Accreditation Management System (AMS) Guide 2019 · Version 05.10.2019 Accreditation Management...
Transcript of Accreditation Management System (AMS) Guide 2019 · Version 05.10.2019 Accreditation Management...
Version 05.10.2019
Accreditation Management System (AMS) Guide 2019
The purpose of this guide is to support residency programs completing their program instrument in the Accreditation Management System (AMS). Instrument replaces the pre-survey questionnaire (PSQ) that programs traditionally
completed prior to a review. Program information is now entered into an online system that is managed by the Royal College. The design of the instrument was developed by a group composed of the Royal College of Physicians &
Surgeons of Canada, College of Family Physicians of Canada, and Collège des Médecins du Québec, named CanERA (Canadian Excellence in Residency Accreditation). Visit the CanERA home page at http://www.canera.ca/canrac/home-e for more information.
The benefit of this system is that rather than an intensified effort to complete PSQs a few months prior to a review,
the maintenance of program information is continual throughout the accreditation cycle (timeline between college on-site surveys). The expectation is, after the initial loading of required documents and information, the AMS will be updated regularly as changes are made to residency programs. e.g. updated academic activities, RPC meeting
agendas, committee membership, updated policies, etc.
The AMS system will be used for 2019-2020 McMaster Internal Reviews. When the AMS system becomes available programs will be asked to sign in and complete their instrument. Each question should be read carefully and answered accordingly. This document is a reflection of
the quality of the program and sets the tone of the meetings that occur during the internal review.
How to use this guide: Guide Left Column is what programs will complete in the AMS and has templates if that can be used. For
documents common to some or all programs, a link provided.
Guide Right Column provides the number of the related Accreditation Standard(s) available at
http://www.canera.ca/canrac/general-standards-e and comments, suggestions, and notes to guide program’s
responses in the left column.
If you have any questions while completing the AMS instrument, contact:
Brenda Montesanto for process questions: [email protected]
Margaret Ackerman for content questions: [email protected]
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Visit CanERA for training, tools & support
frequently asked questions
The Basics Click Here
Navigating CanAMS
Logging in
Changing password
The Standards Click Here
Access the standards
Documents Click Here
Access, upload & remove documents
Working with Instruments Click Here
Working with required documents (evidence)
Working with tables
Adding comments
Working with reference documents
Formatting answers & adding hyperlinks
Managing of assignees
The above links can be found at
http://www.royalcollege.ca/mssites/canera-
uprh/index.html#/
Tips When Naming Files
Try to keep file name short and consistent. Justenough to identify the files contents
Use standard abbreviations, example RPC (residencyprogram committee), ToR (terms of reference)
Use _underscore _ to_separate_words_ or elements
Don’t use spaces or other characters or unnecessarywords such as: and, as, the, at, a, to
Date all documents
Ensure file extension is displayed when saving files
(eg. Doc, .docx, pd, jpg)
Where applicable identify draft with Dft
Examples Curriculum_Plan_20190122.pdf,
Scholarship_ Faculty_20190225.pdf.ToR_RPC_20181015.pdf
Hyperlinks
Use hyperlinks to documents that are stored onlinee.g. PGME policies,
Be sure to test links in your documents periodically
Hyperlinks should take you directly to the document
and not to a site that contains the document.
Hyperlinks should not be password protected.
Templates provided by the College
If there is a template provided by the college, in somecases, you can choose to substitute your document if
it contains all the elements of the template.
1
2
4
3
Update templates-Since the release of the system it was discovered that the curriculum plan template was not made available in CanAMS. The college is currently updating this template; however, a version is available at https://pgme.mcmaster.ca/digital-accreditation-management-system/
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AMS Guide
Program Information Entry Completed
Date:________________
Sections of the AMS Comments, suggestions, notes
Numbers indicate the Standard
Sites
Fill out in the AMS
Site Site
Coordinator
Distribution of Residents by Site
Year
1
Year
2
Year
3
Year
4
Year 5 or
above
Clinical
Fellows
Definition: Clinical Fellows are in
programs that do NOT lead to
certification by the Royal College.
Subspecialty learners e.g. Cardiology,
Geriatric Psychiatry, Maternal Fetal
Medicine are considered to be residents
as the training leads to certification.
