the Chair of the Committee will provide a summative aggregate report to the Vice-Dean PGME on regular intervals. For Level 3 complaints, a confidential draft report will be provided to the resident or fellow and the responsible Program Director, as per the Faculty of Medicine Professionalism Policy, section 7.3.10. The resident or fellow and the responsible Program Director may provide written comments to the Postgraduate Professionalism Investigation Committee within ten (10) working days. A final report is then sent to the Vice-Dean PGME as per the Faculty of Medicine Professionalism Policy, section 7.3.11, who will determine the final course of action.
 

SECTION 6: CONDUCT OF HEARING

6.1 The hearing will be for Level 3 complaints to determine the validity of the complaint.

6.2 The hearing will be attended by Committee members only.

6.3 The hearing will be chaired by the Chair. The Committee will decide any issue as to procedure or evidence at the hearing.   The Committee will appoint an alternate Chair if the Chair is in conflict.

6.4 Third party advice, assistance, written statements or affidavits may be collected prior to the hearing.

6.5 At the commencement of the hearing, the Chair will summarize the procedure for the hearing and reaffirm the allocated time provided for the hearing among the complainant, the respondent, appropriate witness(es) or written statements.

6.6 The complainant and the respondent will be interviewed separately.  Either can have counsel present but counsel are not permitted to participate during the hearing.

6.7 The complainant will make his presentation after which the members of the Committee will be given the opportunity to question the complainant. The complainant will be given the opportunity to make brief closing statements.

6.8 The respondent will then make his presentation after which the members of the Committee will be given the opportunity to question the respondent. The respondent will be given the opportunity to make brief closing statements.

6.9 Since the complainant and respondent are interviewed separately, the Committee may have to deliberate on the evidence and formulate a decision at a later date.

6.10 Summary Minutes of the meeting will be taken by administrative staff,. Hearings are not transcribed verbatim.
 

SECTION 7: DECISION OF THE HEARING 

7.1 The Committee may:

• Find the details of the complaint true and valid;
• Find some of the details of the complaint to be true and valid;
• Find the alleged incident in the complaint to be unsubstantiated at this point and further investigations are needed;
• Find the alleged incident in the complaint to be unsubstantiated and no further investigations are needed.

7.2 The decision of the Committee will be by a show of hands, and will be determined by a majority of the members present. The Chair will vote only in the event of a tie. The decision of the Committee will be recorded in the meeting minutes of the Committee. Individual votes will not be recorded.

SECTION 8: NOTICE OF DECISION AND REASONS

8.1 The Chair will draft a decision and reasons for the decision within 3-5 days of the hearing and will send to the Committee for feedback within 3-5 days.  The decision and the reasons for the decision will then be sent to the respondent and the responsible Program Director within two (2) weeks of the date of the decision. Copies of the decision and reasons will also be sent to the Vice Dean PGME.
 

SECTION 9: MINUTES OF THE HEARING

9.1 The minutes of the Postgraduate Professionalism Investigation Committee will include the date and time of the hearing; those present; a brief summary of the hearing; and the Committee’s decision and reasons.

SECTION 10: REPORT TO THE FACULTY COUNCIL

10.1 The Chair of the Postgraduate Professionalism Investigation Committee will prepare an annual written report for the Vice-Dean PGME, summarizing the activities of the Committee and its decisions, without disclosing the name(s) of the respondents or complainants involved. The report may also propose any general recommendations to improve professionalism within the Faculty.

SECTION 11: APPEAL OF COMMITTEE’S DECISION

11.1 Decisions of the Postgraduate Professionalism Investigation Committee are final and binding as far as the Faculty of Medicine is concerned.

11.2 A complainant or respondent may appeal the decision of the Postgraduate Professionalism Investigation Committee to the Faculty Council according to the policies and procedures of the Faculty of Medicine PGME office.  Any formal discipline, suspension or dismissal of a resident initiated by the hospital would be subject to the grievance procedure in the PARO-CAHO Collective Agreement.

SECTION 12: CONFIDENTIALITY

12.1 The documents provided to the Committee at meetings shall be retained by the Chair of the Postgraduate Professionalism Committee. All deliberations of the Committee and all information received by the Committee shall be confidential except for such disclosure as is necessary for the Committee’s Reports.
 

References
Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007 Nov;82(11):1040-8. PubMed PMID: 17971689. Epub 2007/11/01. eng.

