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FACULTY OF MEDICINE

UPDATE ON ACCREDITATIONand a FOCUS ON

OUR LEARNING ENVIRONMENTS

SURGERY & OB/GYN GRAND ROUNDSDean Brian Postl, March 13, 2013

PRESENTATION OVERVIEW

1. Accreditation Update – UGME

2. PGME Accreditation

3. The Learning Environment, Mistreatment and Accreditation

a. Source Documents re: provision of a safe learning environment

b. Learner Feedbackc. Action to dated. Prevention and mitigation

ACCREDITATION UPDATE POST UGME SURVEY – APRIL 3-6, 2011

Survey team was very impressed:

Remarkable effort

Team approach

Very well-organized survey visit

Student participation

Generous support throughout visit by faculty, staff, students

Thanks to all faculty, staff, residents, students, for past and continued commitment

ACCREDITATION UPDATE POST UGME SURVEY – APRIL 3-6, 2011

October 2011 – Received consolidated Liaison Committee on Medical Education (LCME) and Committee on Accreditation of Canadian Medical Schools (CACMS) letter :

“…the CACMS and the LCME voted to continue accreditation of the educational program leading to the MD degree … for an unspecified term.”

• October 2012 Letter following August 2012 update: continuing accreditation for unspecified term

• Dec. 5 & 6, 2012 Secretariat Consult Visit for Aug.2013 report

ACCREDITATION UPDATE LCME/CACMS CONSOLIDATED LETTER

October 2011: • 118 / 130 standards Compliant• 4 / 130 standards Compliant w Monitoring• 8 / 130 standards Non-compliantOctober 2012, following August 15, 2012 Update:

• 119 / 130 standards Compliant• 8 / 130 standards Compliant w Monitoring• 3 / 130 standards Non-compliant

CACMS/LCME expect compliance with each standard cited within two years

ACCREDITATION UPDATE LCME/CACMS IDENTIFIED FACULTY

STRENGTHS • Re-energized leadership in Decanal team

• Dean & Associate Dean, UGME supported by colleagues, students

• Faculty engaged in current educational program

• OPAL curriculum management system

• Indepth approach to behavioral and socio-economic subjects admired by students

• Clinical Learning & Simulation Facility (CLSF)

• Medical students’ thoughtful, detailed analysis

• Financial resources and support of WRHA and Province

Institutional Setting (IS) StandardsIS-11 Administrative Structure: Changes in deanery in almost

all major positions; new appointments effective Sept.15, 2011.

Educational Standards for MD Degree (ED)ED-8 Comparability of Sites: Clerkship directors have not used

outcome measures to examine/assure comparability of clinical experiences/methods of assessment of sites.

ED-9 Curriculum Renewal: School has initiated a 4-year curriculum renewal effort schedule to continue into 2013.

ED-35 Review: Evidence of indepth reviews of individual courses, curriculum years, preclerkship or clerkship years.

Educational Standards for MD Degree (ED)

ED-37 Monitoring Content: Adequacy of monitoring and management of the content in the final year of the curriculum, particularly electives

ED-47 Student Evaluation: Low student satisfaction with the MSK (musculoskeletal) course and the Public Health Course - improving

Medical Students Standards (MS)MS-19 Career Counseling: Update status of system to assist in career

choice, application to residency program, guide to choosing Electives.

MS-31A Learning Environment: In spite of much effort, the school still struggles to ensure learning environment … promotes development of explicit, appropriate professional attributes

N=3 NONCOMPLIANCE Institutional Setting (IS) StandardsIS-1 Strategic Plan: … in the most recent strategic plan (2008)

outcome measures and timelines to track progress . . . were not clearly defined.