Recommendation: if there are clinical
fellows or AFC trainees, add a comment
in the resource section on how
competition for resources is managed or
avoided.
Policies Entry CompletedDate:________________
Resident Assessment and Promotion
Copy the following links to AMS, ‘Additional Information or reference’ column:
Evaluation, Assessment & Appeals
Policy on Assessment of Learners (PGEC 2019) Appeals Process (PGEC 2009)
5.1.1
This is a list taken from the PGME web site that are
common to all programs. Choose those appropriate to
your program.
In the AMS also Include policies that are program specific
e.g. Promotion and Appeals process used by your
program.
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Learning Environment
Resident Supervision
Supervision of Clinical Activities of Postgraduate Learners (PGEC
2015)
Permitted Activities for McMaster Medical Learners (2012)
5.1.1
Health & Safety
PGME Health & Personal Safety Policy (PGEC 2011)
Communicable Diseases Policy (FHS 2016)
Guidelines for the Support of Learners in Clinical Placements (FHS
2009)
5.1.2
5.1.3
If your program has specific safety issues that are not
covered in the PGME document there should a program
specific safety policy addressing these issues.
Examples:
radiation exposure
biohazards
potentially violent patients
house calls
after hours consultations
resident attending patient transfers
complaint management
fatigue management
Resident Affairs
https://pgme.mcmaster.ca/traineeaffairs/
Resident affairs provides more information & resources on learner
intranet –
https://www.medportal.ca/pg/trainee
5.1.3.2
5.1.3.4
Patient Safety
Guidelines Regarding Patient Safety
Health Records
Health Records Completion by Residents (PGEC 2013)
Health Records Handling & Disposal
Professionalism
Promoting Professionalism Policy & Procedures (PGME 2014)
Professional Behavior Code of Conduct for Learners (FHS)
Guidelines for Appropriate use of Internet Electronic Networking &
Other Media (PGME)
Guidelines for Interaction with Industry (PGEC 2013)
Update: Note that since the release of the system it was discoved that in some cases you cannot link the policy. It must be uploaded.
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Technology & Industry
Guidelines for Appropriate use of Internet Electronic Networking &
Other Media (PGME) this is above
Guidelines for Interaction with Industry (PGEC 2013)
Committees Entry Completed
Date:_______________
Organization Structure:
Upload to AMS your program’s organizational chart.
Residency Program Committee Entry Completed
Date:_______________
What is the function of this committee?
Suggested Introduction:
The RPC is responsible for the overall operations of the
PROGRAM NAME residency program by assisting the Program
Director in planning, organizing and supervising the residency
program, including providing the environment, mentorship, and
experience whereby each resident will have access to an
educational experience required to successfully complete the
program objectives. The RPC supports and assists the Program
Director in:
Program design
Program curriculum
Site/rotation review
Resident evaluation
Appeals and promotion
Resident selection
Resident wellness and safety
Continuous improvement
Career Planning
The RPC responsibilities, as outlined in the Program
Terms of Reference, must describe and do all of the
elements listed in
1.2
2.1
2.2
6.1.1
6.1.2
All Programs must have an effective, fair and transparent
process for the residents to choose their resident
members on the RPC. The number of resident reps must
reflect the size of the program.
Explain how the Program communicates with residents,
teaching faculty, admin staff and Division Director and/or
Chair.
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To whom does this committee report?
Suggestion
The RPC members report to the Program Director, who, in turn,
reports to Division/Department Chair and the Associate Dean of
Postgraduate Education.
Include the reporting structure in your RPC’s Terms of
Reference
How often does this committee meet?
Comments:
1. The Standards no longer specify a minimum meeting frequency. Element
1.2.2.3 says “Meeting frequency is sufficient for the committee to fulfil its
mandate.” Therefore, the response here should indicate not only a
frequency, but a statement about the meeting frequency being sufficient
to manage the program effectively.
2. If the minutes show there are ongoing program issues, such as, lack of
resources, harassment, supervision problems, then there should be a
sufficient number of meetings and the minutes reflect that a process is in
place and working towards resolution.
Recommendation: meetings 3-4 per year. More for large programs or when there
are program issues.