GENERAL PROVISIONS

The PGY-1 Residency Allocation Committee is a standing subcommittee of the Postgraduate Education Committee (PGEC) that acts in an advisory capacity for the allocation of residency positions in each of the PGY-1 postgraduate medical education (PGME) programs offered at the University of Ottawa, and reports on issues relevant to PGY1 resident placement planning.

MEMBERSHIP

The PGY-1 Residency Allocation Committee comprises eight (8) members as follows:

1. Vice-Dean, PGME (ex-officio), who shall sit as Chair;

2. Assistant Dean, PGME (ex-officio);
3. Three (3) Program Directors from any active subspecialty residency training program, or from any AFC program;
4. One (1) resident;
5. One (1) faculty member
6. One (1) community Member

NOTE: Program Directors from any PGY-1 entry program, Department Chairs and Division Heads are not eligible to sit as the faculty member representative.

Membership is for a three (3) year term, renewable once. The terms will normally begin onJanuary 1. 

Program Directors and Department Chairs are invited to submit nominations for membership.  Voting members of PGEC will review nominations for vacant positions and conduct a vote at December PGEC of any given year. Important qualities for potential PRAC members include but are not limited to:

• Experience in Post Graduate Medical Education
• A demonstrated history of collaboration and impartiality

MEETINGS

The committee shall meet once per year to review and determine allocation pursuant to Ministry of Health (MOH) reporting. Additional meetings may be scheduled, as required, for the Committee to respond to appeals, communicate with the PGEC concerning current issues, etc. Quorum is three (3) voting members, in addition to the committee chair.

CONFLICT OF INTEREST

If a member of the PGY-1 Residency Allocation Committee assumes a position of Program Director in an active PGY-1 entry program, Department Chair or Division Head, the individual will be asked to step down as a member of the Committee.

FUNCTIONS OF THE COMMITTEE

The committee will be responsible to:

1. Review the existing allocation of Ministry of Health funded PGY-1 entry residency positions to postgraduate training programs,

2. Ensure an equitable ratio of CMG: IMG PGY1 entry positions for all programs.
3. Review information relating to the need, strengths, and weaknesses of the postgraduate programs within the Faculty and recommend changes as required;
4. Identify and assess positions for new PGY-1 programs.
5. Report decisions to the PGEC concerning the number of residency positions allocated to each postgraduate program based on the needs, strengths and weaknesses, and manage appeals as they arise.
6. Assess the rationalization criteria and include recommendations for changes to the criteria in the final report to be submitted to the PGEC and the MOH.

PROCESSES OF THE COMMITTEE

NOTE: Operational processes of the committee are subject to change due to timing of information received by the MOH and timing of PGEC meetings. Changes to the process noted below should not constitute the requirement for approval from any committee except the PGY-1 Residency Allocation Committee.

Processes of the PGY-1 Residency Allocation Committee include, but are not limited to:

1. In the Fall of every year, the existing Rationalization Criteria are discussed at the full Program Director’s meeting.
2. Each January/February, PGY-1 Program Directors are asked to submit a proposal on the allocation of MOH entry-level residency positions to their program according to the Rationalization Criteria. Department Chairs are sent a copy of this notice. All PGY-1 entry-level programs are required to submit a response.
3. Program responses are sent to members of the PGY-1 Residency Allocation Committee at least two (2) weeks prior to the meeting. Responses are to be accompanied by the following documentation:
   • Memo to committee highlighting issues which need reflection when reviewing documentation;
   • Rationalization criteria;
   • University of Ottawa data (i.e. a summary of positions by program, level and type of funding, distribution of CMG:IMG positions);
   • History of allocations at PGY-1 level, including: quotas, actuals, attritions, transfers, and number of Foreign Medical Graduates/Visa Trainees enrolled;
   • Provincial data (i.e. a summary of positions by University and Program); and
   • PGY-1 Residency Allocation Committee recommendations (from the previous 2 years).
4. Recommendations are drafted and sent to Committee members for final approval.
5. Recommendations are sent to the Program Directors (with a copy sent to Department Chairs), with the appeal mechanism to the PGY-1 Residency Allocation Committee included.

APPEALS PROCESS

If a program does not agree with the recommendations, a notice of appeal must be submitted in writing by the Program Director no later than ten (10) business days following receipt of the annual PGY-1 allocation report. The written notice must include the reason(s) for submitting an appeal.

In the event that a program might be adversely affected by a revised decision due to another program’s appeal, the Vice-Dean will invite the affected program’s Director to meet with the Committee as well.

