Accreditation success:
Key markers of program
quality and how to
achieve them
Dr. Kenneth A. Harris
Ms. Margaret Kennedy
September 23, 2011
Objectives
At the end of this session, participants will be
able to:
• understand the standards of accreditation
• identify key markers of a quality program
• describe common pitfalls and their
avoidance/correction in a residency program
Agenda
• Introductions
• Components of a residency program
• Standards of Accreditation
• Quality indicators
• Pitfalls
• Small group discussion
• Large group discussion
• Summary and conclusions
3
Introductions
• Who we are!
• Who you are!
• Name, specialty
• Biggest challenge
• Biggest surprise
Systematic Approach to Program
Management
• Standards of accreditation
• A and B Standards
• “musts” vs “shoulds”
• Specialty requirements
• Program requirements – SSA
• Resident requirements – STR, OTR
• CanMEDS
Accreditation Standards – University and
training sites
A.1 University Structure
A.2 Sites for Postgraduate Medical Education
A.3 Liaison between the University and participating sites
Accreditation Standards - Programs
B.1 Administrative Structure
B.2 Goals & Objectives
B.3 Structure and Organization
B.4 Resources
B.5 Clinical, Academic & Scholarly Content
B.6 Evaluation of Residents
Categories of Accreditation
• New Approval
• Approval (6 years)
• Provisional Approval (2 years)
follow-up by Internal/External Review
• Intent to Withdraw Accreditation
B1: Administrative Structure “musts”
1.1 Program director
1.2 Residency Program Committee
1.3 Ongoing management and review of program
1.4 Site directors/coordinators
1.5 Research supervisor for residents
1.6 Scholarly environment teaching, faculty, research
B1: Administrative Structure “pitfalls”
• Program director autocratic
• Residency Program Committee dysfunctional
• Unclear Terms of Reference (membership, tasks and
responsibilities)
• Agenda and minutes poorly structured
• Poor attendance
• Department/Division head unduly influential
• RPC is conducted as part of a Dept/Div meeting
• No resident voice
B2: Goals & Objectives “musts”
2.1 Overall goals of the program
2.2 Structured to reflect the
CanMEDS competencies
• Used in planning & assessment
of residents
2.3 Rotation specific and functional
•
Used in planning & assessment
of residents
2.4 Resident & staff have copies
2.5 Regular review by Residency Program
Committee
B2: Goals & Objectives “pitfalls”
• Missing CanMEDS roles in overall structure
• Okay to have rotations in which all CanMEDS roles may
not apply (research, certain electives)
• Goals and objectives not used by faculty/residents
• Goals and objectives dysfunctional – do not
inform evaluation
• Goals and objectives not reviewed regularly
B3: Structure & Organization ”musts”
3.1
Provides all components of training as
outlined in specialty documents
3.2
Appropriate supervision
3.3
Increasing professional responsibility
3.4
Senior resident role
3.5
Balance of service and education
3.6
Equivalent opportunities for each resident
3.7
Adequate opportunity for electives
3.8
Role of each site clearly defined
3.9
Safe learning environment
3.10 Collaboration with other programs
B3: Structure & Organization “pitfalls”
• Graded responsibility absent
• Service/education imbalance
• Service provision by residents should have a defined
educational component including evaluation
• Educational environment poor
B4: Resources “musts”
4.1
Sufficient teaching staff
4.2
Appropriate number and variety of patients
and lab specimens
4.3
Clinical services organized to meet objectives
4.4
Access to technology
4.5
Adequate physical and technical resources
4.6
Supporting facilities as required by Specialty
Specific Accreditation Standards
B4: Resources “pitfalls”
• Insufficient faculty for teaching/supervision
• Insufficient clinical/technical resources
• Infrastructure inadequate
B5: Clinical, Academic & Scholarly
Content of Program “musts”
Evidence of teaching the CanMEDS competencies
Medical Expert
Communicator
Collaborator
Manager
Health Advocate
Scholar
Professional
B5: Clinical, Academic & Scholarly
Content of Program “pitfalls”
• Organized academic curriculum lacking or entirely
resident driven
• Poor attendance by residents and faculty
• Teaching of essential CanMEDS roles missing
• Role modelling as the only teaching modality
B6: Evaluation of Resident Performance
“musts”
6.1 Based on goals & objectives
6.2 Evaluation consistent with characteristic being
assessed
6.3 Timely, regular, documented feedback
6.4 Residents informed of serious concerns
6.5 Final evaluation report provided
B6: Evaluation of Resident Performance
“pitfalls”
• Mechanism to monitor, promote, remediate
residents lacking
• Formative feedback not provided and/or
documented
• Evaluations not timely (particularly when serious
concerns identified), not face to face
• Summative evaluation (ITER) inconsistent with
formative feedback, unclearly documents
concerns/weaknesses
Break Out Session
21
Summary and Conclusions
• Standards are closely related
• Weaknesses in one standard often have impact on
other standards
22