3. If the RPC meets in conjunction with a Division or Clinical Department
meeting, there must be a distinct and separately minuted RPC meeting.
4. Programs that do not have residents every year, still must have a
functioning RPC, a suggested minimum of two meetings per year. It must
ensure the ongoing organization and quality of the clinical sites and
teachers and include new changes to curriculum, policies, etc. There must
be minutes and, if action items, documentation of implementation, etc.
Upload to the AMS as PDF documents:
Terms of Reference
Membership list
Agendas (last two years in a single PDF document)
Other documentation
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Competence Committee (or equivalent):
What is the function of this committee?
Suggestion:
The Program competency committee is a subcommittee of the
RPC that reviews resident progress ensuring progress in achieving
the educational objectives through the levels of training. This
includes readiness for independent practice. If a resident has
difficulty meeting objectives, then it will assist with the
development of individual learning plans. The recommendations
of the Competence Committee will be brought forth to, and
discussed by, the RPC for approval.
Having a Competence Committee is a new requirement,
reflective of the new increasing complexity of assessment
of competence with Competency Based Medicial
Education.
1.2.2.4
3.4.3.1
3.4.3.2
The function of the CC should be reflected in the Terms of
Reference. 3.2.3, 3.4.4
As the complexities of evaluation progresses with CBME
implementation, it can be helpful for residents be
assigned a formal Academic Advisor. 3.4.2.2
Even in very small programs it is helpful to have a
competence committee to assist the Program Director.
To whom does this committee report?
Suggestion:
The Chair of the competence committee is a member of the RPC
reports to RPC.
How often does this committee meet?
This will depend on the length of the program and the
number of residents.
In programs with short training periods e.g. 12 to 24
months, it can be helpful for the Program Director and/or
Academic Advisor to have a meeting with each resident at
the completion of Introduction, Foundation, Core, and
Transition to practice.
The CC should regularly review resident progress to
ensure the resident has completed the requirements of
each phase.
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Upload to the AMS in PDF documents:
Terms of Reference
Membership list
Agendas (from last two years in one single PDF)
Other documentation
Other Committee(s)
It is not a requirement to have other RPC
subcommittees but depending in size and needs these
subcommittees have been implemented by programs:
Wellness/Social 1.2.1.3
CaRMS/selection 1.2.2.2
Research 3.2.5.1
Simulation 3.2.2.3
QI/Patient Safety 1.2.1.4, 3.2.6.1
Narrative - Leadership and Collaboration Entry Completed
Date:_______________
Does the program director have Royal College certification? If yes, please provide the name of the
specialty/subspecialty. If no, please provide specialty qualifications.
Protected time for the program director (in FTE):
Is it adequate?
Yes No
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Why/why not?
1.1.1.1
If you do not have adequate protected time, provide an
explanation
Administrative support available to the program director (in FTE):
1.1.2.2
8.1.1
Is it adequate?
Yes No
Why/why not?
If you do not have adequate administrative support for
your program, provide an explanation.
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Please describe how the residency program collaborates with undergraduate medical education (UGME) and
continuing professional development programs.
2.1.2.3
7.1.1.4
7.1.1.6
Possible examples:
a. Undergraduate Medical Education (UME):
students and clinical clerks are members of clinical
teams and supervised by residents and teachers
resident and teachers involved in presenter/tutor
clerkship specialty teaching week, tutors for
clerkship orientation, UME clinical skills preceptors,
OSCE examination observers, Medical Foundations
(co-)tutor,
b. Resident participation in CPD opportunities e.g.
University Teaching Program
https://fhs.mcmaster.ca/facdev/events.html
Faculty member/teacher is a lead/facilitator for CPD/UME
Does the residency program collaborate with other health professions to provide educational experiences for
learners in all health professions.
Yes No
SURGICAL FOUNDATIONS (for Surgical Programs Only)
Describe how Surgical Foundations functions in this program. Specifically outline the following:
1. Your relationship with the director of Surgical Foundations?
Modify these sections to increase detail as needed
to reflect any specific issues related to your
program.
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2. Who determines the choice and locations of clinical rotations for your residents in Surgical Foundations?