The Committee meets with the Program Director(s) appealing the recommendations. Only the Program Directors are permitted to meet with the Committee.

FINAL RECOMMENDATIONS

PGY-1 Residency Allocation Committee shall meet on an as needed basis to finalize the recommendations.

Final recommendations concerning residency allocation are presented for information only at the June PGEC meeting; a copy shall be sent to the Department Chairs and the Dean. Once presented, no further opportunities to modify the recommendations will be permitted.

Membership

Chair: Faculty member, appointed by the Vice-Dean, PGME

Voting Members:

Six faculty members with at least one member from each of the following:

• Family Medicine
• Royal College - surgical specialty or subspecialty
• Royal College – non-surgical specialty or subspecialty

Resident Members:

Two residents - one appointed by PARO

Non-voting members:

Assistant Dean, PGME
Assistant Dean, Wellness
Director of Academic Support
Vice-Dean, PGME (ex-officio)

The Chair will invite the Program Director or delegate to present to the committee when any new plans are being proposed involving a trainee, including extension of training, reintegration, remediation, probation and reclassification. Note that the invited Program Director or delegate will be present at the meeting to provide background and answer questions regarding their own specific trainees.  Once they have presented and have answered these questions, they will be asked to leave the meeting so committee members may continue to review the plans or decisions.  Trainees will be invited to provide a written submission to the committee.

Term Of Appointment

5 years, renewable once

Resident member – 1 year (renewable)

Quorum

Chair and four voting members of the committee, one of which must be a trainee.

Frequency Of Meetings

The subcommittee meets monthly from September to June, and ad hoc at the request of the chair.

Attendance At Meetings

It is expected that subcommittee members will attend at least 75% of scheduled meetings. Failure to attend the required percentage of meetings will result in removal from the subcommittee.

Functions Of The Subcommittee

On behalf of the Faculty Postgraduate Medical Education Committee (PGEC):

• To review the Policy for the Assessment of Postgraduate Trainees at least once annually and suggest recommendations for revision as required.
• Ensure that regulations and policies have been adhered to and that trainees are being treated fairly. The Chair of the Evaluation Subcommittee will receive a letter from the Assistant Dean, PGME outlining that he/she has met with the trainee, has ensured that the trainee has been given the opportunity to address the RPC either in person or in writing, has ensured that the trainee has been made aware that they can make a written submission to the evaluation subcommittee, and has reviewed the PGME Assessment Policy and Appeals policies with the trainee.
• At the request of the Assistant Dean, PGME, to review the cases of trainees in academic difficulty and review recommendations from the Program for extension of training, reintegration, remediation, probation and reclassification in order to make recommendations on the progression of trainees through the program. The review may include the evaluation of the trainee’s academic, behavioral, ethical and professional performance in the program, or the evaluation/recommendation from an independent process. The subcommittee may accept (ratify) or deny (fail to ratify) the Program recommendation. If the program’s recommendation is denied, the committee will define an alternate plan which will be binding on the program and the RPC. The subcommittee may also make recommendations for modifications to plans proposed by the Program.

Voting

The Chair will only vote in the case of a tie.

Conflict Of Interest

A subcommittee member must declare a potential conflict of interest with any case presented.  The concerns will be disclosed by the member to the Chair, who will decide on the appropriate course of action. The Chair will also consider requests from the resident whose case is being presented to exclude a subcommittee member from deliberations if the resident declares a potential conflict of interest with the subcommittee member. If a resident subcommittee member is excluded from deliberations due to a potential conflict of interest, the Chair will seek a temporary resident replacement to maintain resident representation on the subcommittee.

If the Chair of the committee declares a conflict of interest, an interim chair from the faculty membership of the committee will be appointed by the Assistant Dean, PGME.

Confidentiality 

The committee shall meet in camera. The documents provided to the committee at meetings shall be retained by the Executive Assistant and Administrative Supervisor, PGME. All deliberations of the committee and all information received by the committee shall be confidential except for such disclosure as is necessary for the committee’s report.

General Provisions

The Accreditation Subcommittee is a standing committee of the Postgraduate Education Committee (PGEC) that is responsible for reviewing all internal accreditation documents and maintaining the overall standards of the University Internal review process.

