Accreditation is a process of quality assurance for Canadian and American medical schools through assessment of the adherence by the institution to a comprehensive set of standards. Accreditation is also intended to foster institutional and program improvement.

In Canada, accreditation is the responsibility of the Committee on Accreditation of Canadian Medical Schools (CACMS), a committee of the Association of Faculties of Medicine of Canada (AFMC), with representation from the Canadian Medical Association (CMA).

The CACMS is a committee of 15 voting members composed of medical educators, administrators, practicing physicians, public members, medical students, and administrative staff.

The standard term of accreditation is eight years. If significant problems are identified after a medical education program’s full accreditation review, the Committee on Accreditation of Canadian Medical Schools (CACMS) may continue accreditation until a limited site visit is conducted, to determine how the program has addressed its problems. Limited site visits typically take place within two years of the full review. If the program has made satisfactory progress or fully resolved its problems, accreditation will be continued for the balance of the eight-year term. In rare cases, CACMS may shorten the term of accreditation.

They are assessing whether the school meets a set of 12 standards set by the CACMS. The standards for educational program quality are contained in the document CACMS Standards and Elements, available electronically from the CACMS website. These standards are related to the following areas

1. Mission, Planning, Organization, and Integrity
2. Leadership and Administration
3. Academic and Learning Environments
4. Faculty Preparation, Productivity, Participation, and Policies
5. Educational Resources and Infrastructure
6. Competencies, Curricular Objectives, and Curricular Design
7. Curricular Content
8. Curricular Management, Evaluation, and Enhancement
9. Teaching, Supervision, Assessment, and Student and Patient Safety
10. Medical Student Selection, Assignment, and Progress
11. Medical Student Academic Support, Career Advising, and Educational Records
12. Medical Student Health Services, Personal Counseling, and Financial Aid Services

The school under evaluation submits an extensive set of documents prepared with the participation of administrators, faculty, staff, and students. These documents are submitted to CACMS about three months prior to the visit and are thoroughly studied by the accreditation team.

The site visit typically begins with an evening entrance conference with the dean and concludes three days later with an exit conference with the dean and the president and vice-chancelor or the provost vice-president Academic Affairs of the university to summarize findings about the program's strengths and areas of noncompliance. The purpose of the visit is to verify and update information compiled in the school's DCI, clarify any issues that are unclear, view the environment and facilities for learning first-hand, and meet with administrators, faculty members, and students.

A draft report is submitted to the CACMS and to the Dean for checking of factual accuracy, and a final report is submitted to the CACMS. The CACMS considers the report and issues the final decision to the medical school. This may be accompanied by a request for progress reports outlining actions taken to correct any perceived deficiencies.

The principal benefit is the encouragement to medical schools to assess seriously and in detail the conditions and processes associated with their undergraduate medical education program. Canadian medical schools view accreditation as a measure of quality; it is a source of pride for those with no areas of non-compliance, and most medical schools tend to go beyond what is outlined in the standards thus stimulating innovation.

Depending on the number and nature of the citations involved, the Committee on Accreditation of Canadian Medical Schools (CACMS) may ask a program to provide one or more written reports (called “status reports”) documenting how it has addressed its problems or may send a site visit team to the program to verify that problems have been satisfactorily addressed.

Probation represents a judgment by the Committee on Accreditation of Canadian Medical Schools (CACMS) that a program is not in substantial compliance with accreditation standards, and that the quality of the school’s educational program will be seriously compromised if the issues are not addressed. A program on probation remains fully accredited, with all the rights and privileges associated with accreditation. However, it must publicly disclose to all faculty members, students, and applicants that it is on probation. If a program on probation does not achieve full compliance with accreditation standards within the time established by CACMS, its accreditation may be withdrawn.

If the medical education program is scheduled for an accreditation review, the issue should emerge from the Medical School Self-study and the Independent Student Analysis. Occasionally, an issue considered important by medical students does not relate to accreditation standards (e.g., scarce or expensive on-campus parking). In such cases, the site visit team may comment on the problem in its report, but the Committee on Accreditation of Canadian Medical Schools (CACMS) cannot compel the program to take corrective measures because the issue does not involve noncompliance with accreditation standards.