3. Who receives the rotation evaluations for your residents during the first two years in your program?
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Narrative - Educational Design and Delivery
Upload your curriculum plan to the AMS. As guidance, a template has been provided in the "documents” section
of your dashboard in the “From the College – DO NOT DELETE” folder; however, an alternate format would also be
acceptable, provided it includes all information requested in the template.
For assistance and guidance, please contact Brenda Montesanto in the PGME office.
The following is the explanation for the Program Profile Instruments provided by CanERA:
CanAMS Program Profile Instrument: Education Design and Delivery Section Guidance (Royal College Programs)
For Royal College residency programs, the Education Design and Delivery section of the program profile instrument within
CanAMS, the digital accreditation management system, requires uploading or population of two key tables: a curriculum plan
and a detailed description of educational experiences by stage/year, including their sequence, purpose/goal(s), and assessment
methods. Guidance is provided below to assist in the completion of these tables:
1) Curriculum Plan
Each residency program is asked to upload a curriculum plan, which will be evaluated to determine compliance with the
expectations detailed in requirements of Standard 31. To assist residency programs with the provision of a curriculum
plan, the Canadian Residency Accreditation Consortium (CanRAC) has developed a template available within the
documents section of the CanAMS program profile instrument. Use of the template is not mandatory; however, it is
expected that the curriculum plan captures the information in the template, at a minimum. In the future, a curriculum
plan template may be developed to enable pre-population of some details based on discipline-specific documentation.
In completing the curriculum plan, please consider the following:
Time-based vs. competency-based:
To facilitate the transition and reduce the burden on residency programs preparing for accreditation, each residency
program is expected to submit one curriculum plan, even if the residency program has both CBD and non-CBD cohorts
of residents. Whether the curriculum plan is based on competencies (i.e. the discipline’s CBD Competencies), or based
on the traditional curriculum (i.e. the discipline’s Objectives of Training Requirements (OTR)), is determined by the
discipline-specific standards that were in place 12 months in advance of an accreditation activity. For example, if a
program transitioned to CBD more than 12 months in advance of an accreditation review, the curriculum plan is
expected to be based on the discipline’s CBD Competencies. o Notwithstanding the principle of applying those standards
in place 12 months in advance of an accreditation activity, please note that to support programs in transitioning to CBD,
programs in disciplines that have transitioned to CBD less than one year may choose to submit a competency-based
curriculum plan. This
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option recognizes that it may work best for programs to focus their efforts during the transition period on the
development of a competence-based curriculum and that the CBD Competencies document does not represent a
significant departure from the discipline’s OTR. The submission of a competency-based plan should be clearly identified
on the program’s submission to ensure it is clear for surveyors, Specialty Committees and the Residency Accreditation
Committee.
Objectives/Competencies:
Please identify the relevant objectives/competencies associated with, and organized by, each CanMEDS Role. It is
expected that the identified objectives/competencies be based on the OTR/Competencies document for the discipline, as
applicable. It is recommended that the curriculum plan be detailed to the enabling competencies sub-level (e.g., 1.2) of
the OTR/Competences document. There may be instances where it is more appropriate to group all
objectives/competencies together in a common row or activity (e.g., all of Communicator 1), or to break down the
expectations further (e.g., 1.2.2.). Both approaches are acceptable, provided the overall curriculum plan clearly outlines
how all objectives/competencies are taught/learnt and assessed.
How Taught/Learnt and Assessed:
Please identify the various methods for how the identified objectives/competencies are taught/learnt and assessed.
Within the template provided, it is suggested that a list of all of the various methods be provided and then for each
objective/competency identified, the applicable methods be indicated by an “X”. An example is provided in the template.
In addition to this, within the CanAMS program profile instrument, there is a question that asks for examples of each
assessment method identified in the Curriculum Plan. Time-based programs will be expected to provide a
template/sample of each tool identified; however, for CBD programs, it is only expected that samples/templates be
uploaded where the assessment method(s) identified in the Curriculum Plan differ(s) the Royal College CBD suite of
assessment tools.
2) Educational Experiences (Rotations) by Year (non-CBD)/Educational Experiences by Stage (CBD)
Each residency program is asked to populate a table (or upload an equivalent document) detailing the educational
experiences by year (time-based)/by stage (CBD), including the sequence of this training, the associated purpose/goal(s)
of the educational experience, and the associated assessment methods.