Educational Standards for MD Degree (ED)ED-31 Formative Feedback - system for ensuring timely mid-

clerkship feedback . . . in two major specialties (surgery & medicine) not done for 1/3 to 1/2 of students; (medicine improved 2012)

ED-33: Curriculum Management - Recurrent problems with logical sequencing of segments of the curriculum and content is not integrated within and across academic periods

OPAL Clerkship Rotation Data as of April 4, 2011

Periods 1 to 4

Class of 2012 No. of Students

completing MITERs

No. of MITERs completed

with preceptor oversight

% MITERs completed

w preceptor oversight

Family Medicine 53 50 90.9

Internal Med (core) 53 37 68.5

Internal Med (selective)

52 30 55.6

SURGERY 51 22 41.5

OB/GYN 55 55 100.0

Pediatrics 55 55 100.0

Psychiatry 55 44 80.0

STANDARD ED-31 – MID & FINAL EVALUATIONSOPAL DATA: ACCREDITATION SURVEY APRIL 2011

STANDARD ED-31 MID & FINAL EVALUATIONSAUGUST 2012 ACCREDITATION REPORT # Students vs. # Outstanding

MITERs  

TOTAL MITERs vs. Outstanding

% MITER Completion PERIODS 1-6

CLASS 2013 Reporting

As Of:Dec. 22

2011Feb. 13

2012Feb. 22

2012May 42012

July 132012

For PERIODRotation /

Date

1 Sept 28-

Nov8

2Nov 9 –Dec 20

3Jan 4 –

Feb14

4Feb15-Mar27

5Mar 28 – May 8

6May 9 – June 19

OB/GYN 13/0 15/0 14/0 13/0 11/0 14/0 80 / 0 = 100.0

Internal Med (core)

15/0 14/0 14/2 14/3 14/4 14/4 85 / 13 = 84.7

Internal Med (selective)

12/1 14/0 13/3 14/2 13/3 13/7 79 / 16 = 79.7

SURGERY CORE -

GENERAL

13/5 11/4 14/7 13/9 14/8 13/3 78 / 36 = 53.8%

STND ED-31 CURRENT DATA: CLASS 2013 #OUTSTANDING & % COMPLETION (Mean = 11-14

Students)

REPORTED as of July 13, 2012+

SURG. GENERAL CORE 4 WEEKS

S.GEN.SELECT.2 WEEKS

S. SELECT.2 WEEKS

OB/GYN4 WEEKS

MITER FITER FITER ONLY

FITER ONLY

MITER & FITER

+18 wks Post Mid.Pt

For PERIOD 4: Feb.15 - Mar. 27

9/13

30.8%

2/13

84.6% 100% 100% 100%

+12 wks Post Mid.Pt

For PERIOD 5: Mar. 28 - May 8

8/14

42.9%

2/14

85.7% 100% 100% 100%

+6 wks Post Mid.Pt

For PERIOD 6: May 9 – June 19

3/13

76.9%

4/13

69.2%

4/13

69.2%

7/13

46.2% 100%

STND ED-31 CURRENT DATA: CLASS 2014 #OUTSTANDING & % COMPLETION (Mean = 12-15

Students)

REPORTED as of FEB. 27 & 28,

2013+

SURG. GENERAL CORE 4 WEEKS

S.GEN.SELECT.2 WEEKS

S. SELECT.2 WEEKS

OB/GYN4 WEEKS

MITER FITER FITER ONLY

FITER ONLY

MITER & FITER

+19 wks Post Mid.Pt

For PERIOD 1: Sept.25 – Nov. 6

4/13

69.2% 100%

1/13

92.3% 100% 100%

+13 wks Post Mid.Pt

For PERIOD 2: Nov. 7- Dec.18

5/13

61.5% 100%

2/13

84.6%

2/15

86.7% 100%

+5 wks Post Mid.Pt

For PERIOD 3: Jan. 3 – Feb. 12

7/15

53.3%

4/15

73.3%

6/15

60.0%

5/14

64.2% 100%

ACCREDITATION CONCLUSION

The Learning Environment, The Learning Environment, Mistreatment,Mistreatment,

andandAccreditation Accreditation

Source Documents Royal College of Physicians and Surgeons / College of

Family Physicians of Canada: “General Standards of Accreditation”

Royal College: “Accreditation And The Issue Of Intimidation And Harassment In Postgraduate Medical Education: Guidelines For Surveyors And Programs”

LCME Accreditation Standards

Faculty of Medicine “Guidelines for Conduct in Teacher-Learner Relationships”

U of M “Respectful Work & Learning Environment” Policy

WRHA “Respectful Workplace” Policy

Includes: • Statement of Philosophy• Responsibilities in the Teacher-Learner

Relationship• Behaviours Inappropriate to the Teacher-

Learner Relationship• Avenues for Addressing Inappropriate

Behaviour• Procedures for Handling Allegations

Guidelines on Professionalism & Diversity webpage

Faculty of Medicine Guidelines for Conduct in Teacher-Learner Relations

PGME ACCREDITATION Moved to Feb. 23-28, 2014

Canadian Association of Internes & Residents (CAIR) website:Facts about the Accreditation Process

“Accreditation is singly the most important process that residents can be involved in.”