If a major issue surfaces and a program is not scheduled for an upcoming CACMS review, students can bring the issue to the attention of CACMS by submitting a formal complaint. Details of the complaint procedure are contained in the CACMS Rules of Procedure document, which is available from the CACMS website.

A lot. The task would be overwhelming where it not for everyone’s participation. It is likely that well over 100 faculty, staff and students will be significantly involved in preparation for the accreditation visit. The documentation that must be submitted to CACMS and the accreditation team is substantial and requires a large investment in time and patience.

18-24 months prior to the visit

• CACMS Secretariat establishes visit dates with the medical school dean.
• The faculty accreditation lead initiates data collection activities.
• A committee of students responsible for the Independent Student Analysis (ISA) is formed and begins drafting questions for the ISA survey of the student body.

15 months prior to the visit

• The ISA survey is distributed to the student body.

15-12 months prior to the visit

• School appoints members of the medical school self-study (MSS) task force. The task force establishes its objectives, scope of study, and methods of data collection, and establishes various subcommittees.
• The students charged with conducting the ISA provide survey data to the faculty accreditation lead and begin independent analysis of the data.
• Various individuals or groups begin responding to questions in the DCI.

12-6 months prior to the visit

• Students provide the final ISA to the faculty accreditation lead.
• Faculty accreditation lead distributes the ISA report and completed DCI sections to the self-study task force and appropriate subcommittees.
• Subcommittees review and analyze the relevant sections and prepare reports that are forwarded to the task force.
• If not begun already, action should be taken to correct issues identified by the various subcommittees.

4-3 months prior to the visit

• The CACMS Secretariat sends the faculty accreditation lead instructions for the visit and a final list of visiting team members to the dean.
• The faculty accreditation lead reviews the DCI, self-study summary report, and other required documents and makes any required updates/corrections.

3 months prior to the visit

• The final accreditation package, consisting of the DCI and supporting documentation, the ISA report, and the MSS Report is submitted.

2-3 months prior to the visit

• The secretary of the visiting team will contact the faculty accreditation lead to begin work on the visit schedule and will contact the staff visit coordinator to discuss logistical planning.
• Based on initial review of the accreditation package, the team secretary may request additional information/materials and/or that additional sessions with specific faculty or staff be added to the schedule.

2 months prior to the visit

• If necessary, corrections and/or updates to the DCI are sent to the visiting team secretary.
• The team secretary and school finalize the visit schedule.

1 month prior to the visit

• If necessary, corrections and/or updates to the DCI are sent to the visiting team secretary.

Full site visit

• Team visits the school and conducts an exit conference.
• The faculty accreditation lead submits an update to the CACMS Secretariat containing any supplementary material provided to the team before or during the visit, and any corrections or updates provided to the team after the initial submission. This includes updates/corrections made at the time of the visit.

1-2 weeks after the visit

• The visiting team secretary sends a first draft of the report to the CACMS Secretariat for review; Secretariat feedback is incorporated as seen fit by the team into a second draft, which is sent to the dean for review.

2-4 weeks after the visit

• The dean provides feedback within 10 business days; feedback is incorporated into the final
• report at the discretion of the team secretary and chair.

4-6 weeks after the visit

• The report is finalized and sent to the CACMS Secretariat. The Secretariat sends final report to the dean and circulates it to CACMS members for review prior to the next CACMS meeting.

2-4 months after the visit

• The CACMS determines an accreditation decision at its next regularly scheduled meeting (January/May/September).

Within 30 days of the CACMS meeting

• The university president and vice-chancelor and medical school dean are sent copies of the final report and are notified, in writing, of the final decision regarding accreditation status and any required follow-up.