In completing the educational experiences table, please consider the following:
Time-based vs. competency-based:
Should your program be transitioning to CBD, with both time-based and CBD cohorts progressing through the program
at the time that the work begins to populate CanAMS (i.e. one year in advance of the accreditation review), please
provide content addressing the rotations/learning experiences for both time-based and CBD cohorts (i.e. populate the
table twice, or upload two documents).
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Purpose/Goal of Rotation:
For time-based programs/cohorts, please populate the purpose/goal of the rotation column with relevant rotation-
specific objectives. Should you wish to upload existing Rotation-Specific Objectives, rather than detailing the purpose of
each rotation in the provided table, please ensure to complete the table in the same order of experience as is listed in
your RSO document to ensure the linkage is clear. (i.e., that the link between the content of the uploaded document and
the completed columns of the table is clear). For programs/cohorts that have transitioned to CBD, please populate the
purpose/goal of experience with the competencies to be acquired/EPAs to be observed. Should you wish to upload a
document detailing these rather than detailing these within the table, please ensure that all other sections of the table
are populated in the same order as the competencies to be acquired/EPA’s to be observed.
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For each method of assessment identified in the curriculum plan, Upload an example (e.g. template).
- Upload in AMS
The curriculum plan should be reflected in the clinical experience and Academic Half/Full Day sessions e.g. didactic, simulation,
workshops, etc. Over a specific period of time, depending on the length of program, all components of the curriculum should be
covered.
Curriculum Plan [Template - with example]
Academ
ic C
urr
iculu
m
Mic
roscopic
sig
n-out
Rota
tion
Pre
para
tion L
ab R
ota
tion
Quality
Assura
nce R
ota
tion
Rapid
on-site e
valu
ation R
ota
tion
[Add a
ddit
ional colu
mns a
s n
eeded]
Assig
nm
ent
(re
searc
h/schola
rly p
roje
ct)
In-Tra
inin
g E
valu
ati
on R
eport
Ora
l and s
lide e
xam
s
Multis
ourc
e f
eedback t
ool
[Add a
ddit
ional colu
mns a
s n
eeded]
1.1
(Example) Demonstrate knowledge of criteria for
spiment adequacy and assessment of slides to
diagnose benign, pre-malignant and malignant
conditions.
X X X X X
[Add additional rows as needed]
[Insert applicable objectives/competencies]
[Add additional rows as needed]
[Insert applicable objectives/competencies]
[Add additional rows as needed]
[Insert applicable objectives/competencies]
[Add additional rows as needed]
[Insert applicable objectives/competencies]
[Add additional rows as needed]
[Insert applicable objectives/competencies]
[Add additional rows as needed]
[Insert applicable objectives/competencies]
[Add additional rows as needed]
Communicator
Objectives/Competencies (Based on the
specialty specific standards and
associated OTR/Competencies document,
as applicable)
CanMEDS Role
How Learned / Taught How Assessed
Medical Expert
Collaborator
Leader
Health Advocate
Scholar
Professional
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Educational Experiences (Rotations) by Year (non-CBD) / Educational Experiences by Stage (CBD)
Populate the table(s) in the AMS, as applicable, or Upload an equivalent document detailing all educational
experiences (eg. rotations) by year (non-CBD) and/or stage (CBD), including the associated learning sites,
rotation-specific objectives (non-CBD) or experience-specific competencies, milestones, and EPAs, as applicable
(CBD), as well as the associated methods of assessment. For residency programs with both CBD and non-CBD
cohorts, please populate both tables.
PGY Rotations Learning
Site(s)
Purpose/goal
of rotation
Assessment
Method(s)
Stage (CBD) Educational
Experience
(CBD)
Learning
Site(s)
Purpose/goal
of experience
(CBD)
Assessment
Method(s)
Describe how the program ensures that all residents are provided with increasing professional responsibility.
SUGGESTIONS:
PGY -Residents assume responsibility for teaching and mentoring
more junior residents, clerks, and medical students. Senior
residents take on the role of junior faculty and be supervised by a
staff physician and is responsible for clinical, administrative and
educational tasks under supervision.