“The single most critical "zero-tolerance" issue in Accreditation is intimidation and harassment.”

CAIR Mantras Intimidation/Harassment

(Canadian Association of Interns & Residents)Intimidation / harassment include, but not

limited to:

Derogatory written or verbal communication or gestures re: race, national or ethnic origin, colour, religion, age, sex, marital status, family status, disability, or sexual orientation.

Unwelcome physical contact

Physical or sexual assault

CAIR Mantras Intimidation/Harassment cont.

Intimidation / harassment include, but not limited to:

Abuse of authority that undermines a resident’s performance or threatens a resident’s career

Patronizing or condescending behaviour intended to humiliate a resident’s performance (distinctly different from timely, constructive feedback from preceptors).

Any coercion in the accreditation process

FOR ROYAL COLLEGE HARASSMENT VERY SERIOUS

e.g. “Harassment imperils N.L. anesthesia training”

February 2011 - Residency program in Anesthesiology at Memorial

University received Notice of Intent to Withdraw Accreditation due to

“Ongoing allegations of intimidation which remain unresolved by

the program, faculty or university processes (B3.8)”

“Harassment imperils N.L. anesthesia training”

RE: Notice of Intent to Withdraw Accreditation: Major and/or continuing weaknesses are identified which

bring into question the ongoing program accreditation

Residents in the program, those already contracted to enter the program, and applicants to the program, must be advised immediately by the program director of the status of the program.

Within 2 years of Notice, an external review is conducted - the program must show cause why accreditation should not be withdrawn.

Jan. 2011/July 2012 GENERAL STANDARDS APPLICABLE TO ALL PROGRAMS

STND B3: STRUCTURE AND ORGANIZATION OF THE PROGRAM

9. “Teaching and learning must take place in environments which promote resident safety and freedom from intimidation, harassment and abuse.”

RCPSC Position Paper: “Accreditation And The Issue Of Intimidation And Harassment In PGME: Guidelines For Surveyors & Programs”

Definition of Harassment:

. . . Repeated, often public, critical remarks or ridicule. Singling out for grilling or interrogation. Unjustified negative remarks or inappropriately positive remarks about appearance or dress. Unjust assignment of duties.

Definition of Intimidation: . . . the use of authority to influence someone to do/refrain from an action or to do something they would not do or should not do otherwise.

e.g. asked to do extra work; refraining from reporting patient events; falsely positive faculty evaluations.

It can also include ‘flattering’ intimidation such as “you are different than the others so I wonder if you can..”; “you’re great, you never complain and I wonder if you could take on this task for me…”

RCPSC: “Accreditation And Intimidation Guidelines . . .

PRINCIPLES:

1. Timely identification of a concern about intimidation and harassment should be the goal of all programs.

2. Trainees should be encouraged to inform their program director or university administration of problems.

3. The initial discussion must occur in a confidential setting.

RCPSC: “Accreditation And Intimidation Guidelines . . .

PRINCIPLES:

4. There should be a process to clarify the facts concerning the allegation.

5. The process of clarification must occur in an atmosphere free of retribution.

6. There should be a process to address and resolve allegations in a timely manner.

UGME STNDS- The Learning Environment

MS-31: there should be no discrimination on the basis of age, creed, gender identity, national origin, race, sex, or sexual orientation in any of the program’s activities.

MS-31A Annotation: . . . the school … should regularly assess the learning environment to identify positive and negative influences on the maintenance of professional standards and conduct, and develop appropriate strategies to enhance positive/mitigate negative influences.

MS-32 Annotation: Mechanisms for reporting violations -- such as incidents of harassment or abuse -- should assure that they can be registered and investigated without fear of retaliation.