Membership

The Accreditation Subcommittee has sixteen (16) members.  The subcommittee Chair will sit for a 5-year term, renewable once.  Other committee membership is for a three-year term, renewable twice.  Membership is as follows:

1. Chair – faculty member nominated by the Vice-Dean, Postgraduate Medical Education (PGME) and approved by the Postgraduate Education Committee;
2. Vice-Dean, PGME (ex-officio);
3. Assistant Dean, PGME (ex-officio);
4. Ten (10) additional faculty members having experience or committed to gaining experience in the standards of education and accreditation as required by the Royal College of Physicians and Surgeons of Canada (RCPSC) and by the College of Family Physicians of Canada (CFPC):
   1. At least one faculty member with Royal College certification in each of the following categories: Internal Medicine (general or sub-specialty), Surgery (general or sub-specialty), Laboratory Medicine and Pediatrics (general or sub-specialty)
   2. At least two (2) faculty members with CFPC certification
   3. Up to three (3) faculty members with Royal College certification in any other specialty (e.g. Anaesthesia, Emergency Medicine, Diagnostic Radiology, Psychiatry, etc.)
   4. One (1) faculty member with Royal College certification in an AFC program
5. Two (2) resident representatives, selected from the entire resident body following consultation with the University of Ottawa PARO General Council whose terms will be a minimum of 1 year to a maximum of 3 years.
6. Accreditation Program Administrator (non-voting)

It is expected that Subcommittee members will attend/participate by teleconference at least 75% of scheduled meetings.  Failure to participate in the minimum number of meetings will result in removal from the Subcommittee.

Meetings

The Subcommittee shall meet at least four (4) times a year and additionally as required.  Communication with the Faculty PGEC will be on an as needed basis for issues that arise.

Quorum is set at four (4) members in attendance including the Subcommittee Chair or his/her delegate.

Conflict of Interest

A Subcommittee member must not participate in the review of his/her own academic program.  The Subcommittee member must declare a conflict of interest when their program review is to be discussed. The member will leave the meeting during the program’s discussion and refrain from adding written commentary on the documents under review.

Functions of the Subcommittee

1. Review all accreditation preparatory and mandated internal reviews, and progress reports, and make recommendations regarding individual programs as necessary.
2. Report to the Vice-Dean, PGME and to the PGEC on issues that arise as they pertain to standards of accreditation of the RCPSC and CFPC.  The Subcommittee Chair will convey at a minimum, an annual report to the full membership, but may report at additional meetings should the need arise.
3. Assume responsibility for the overall standards of the PGME Internal Review process and make recommendations as necessary to the PGEC.
4. Ensure reports generated by review teams are of high quality.
5. Provide feedback to review teams on the quality of the reports.
6. Provide faculty development and support on accreditation-related activities.

Procedures

1. The Subcommittee Chair, along with the Assistant Dean, PGME, set an eight (8) year schedule that outlines the timing of internal reviews for all RCPSC and CFPC training programs at the University of Ottawa.  It is expected that during the time between full external reviews of all University of Ottawa postgraduate programs (conducted by the RCPSC and CFPC every eight years), each program will be subject to at least one full internal review as per the Royal College or CFPC accreditation format.  Programs may also be subjected to additional preparatory reviews as deemed necessary.  At the discretion of the Subcommittee Chair, Assistant Dean, and Vice-Dean, programs may be subjected to an increased level of scrutiny including, but not necessarily, additional internal reviews, particularly if programs are scheduled for an Action Plan Outcomes Report (APOR) or External Review.

2. Reviewers are assigned to reviews by the Accreditation Program Administrator with oversight by the Chair and the Assistant Dean.  Internal reviews are conducted by two (2) Physician Faculty members and one (1) Postgraduate trainee from the Faculty of Medicine, University of Ottawa.  In most cases, the more experienced faculty reviewer will be designated as the Lead Reviewer by the Accreditation Program Administrator and will be the primary author of the report.
3. The Subcommittee is responsible for reviewing all internal review reports and providing formative feedback to the review teams.  Report documents can be accessed by all Subcommittee members in a secure digital environment.  Comments and/or track changes will be used by members to ask for clarity or provide feedback in the draft report.  The Chair is responsible for summarizing the comments/changes before returning the report to the review team for revisions.  Quarterly, the Subcommittee will meet to ensure that program reports are meeting the General Standards of Accreditation as set out by the RCPSC and CFPC.  Feedback regarding any program deficits will be provided by the Subcommittee Chair to the Vice-Dean and Assistant Dean after each internal review, and each Program Director and Department Chair will have access to the report to guide programmatic change.