CBD-There is a progressive increase in responsibility, as resident
move through the competency phases of transition to discipline,
foundations, core, transition to practice.
Assessment methods have been developed to inform decisions
about resident readiness to progress through these stages. During
transition to practice, residents have the opportunity to work
independently, in preparation for future practice.
Comment:
The content of this answer will vary if the program is
traditional or CBME.
The answer must provide information that
demonstrates increasing responsibility. The
suggestions provided in the left column are just to get
you started and should be elaborated as appropriate.
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Describe how community and societal needs served by the discipline are considered in designing the residency
program.
SUGGESTIONS:
-Programs with residents at community sites are helping provide
clinical service, introduces residents to the benefits of community
practice and potential recruitment
-Partnering with community services to meet patient needs
3.1.1.4
3.2.3.1
4.1.1.2
What changes have been made in your program, or
provide examples, where needs of the community or
region have been considered in your program’s design.
CBME curriculum is about socially accountable medical
education.
Describe how individual residents’ educational experiences are tailored to accommodate learning needs and future
career aspirations.
SUGGESTIONS:
Selectives/electives
Special projects
Choice of learning sites
3.2.3.1
3.3.1.2
Elaborate on the experience.
Describe how the program ensures residents' clinical responsibilities do not interfere with their ability to
participate in academic activities.
3.2.5.2
When residents are participating in protected academic
activities/AHD:
who covers for the resident
how are pages/calls diverted from resident
call schedules and AHD attendance post call
how does the program ensure work is not just left
for the residents after AHD.
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Describe the scholarship and research activities available to residents.
Resources to consider:
Program
AHD curriculum
Faculty member responsible for resident research,
reports to RPC
Division/Department
Faculty research and scholarly activity open to
participation of residents
Faculty mentors/research supervisors
PGME
CIP
MAD day (there is only one this year)
FHS
Program for Faculty Development
McMaster Education Research, Innovation and
Theory (MERIT)
HRM
Master of Science in Health Science Education
Clinical Educator Program Area of Focused
Competence
FHS Health Research Services
RMA grants
PSI grants
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Populate the text box below and/or Upload a document listing resident contributions to scholarship (e.g.
Publications, presentations, etc) since the last regular accreditation review.
3.2.5
4.2.1.3
4.2.1.4
Note Change:
In the past, the program listed the number of resident
publications in the past 5 years. The new accreditation
cycle will be 8 years. The last McMaster on-site
accreditation review was 2012.
The new expectation is documentation of all scholarly
activities.
Narrative – Clinical Learning Environment Entry Completed
Date:_______________
How does the Residency Program Committee stay informed of issues related to resident wellness and safety?
5.1.2
Suggestions:
PD membership on PGME PD committee where issues
pertaining to all programs would be disseminated.
At program level,
concerns brought to RPC meeting by a member,
faculty or resident representative;
residents speaking to PD
Program could have a faculty member responsible
for resident wellness. 1.2.1.3 and possibly a RPC
subcommittee
Program could have QI member responsible for
safety issues 1.2.1.3
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How does the Residency Program Committee stay informed of issues related to quality of care and patient safety
at learning sites?
1.2.1.1
Suggestion:
Include this as part of the job description of the site
coordinators who would report on these issues at the RPC
meeting. Or the QI member of the RPC.
Are there hospital committees providing reports to
Division/Department with issues that inform the RPC?
Narrative - Resident Assessment and Promotion Entry Completed
Date:_______________
Describe the residency program’s program of assessment, including roles, tools, and frequency.
3.4.1
3.4.2
Describe how decisions regarding resident progress are made, including data/information considered, frequency,
process, etc.
3.4.3
Provide a list of data/information considered by the Competence Committee (or equivalent).
Resident names or identifiers should be removed.
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Describe the support provided to residents who are not attaining required competencies as expected including
support provided to those residents who require formal remediation.
Elaborate on support resources:
https://fhs.mcmaster.ca/postgrad/trainee_well_being.html
In addition to PGME resources, describe program specific
support and process.
Describe the process for appeals.
3.4.4
6.1.1.1
Describe program level and précis PGME process with
links to Appeals Policy
Have there been any appeals in the last two years?