For programs undergoing a full accreditation site visit, the site visit team will normally consist of four to six members who are knowledgeable about medical education and clinical practice. One of the team members is designated as the Chair of the team. The team Chair, typically a current or recent medical school dean, functions as the official voice of the team during the visit and leads its deliberations. Another member is designated as team secretary and is responsible for visit preparations and logistics, functions as the main liaison with the medical education program and compiles the site visit report. The remaining team members will include a student member when possible and a faculty fellow as described above who functions as a regular team member.

The principal focus is on the MD Program, but the study includes many aspects that are only partially related to this. Research, faculty workloads, resources of all kinds (human, financial, library, relaxation areas), administrative organization, and contributions to teaching by graduate students and residents are all considered.

There is extensive involvement. Many faculty and administrators currently involved in the curriculum will be asked to complete parts of the database. Each sub-committee will have about ten members, and these will represent several different areas. Many students and faculty will be asked to meet with the accreditation team, and they should be aware of the process and the self-study.

Are you interested in learning more about the policies and operations of your medical education program? Do you feel there is room for improvement in the way we do things? Would you like the opportunity to influence the directions of our Faculty? Would you like to meet and interact with others who are dedicated to improving our programs?

The CACMS and LCME maintain very informative websites. In the accreditation documents/publications section, very detailed descriptions of all aspects of accreditation may be downloaded. Dr. Ken Marshall is the Director of Accreditation, MD Program, University of Ottawa and can be contacted by e-mail at: [email protected].

The outcome of the visit in 2010 was seen as extremely favorable, though a few criticisms were made.

Students conduct an independent student analysis (ISA) of the medical school in parallel to the self-study that the medical school completes as part of their accreditation preparations. The site visit team that reviews a program will meet with students selected from all class years and will tour educational facilities with assistance from student guides.

The site visit team will include students’ perspective taken from the ISA survey data, from the AFMC GQ, and from students it meets on-site when making its determinations about the extent to which the medical school meets the requirements of the accreditation elements.

Two of the 15 voting members of the CACMS are medical students. Two additional student members also serve on the committee. The four student members also play a prominent role in the development and revision of accreditation elements, and in CACMS policies. Two students serve on the Standards Subcommittee and two serve on the Policy Subcommittee.

The site visit team evaluating a medical education program will meet with a group of first year and second year students over lunch on the Monday of the site visit, and with a group of third year and fourth year students over lunch on the Tuesday of the site visit. The program and its students will determine which students meet with the team. Students also guide the team on inspection tours of the school’s educational facilities.

From the site visit team’s perspective, it is desirable to meet with a representative group of students from all classes, including some who were directly involved in the leadership of the independent student analysis and who are familiar with the data collected by the student survey. To better understand how the program functions, it may also be desirable to include students who have direct experience with the school’s academic counseling, personal counseling, student well-being, and/or systems for addressing mistreatment issues, as well as students who are involved in medical school committees, such as the Curriculum Committee or its equivalent.

The medical school or its students may also want to include some participants who are in joint degree programs, and students involved in research or service learning programs. In summary, it is desirable that the site visit team meet with a breadth of students, not just class leaders. The medical school is more likely to be effectively represented if the selection of students results from mutual agreement among medical school leaders and faculty, and the student body. A site visit team would likely be concerned if students had no voice at all in deciding which of them met with the team.

The MD Program at the University of Ottawa is fully accredited for the 2018-2026 accreditation term.

The program's last full accreditation visit was in April 2018.

In March 2021, a status report was sent to CACMS for review as required when elements are found to be “satisfactory with monitoring” or “unsatisfactory.” The CACMS voted to continue accreditation for the remaining of the eight-year term and requested a status report for three elements (1.1.1, 11.2, and 12.1), to be submitted by March 15, 2024.

The CACMS maintain very informative websites. In the accreditation documents/publications section, very detailed descriptions of all aspects of accreditation may be downloaded.

The Assessment, Evaluation, and Curriculum Office works with strategic partners in academic and clinical leadership throughout the University of Ottawa Medical School to oversee the full CACMS accreditation process. These key contacts are available to address any questions or comments you may have.

Ken Marshall, PhD, Director of Accreditation, MD Program

Philippe Rousseau, PhD, Quality Assurance and Accreditation Coordinator