Expected Timelines for Internal Reviews

1. The Accreditation Program Administrator receives either the Pre-Survey Questionnaire (PSQ) and supporting documents (for AFC programs) or the data from the CanAMS (Accreditation Monitoring System) from the program at least one (1) month prior to the review.
2. The Accreditation Chair, Vice Dean, PGME and Assistant Vice-Dean, PGME have one (1) week to review and provide commentary on the information submitted.
3. The program has one (1) week to make final edits before re-submitting the final documentation to the Accreditation Program Administrator.
4. Review team members receive access to the program’s documentation two (2) weeks prior to the review date.  The draft report must be submitted within two (2) weeks following the survey visit.
5. Formative feedback on the quality of the report and all requests for clarification from the Accreditation Subcommittee are provided back to the review team within 10 days.
6. All final edits by the Lead Reviewer are asked to be re-submitted within ten (10) days.
7. Once the report has been approved by the Accreditation Subcommittee Chair and/or the Assistant Vice-Dean, the final report is sent to the Program Director and the responsible Clinical Department Chair.
8. The Accreditation Program Administrator will process the reviewers’ remuneration for completion of the review and the final report. 
9. Reviewers must submit an invoice to [email protected] to indicate to whom the funds should be paid.

Purpose

To adjudicate the following annual awards:

• Educational Advancement and Innovation for Faculty Members
• Fellowship
• Faculty of Medicine Awards in Education (PGME) 
• PARO 
• CSCI-CIHR 

Membership

The Vice-Dean of Postgraduate Medical Education (PGME) or his designate will be a permanent member, and will act as the Chair (ex-officio voting member).

There will be five members in total with each member having a three-year term, with the option of one three year renewal, subject to the agreement of the member and support of the majority of the subcommittee.
 

Meeting Frequency

The subcommittee will meet at least two times annually. If a meeting cannot be convened, the committee may deliberate via e-mail.

Eligibility Criteria 

In order to be considered for a PGME award, applicants or nominees must meet the following criteria:

• be enrolled in a PGME program at the University of Ottawa;
• be in good standing (e.g no issues of professionalism); and 
• meet eligibility criteria of award (prerequisites and additional requirements).

Subcommittee Decisions 

All decisions of the subcommittee will be captured in the meeting minutes. These decisions are not appealable.

Preamble

The Faculty Postgraduate Education Committee is a standing committee of the Faculty of Medicine that coordinates Postgraduate Education in all recognized programs, be they:

1. Royal College Specialty Residency Programs
2. Family Medicine Residency Programs

Membership

• The Faculty PGEC Full includes all the members of the PGEC Executive (as noted below) and all Residency Training program directors (or their delegate).
• The Faculty PGEC Executive membership shall comprise:
  • Vice-Dean, PGME (Chair)
  • Assistant Dean, PGME (voting)
  • Dean, Faculty of Medicine (non voting)
  • Assistant Dean, Social Accountability (non voting)
  • Director of Academic Support (non voting)
  • Chair of Accreditation Subcommittee (non voting)
  • Chair of Professionalism Subcommittee (non voting)
  • Program Directors (or delegates) representing the following twelve residency programs. These programs will retain permanent positions on the Faculty PGEC Executive. (voting)
    • Anesthesiology
    • Emergency Medicine
    • Clinician Investigator Program
    • Family Medicine
    • Family Medicine Enhanced Skills
    • General Surgery
    • Internal Medicine
    • Anatomical Pathology
    • Obstetrics & Gynecology
    • Orthopedic Surgery
    • Pediatrics
    • Psychiatry
• Seven program directors (or their delegate) representing all other programs. These Program Directors will be appointed on a rotational basis for a duration of two years. (voting)
  • The Director of Faculty Distributed Medical Education (DME). (non voting)
  • The Chair of the Department of Innovation in Medical Education (DIME). (non voting)
  • Representatives from Administration of the major teaching hospitals. (non voting)
    • The Ottawa Hospital (TOH)
    • Children’s Hospital of Eastern Ontario (CHEO)
    • The Royal Ottawa Hospital (ROH)
    • L’Hôpital Montfort
    • Bruyère Continuing Care
  • Two resident representatives selected by PARO. (voting)
  • Guests from affiliated organizations will be invited to meetings as needed at the discretion of the Chair. (non voting)

Frequency Of Meetings

The PGEC Executive will meet 10 times per year from September to June. Four (4) of these meetings will be held to include the entire contingent of Program Directors (or delegates) and will be known as the PGEC Full meeting.