Yes No
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Narrative - Resource Allocation Entry Completed
Date:_______________
Please describe how the Residency Program Committee identifies and advocates for the resources needed by the
residency program.
Describe the process that your RPC uses for identifying
the current and future needs of the program.
What is the mechanism by which the educational experts
within a department can identify what lies ahead for
residency training, how are these issues flagged for the
department or PGE office, and what strategize they use
to acquire the resource(s) e.g. advocating at the hospital
level for ultrasound machines needed for patient care.
In the AMS: List by teaching site the teachers who have a major role in this program, including members from
other departments. In indicating a subspecialty, use as a criterion whether he or she is considered by colleagues
as a subspecialist and functions academically and professionally as one.
Teaching Site Name University
Rank
Specialty
Qualifications
Subspecialty
(if any)
Nature of
interaction
with
Residents
Describe the process to select, organize, and review the residency program’s learning sites.
See requirements: 2.2.1, 2.2.2, 2.2.3
Element 2.2 and Element 9 (9.1.1 and 9.1.2) link direct
to the mandate of the RPC and should be in the Terms of
Reference. The minutes of the RPC should demonstrate
that there is a process with a timetable, so all elements
are reviewed, evaluated, and changes/revisions made on
an ongoing basis.
Resident input must be sought and documented in the
minutes. This can include and not limited to: information
from Resident Retreats, Chief Residents, RPC resident
representatives, exit surveys.
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In the AMS when given permission by PGME, please Upload any Inter-Institution Affiliation Agreements relevant
to the residency program.
Do residents have free 24/7 access to online libraries, journals, and other educational resources?
Yes No Partially
Do residents have adequate space to carry out their daily work?
Yes No Partially
Are technical resources required for patient care duties located in the work setting?
Yes No Partially
Do facilities allow resident skills to be observed?
Yes No Partially
Do facilities allow for confidential feedback/discussions?
Yes No Partially
Describe other technical resources, including simulation facilities, teaching space, etc. available to the residency
program.
Program specific information.
FHS and Hospital Simulation resources
Examples:
McMaster Centre for Simulation-based Learning
https://simulation.mcmaster.ca
Program Specific Simulation Resources
-Critical Care
-Emergency Medicine
Centre for Minimal Access Surgery (CMAS)
With which programs does the residency program collaborate to share educational resources and provide
educational experiences in other disciplines? Please describe.
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Narrative - Resident Wellness and Support Entry Completed
Date:_______________
Please describe the career planning and counselling available to residents in the program.
Program Specific
PGME central programs
-?MAD
CMPA
3.2.3
6.1.2
The RPC must oversee/monitor this process. The key is it
must happen throughout the program, and for each
resident. Document the discussions at semi- or annual
reviews so there is evidence of purposeful meetings.
Ad hoc meetings with ‘willing faculty members’ or during
clinical ‘downtime’ are not enough.
Demonstrate that the program can be tailored to
resident’s future interests, based on career discussions.
Examples: formal mentor program, annual/twice a year
meetings with Program Director, resident meetings with
their Academic Advisor, annual retreats, lectures or
seminars in half-day, career fairs.
Is there a mentorship program available to residents in the program?
Yes No
Describe or upload in the AMS: A list of leadership opportunities for residents.
Examples
Program:
RPC resident rep
Chief Resident
President/Executive of resident group/organization
University:
PARO, RDoC
PGEM Committees
Internal review resident member
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Narrative - Teacher Support and Development Entry Completed
Date:_______________
Describe how teachers in the program are assessed.
7.1.1
7.1.2
System of teacher evaluation, regular
Recognition of teaching excellence
Includes resident input
Teachers receive recognition for contributions outside of
residency: exam boards, specialty committees,
accreditation committees, medical advisory boards, peer
reviewer.
Contributions to medical scholarship
Describe how any unprofessional behaviour by teachers is identified, documented and addressed.
Outline process:
Poor assessment is received what process is followed
who speaks with teacher e.g. Program Director, DEC,
Division Director or Chair
time lines
how is intimidation or harassment addressed
when a designated supervisor is not available or
responding to the resident, etc.
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Please describe faculty development provided to teachers in the residency program.
How are needs and priorities identified and addressed?