Student FeedbackStudent Feedback

Canadian Medical School Graduation Questionnaire (CGQ)

Since 2001, comprehensive, national survey re: graduates’ 4 years

38 questions, many with subsets. 89% U of MB graduates completed 2010 86.5% U of MB graduates completed 2011 89.7% U of MB graduates completed 2012

(75.4% Average ALL Schools 2012)

Three 2012 Reports received: o U of M data o Comparative data for “All Schools”o U of M narrative comments

CGQ – Key Component on Mistreatment

Asks Students about:•Awareness of, and satisfaction with mistreatment policy•Witnessed and experienced mistreatment.•Reporting of mistreatment• Source of mistreatment

• i.e. Faculty, residents, nurses, administrators, students, patients or patients’ family.

• Type of mistreatment:• i.e. General mistreatment (public belittlement,

humiliation); sexual mistreatment; racial/ethnic mistreatment; sexual orientation mistreatment.

CGQ 2012, 2011 & 2010#29. Awareness of a mistreatment policy:

Year U of M All Schools

2012 88.5 % 78.3 %

2011 79.3 % 74.9 %

2010 64.8 % 79.6 %

CGQ 2012, 2011 & 2010#30. Did you witness mistreatment of another learner,

patient or other health care professional?

Year U of M All Schools

2012 37.5 % (36 of 96) 38.7 %

2011 38.6 % (32 of 82) 37.9 %

2010 27.5 % (25 of 91) 31.9 %

CGQ 2012, 2011, & 2010 (All = 17 Med Schools)#30a. Source of witnessed mistreatment:

Source U of M U of M U of M ALL ALL ALL

2012 2011 2010 2012 2011 2010

Nurses 75.0% 53.1% 84.0% 49.1% 50.9% 50.1%

Residents 75.0 46.9 76.0 41.7 36.4 42.5

Clinical Faculty 58.3 68.8 68.0 78.0 79.0 76.8

Students 30.6 21.9 48.0 22.7 18.0 22.7

Patients/Family 28.1 28.1 40.0 25.0 26.9 29.0

All other categories

<15.0 <15.0 <20.0 <20.0 <8.0 <20.0

#31. PERSONAL MISTREATMENT 2012 CHANGE IN SCALE - Includes ALL

Students, i.e. “For each of the types of mistreatment,

indicate frequency you personally experienced

Year Personally Experienced ANY FORM of LISTED MISTX – U

of MALL

Schools

2012 60.4% (58 of 96) 57.4% (1065 of

1856)“Have you personally been mistreated during med. school?”

2011 27.7% (23 of 82) 24.3%

2010 22.0% (21 of 91) 23.6%

Source of personal mistreatment: (ALL = 17 Med Schools)

Source U of M U of M U of M All All All

2012 2011 2010 2012 2011 2010

Clinical Faculty 55.2% 60.9% 60.0% 73.4% 75.9%

72.4%

Residents 56.9 39.1 50.0 32.0 38.1 31.5

Nurses 43.1 47.8 20.0 34.5 43.0 39.0

Students 13.8 17.4 15.0 7.0 7.9 10.2

Patients /Family 10.3 21.7 15.0 18.5 20.5 20.1

All other categories

<15.0 <15.0 <10.0 <10.0 <8.0 <10.0

Nature of personal, GENERAL mistreatment (Mistx):

Public belittlement or humiliation

Threatened with harm or physically harmed

Required to perform services (shopping, babysitting)

2011 – 17 of 23 of those who reported mistreatment

2010 – 17 of 21 of those who reported mistreatment

2012 No. Experienced General Mistx 0f N=96 Responses / and U of M% vs ALL%

Gen. Mistx 1X 2-4 X 5-10 X >10 X

Humiliation/ Belittlement

1313.5 vs 17.1%

3031.3 vs 26%

9 9.4 vs 5.5%

3 3.1 vs 1.9%

Threat/Harm 3 3.1 vs 3.5%

3 3.1 vs 1.9%

0 0

Perform Services

88.3 vs 4.6%

2 2.1 vs 2.9%

1 0

No. Experienced SEXUAL MISTX 0f 96 Responses / and U of M% vs ALL% (slide

1 of 2)