It is expected that PGEC Executive members will attend all PGEC (Full and Executive) meetings and all other residency program directors attend all PGEC Full Meetings. Non-executive members are invited to attend any and all PGEC Executive meetings.

Quorum

The quorum for PGEC Executive and PGEC Full meetings shall be at least 1/3 of the total number of voting members or such greater number of members as the PGEC may determine.

Function

• Admissions and Registration:
  • Ensure appropriate admissions criteria and procedures are established for all levels of residency training programs.
  • Ensure that appropriate conditions of enrollment are in place, whether these conditions are local or provincial requirements (i.e. PRP, AVP, PEAP, immunization, licensure, and medico-legal liability coverage)
• Evaluation with respect to: 
  • Established Standards of Accreditation according to the RCPSC and CFPC.
  • Maintaining an effective Evaluation Policy and Promotions policy
• Monitoring of programs.

Administer an Accreditation Subcommittee for the purposes of:

• Preparing for the on-site Accreditation visits from the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada, as well as the Liaison Committee on Medical Education (LCME) Faculty Accreditation visit.
• Conducting Internal Reviews and the review and approval of reports.
• Ensuring that Educational Sites meet Standards of Accreditation.
• Accountability. The PGEC is accountable to the Dean and the Faculty Council of the Faculty of Medicine.

The PGEC is also accountable to report, as necessary, to:

• the Royal College of Physicians and Surgeons of Canada
• the College of Family Physicians of Canada
• Subcommittees: 

The PGEC may establish Subcommittees as are necessary to implement policies and procedures as listed above. Terms of reference are to be determined by each Subcommittee and approved by the PGEC.

Chairs or delegates of these Subcommittees will report to the PGEC on an annual basis.

Subcommittees include:

• Evaluation Subcommittee
• Professionalism Subcommittee
• Accreditation Subcommittee
• PGY1 Residency Allocation Subcommittee (PRAC)
• Transfer Subcommittee
• Competency-Based Medical Education (CBME) Subcommittee

Recognition

It is recognized that the University of Ottawa, Faculty of Medicine, has agreements with each hospital defining their affiliation with the University. It is recognized that the affiliated hospitals through the Council of Academic Hospitals of Ontario (CAHO) represent the teaching hospitals and the University of Ottawa for the purposes of negotiating non-academic terms and conditions related to residents with the Professional Association of Residents of Ontario (PARO). For matters pertaining to their employment status, residents are responsible to their employer.

Mandate

Provide collaborative support, orientation, and essential knowledge pertaining to the Program Administrator (PA) role in medical education. Encourage the professional development of all PAs in Postgraduate Medicine Education at the University of Ottawa in accordance with the CanMEDS-ATA.

Membership

The PA Executive Committee is made up of a core group 10 Program Administrators working in medical education at the University of Ottawa, plus 1 representative from the PGME Office.

PA Members:

• Chair
• Vice-Chair or Past Chair
• Treasurer
• Secretary
• Corresponding Members and/or Members at large

PGME Representatives:

• Manager
• PGME rep

PA Members of the PA Executive Committee are appointed for a term of three years.

Members wanting to renew for another term must notify the Chair at least two months prior to the end of the academic year. The PA Members of the Committee will vote to indicate agreement for the renewed term.

If an agreement is not reached, and the membership is not renewed, then the position will be opened for recruitment.

Recruitment

The recruitment process is carried out at the end of each academic year. A call for nominations will be done at the Spring Bi-Annual Program Administrators meeting. Each nominee will be asked to submit a bio and/ or letter of interest for consideration by the PA Executive Committee. The PA General Assembly will vote and select member(s) from the pool of nominees.

Members are expected to accept assignments involved in the planning of the professional development workshops and creation of ad-hoc working groups or sub-committees.

Member Eligibility

To be eligible for membership on the committee, the individual must be the designated Postgraduate Program Administrator for an accredited CCFP or RCPSC residency program at the University of Ottawa.  There may only be one representative per program on the committee.