Resources available at McMaster University
Faculty of Health Sciences
Program for Faculty Development
https://fhs.mcmaster.ca/facdev/events.html
Academic Development: interprofessional workshops and
sessions
Teaching & Learning Certificates
University Teaching Program
Peer Observation of Teaching (POT) Project
Practice Based Small Group-Education: Series on Medical
Education for Clinical Teachers
PGME
Clinical Educator AFC
School of Graduate Studies
Masters in Health Sciences Education (MSc)
https://hsed.mcmaster.ca
or other University MEd
Department
Does your Department host faculty Workshops, etc.
Please describe the opportunities and support for teachers to contribute to scholarly activity, including research.
MSc. PhD Program in Health Research Methodology
http://hrm.mcmaster.ca/index.html
Graduate Diploma in Clinical Epidemiology (Online)
http://hrm.mcmaster.ca/gdce.html
identify funding agencies, Department awards,
collaboration
protected time
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Please list or upload a list of teachers’ contributions to scholarship activity, including research.
Add to Table in AMS or Upload your own file to AMS
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Narrative - Program Administrative Support and Development
Entry Completed
Date:_______________
Upload in the AMS: The program administrator job description.
Describe the process to provide program administrative personnel with feedback about their performance.
8.1.1
This is new, so programs need to implement.
Describe the professional development opportunities available to the program's administrative personnel. How are
learning needs identified?
PGME workshops
support to attend ICRE
member of ICRE organizing/planning committee
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Narrative - Program Evaluation and Improvement Entry Completed
Date:_______________
Describe the process to review and improve the residency program.
Suggested Program Initiatives:
-annual or every second year all rotations are reviewed
-resident evaluations of rotations
-resident exit surveys
PGME provides an Internal Review Process.
Internal reviews of each residency program are
conducted between on-site accreditation site visits from
the RCPSC and the CFPC. Internal reviews are intended
to support continuous quality improvement within all
programs, to assist the University in maintaining the
quality of its residency programs, and to provide the
Postgraduate Medical Education Committee and Program
Directors with valuable information about the strengths
and weaknesses of their programs. Internal reviews
may also serve as an important trigger for corrective
measures to be taken, where appropriate, before the
next on-site survey.
Internal reviews are conducted by teams of 3 surveyors;
each team includes a faculty Chair, a faculty member,
and a resident representative. Many of the faculty
members who serve as surveyors for the internal review
process are current or past program directors. Every
program director is required to undertake at least one
internal review of another program. Survey teams
review each program against the General Standards of
Accreditation for Residency Programs, using a review
format identical to that used by the RCPSC and CFPC
during on-site visits.
Programs complete the AMS, identical to that which will
be used at a regular on-site survey, and this instrument
is made available to the surveyors in advance of the
internal review. Surveyors are provided with a checklist
to guide and facilitate the review. After the review, the
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survey team prepares a report using the same report
template used by the RCPSC or the CFPC. Strengths and
weaknesses of the program are listed in the report, each
one linked to specific standards of accreditation.
Surveyors are instructed to describe any weaknesses -
especially those of sufficient importance to affect the
accreditation status of the program - fully and clearly.
Each report is reviewed by the PGME Internal Review
Committee. This subcommittee functions in a similar
fashion to the RCPSC Residency Accreditation
Committee: each report is assigned to two reviewers
from the subcommittee, who present the findings to the
full subcommittee. Based on these presentations and
the ensuing discussion, the subcommittee votes on a
proposed status of accreditation, which is intended to
represent a best guess about the accreditation status
that would have been assigned had the report arisen
from an on-site survey. The program then receives a
transmittal letter from the PG Dean summarizing the
strengths and weaknesses and the proposed status,
along with a copy of the full report.
The Internal Review Committee presents a summary of
its findings at least annually to the PGME Committee.
A follow up chart with the list of weaknesses found by
the internal review team and a space for reporting a
timetable of work planned to document progress on this
specific area is provided to each program. The PGME
Office and the Internal Review Committee monitors
progress of these areas of the program at the 6 and 12
month mark following the internal review.
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Provide a list or description of the data and information used to review and improve the residency program.
New
Describe how strengths and areas for improvement, and resulting action plans, are shared with the residency
program's stakeholders.
New