SEXUAL MISTX 2012 2011 2010

1X 2-4X 5-10X

Denied opportunities

because of gender

0 44.2 vs 4.4%

33.1 vs 1.4%

3/23 6/21

Offensive sexist remarks

44.2 vs 5.2%

44.2 vs 4.1%

11.0 vs 0.9%

3/23 4/21

Received lower grades due to

gender

11.0 vs 2.3%

22.1 vs 1.2%

0 3/23 4/21

No. Experienced SEXUAL MISTX 0f 96 Responses / and U of M% vs ALL% (slide

2 of 2)

SEXUAL MISTX 2012 2011 2010

1X 2-4X 5-10X

ASKED TO EXCHANGE

SEXUAL FAVOURS FOR

GRADES

2/952.1 vs 0.3%

1/951.1 vs 0.2%

0 0/23 3/21

UNWANTED SEXUAL

ADVANCES

22.1 vs 2.2%

52.1 vs 0.3%

0 2/23 5/21

No. Experienced RACIAL/ETHNIC Mistx 0f 96 Responses / and U of M% vs ALL%

RACIAL/ETHNIC MISTX

2012 2011 2010

1X 2-4X 5-10X

Denied opportunities

because of race

33.1 vs 1.6%

11.0 vs 1.0%

0 2/23 2/21

Offensive racial/ethnic

remarks

11.0 vs 4.2%

33.1 vs 2.4%

22.1 vs 0.3%

3/23 3/21

Received lower grades solely due

to race/ethnicity

11.0 vs 2.3%

22.1 vs 1.2%

0 2/23 1/21

No. Experienced SEXUAL ORIENTATION Mistx 0f Total Responses / and U of M% vs ALL%

SEXUAL ORIENT’N MISTX

2012 2011 2010

1X 2-4X 5-10X

Denied opportunities because of sexual

orientation

0 1/951.1 vs 0.4%

0 0/23 1/21

Offensive remarks because of sexual

orientation

0 1/951.1 vs 0.5%

0 0/23 2/21

Received lower grades solely due to

sexual orientation

0 1/941.1 vs 0.2%

0 0/23 1/21

CGQ 2012, 2011 & 2010

#31c. Did you report the incident(s) to a designated faculty member or member of the medical school administration?

YES 2012 2011 2010U of M: 10.3% of 58 26.1% of 23 28.6% of

21 (N=6) (N=6)

(N=6)

ALL Schools: 15.5% 26.9% 25.4%

CGQ 2012, 2011 & 2010 #31d. If yes, to whom did you report mistx experience(s)?

REPORTED TO

U of M U of M U of M All All All

2012 2011 2010 2012 2011 2010

Dean or A/Dean Student

Affairs

50.0% 16.7%

16.7%

27.2 42.9% 35.3%

Designated counselor or

advocate

33.3 16.7 33.3 15.6 18.4 9.4

Other medical school

administrator

0.0 0.0 33.3 20.0 21.4 18.8

Faculty member

50.0 33.3 50.0 42.8 34.7 50.6

1. Distribution of CGQ report to: Dean’s Council Department Heads Curriculum Committees Faculty via Dean’s presentations at Grand Rounds

2. Ongoing Scanning of Environment via: PreClerkship course evaluations Clerkship rotation evaluations Electives evaluations PARIM survey

Action

Action3. Meetings with:

Clinical Departments / grand rounds Individual departments identified by residents and

students in Accreditation reports and internal reviews WRHA leadership including Nursing PARIM and residents HSC leadership

4. Core/required presentations by Dean/Associate Deans during medical students’ and residents’ orientations and during “Introduction to Clerkship”

Prevention1. Education of learners :

Curricular components:o PreClerkshipo Introduction to Clerkship (ITC)o Introduction to Residency in renewed curriculum

Education of teachers including residents, faculty

2. Policy development / entrenchment – Faculty & Program

3. Ongoing management of compliance with standards of the Royal College and LCME/CACMS

Mitigation

1. Surveillance of learning environment

2. Share information on learning environments through existing liaison committees

3. Encourage a culture of disclosure and support

4. Move to Zero tolerance

QuestionsQuestions

andand

CommentsComments

The Learning Environment

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