Specific responsibilities of PA Members

Chair

• Normal mandate is for a two year term plus an additional year as Past Chair (total 3 yr term).  The length of the term may be extended by committee approval.
• Sets the strategic direction for the upcoming academic year in collaboration with the committee.
• Sets the agenda in consultation with the PGME manager for the meetings.
• Serves as the primary contact between the PGME Office and the PA Executive Committee.
• Reviews the PA Executive Committee Terms of Reference (TOR) on an annual basis and presents updated TOR for review and approval by the committee.
• Participates in all meetings.
• Assigns additional duties to committee members in order to achieve overall committee goals.
• Collaborates with other professional development groups in order to ensure shared goals and objectives.
• Presents the PA Executive Committee update to all PAs at the PA Bi-Annual meeting (General Assembly).
• Represents the PA Executive Committee on the Program Directors Postgraduate Education Committee
• Contributes ideas (sessions, speakers) to the professional development sessions, and serves as a resource for other committee members as questions arise.
• Solicits input from other member organizations regarding current concerns. Serves as an advocate concerning those issues related to PAs.
• Accepts Committee assignments for planning and professional development.

Past Chair or Vice-Chair

• The Past Chair will serve during the first year of the Chair’s mandate.  A Vice-Chair will be selected in the second year of the mandate.
• Serves as the chief advisor to the Chair.
• Participates in all meetings.
• Contributes ideas (sessions, speakers) to the professional development sessions.

• Accepts Committee assignments for planning and professional development.
• As Past Chair, provides historical background and knowledge of Chair duties and responsibilities to support the Chair and the Committee.

Treasurer

• Maintains the finances.
• Must be a member of the committee who has served at least one year.

Secretary

• Must attend all meetings.
• Records Committee minutes.

Corresponding Members and/or Member at large

• A corresponding member from all major sites (affiliated hospitals). Ideally, members are recruited from all the core sites and affiliated teaching hospitals to give perspective and a voice to committee with a perspective from each site.  If no one volunteers from a particular site, a member at large can be added instead. Participates in all meetings.
• Contributes ideas (sessions, speakers) to the professional development sessions.
• Accepts Committee assignments for planning and professional development.

Specific responsibilities of PGME Representatives

Manager

• Assists in setting the agenda for all PA Executive meetings.
• Participates in all meetings.
• Contributes ideas (sessions, speakers) to the professional development, and serves as a resource for other committee members as questions arise.
• Acts as liaison with PA members in the planning of the professional development curriculum.

Voting Process for PA Executive Roles

• Chair asks PA Executive Members for nominations for the open position.
• Chair will provide list of nominated names for PA Executive Members to vote.
• In the event of a tie vote, the Chair will cast the deciding vote.

Quorum

• A quorum will be 50% plus one.

Frequency of Meetings

The chair approves all scheduled meeting dates.  Meeting length is two-hours (maximum 2 ½ hours). These meetings occur a minimum of four times a year (with additional meetings as required) between September and June of every year.  The organization of the meeting is the responsibility of the Chair with assistance of the PGME Manager or other PGME staff.

Attendance

All Committee members are required to participate in at least 75% of the scheduled meetings, and are expected to participate in the professional development curriculum planning.

Dismissal

Concerns may be brought to the Chair in writing should a member of the committee demonstrate incompetence, dishonesty, personal conduct that substantially impairs the committee’s fulfillment of its responsibilities and mandates (see code of conduct document), or fails to maintain 75% attendance at the meetings. The PA Executive Committee Chair (or the Vice/Past Chair in cases involving the current Chair) and the PGME Representative (Manager) will review the charges and a motion to dismiss will be presented to the PA Executive Committee. The outcome will be based on the charges and voted among the PA Executive Committee members. Should the outcome be that of a dismissal the member will be approached and asked to resign from their position on the committee.

Accountability

The PA Executive Committee is accountable to the PGME Office and all program administrators and program directors at the University of Ottawa.

Procedures

All communications and documents presented on behalf of the PA Executive to external groups must be pre-approved by the PA Executive members either at a PA Executive Meeting or via electronic email approval.

Sub-Committees

All sub-committees will be chaired by a member of the PA Executive.  The number of sub-committees will be determined on an annual basis according to the PA Executive Objectives for that year. Professional Development activities are the exception as no separate sub-committee exists, rather these activities are coordinated by the main PA Executive Committee.

Any PA from the larger General Assembly group is eligible to participate on a sub-committee, they do not have to be a member of the PA Executive. 

General Provisions

The Faculty’s Clinical Fellowship Committee (CFC) is a committee of Postgraduate Medical Education (PGME) that coordinates Faculty of Medicine Post-Residency Fellowship Education in all recognized programs.

It must be clearly understood that each Fellowship program must have a designated Fellowship Director.

A fellow is defined as a clinical trainee in postgraduate medical education undertaking an unaccredited fellowship or a fellowship in an Area of Focused Competence (AFC) post-residency.

Membership

Membership to the CFC include:

• Vice-Dean, PGME (Chair)
• Assistant Dean, PGME ( ex-officio)
• Dean, Faculty of Medicine (ex-officio)
• One representative from each of the following clinical departments and schools:
  • Anesthesiology
  • Radiology
  • Emergency Medicine
  • Family Medicine
  • Medicine
  • Surgery
  • Pediatrics
  • Obstetrics and Gynecology
  • Ophthalmology
  • Otolaryngology
  • Psychiatry
  • Pathology and laboratory medicine
  • Epidemiology, Public Health and Preventative Medicine
  • Innovation in Medical Education
• Chair, AFC Fellowship Directors Subcommittee
• Fellow

Guests may be invited to meetings, as required and at the discretion of the Chair.
 

Meetings:

The CFC will meet a minimum of two (2) times per year, from September to June. Quorum for CFC meetings shall be at least 1/3 of the total members or such greater number of members as the CFC may determine.

Functions of the Committee:

1. Admissions and Registration
   a) Ensure appropriate admissions criteria and procedures are established for all postgraduate fellows.
   b) Ensure appropriate conditions of enrolment are in place, whether these conditions are local or provincial requirements (i.e. Pre-Entry Assessment Program, English Language Requirements).
2. Evaluation. Standards around assessment for all fellowship programs.
3. Accountability. The CFC is accountable to PGME.
4. Subcommittees. The CFC may establish Subcommittees as are necessary to implement policies and procedures as listed above. Terms of reference are to be determined by each Subcommittee and approved by the CFC. Chairs or delegates of these Subcommittees report to the CFC on an annual basis.

Recognition:

It is recognized that the Faculty of Medicine, University of Ottawa, has agreements with each hospital defining the hospital’s affiliation with the University.
For matters pertaining to their employment status, fellows are responsible to their employer.

General Provisions

Under the Postgraduate Education Committee (PGEC), the competency-based medical education (CBME) subcommittee is accountable to the Vice-Dean, Postgraduate Medical Education, Faculty of Medicine. This advisory subcommittee is responsible for the overall oversight and strategic planning for the implementation of Competence By Design (CBD) in the RCPSC programs at the University of Ottawa as well as ensuring that there is overall alignment with the Triple C curriculum for our CFPC programs. Working groups that will facilitate the implementation of CBME will report to this subcommittee. 

Functions of the Subcommittee

The CBME subcommittee will adhere to the mission and policies of the Faculty of Medicine. It is responsible for strategic planning in all areas related to CBME at the University of Ottawa, including but not limited to: 

• Identifying resources / technology infrastructure that will enable the successful adoption of competency by design at uOttawa. 
• Support strategies for faculty, learners and administrative staff.

• Proposing and drafting new policies as needed to support competency based medical education. 

Members:

Vice-Dean, PGME (Ex-officio)

Chair of CBME subcommittee, Assistant Dean, PGME

Chair of Accreditation subcommittee (Ex-officio)

Assistant Dean, Office of Continuing Professional Development (Ex-officio)

Hospital Liaison, (Ex-officio)

Faculty members:

Program Director or delegate from the following:

• a non-surgical specialty or subspecialty
• a surgical specialty or subspecialty
• Surgical Foundations
• Specialties or subspecialties that launched CBD in 2017 and 2018
• Family Medicine

Term: 2 years, renewable once
 

Resident members:

3 residents (1 PARO elected member, one RCPSC, one CFPC)

Term: 2 years, renewable once

Program Administrators:

2 Program Administrators:

• One whose program has launched, or has been involved in CBD workshops hosted by the RCSPC
• One at large

Term: 2 years, renewable once

uOttawa staff (Ex-officio):

• PGME CBME Coordinator (provides administrative support to the chair)
• MedTech – Business Analyst assigned to Entrada 
• PGME Project Coordinator
• PGME Operations Manager

Quorum

Chair and 50% of the subcommittee members.

Frequency of Meetings

The subcommittee will meet at least 4 times per year.

Attendance at Meetings

It is expected that subcommittee members will attend at least 75% of scheduled meetings. Failure to attend the required percentage of meetings will result in removal from the subcommittee.

Resident_Wellness_Committee.pdf (pdf, 128.91 KB)

Accommodation_Planning_Committee.pdf (pdf, 105.82 KB)