Guidefortheconductof Cacmsaccreditationsitevisits

GUIDEFORTHECONDUCTOF CACMSACCREDITATIONSITEVISITS

For full accreditation visits scheduled in 2015-2016

Published November 2015

GuidefortheConductofCACMS AccreditationSiteVisits

Committee on Accreditation of Canadian Medical Schools

For additional information, contact:

CACMS Secretariat

Association of Faculties of Medicine of Canada

2733 chemin Lancaster Road, Suite 100

Ottawa, ON K1B 0A9

Phone: 613-730-0687, ext. 225

Email:

©Copyright November 2015 by the Committee on Accreditation of Canadian Medical Schools. All rights reserved. All material subject to this copyright may be reproduced, with citation, for the noncommercial purpose of scientific or educational advancement. CACMS is a registered trademark of the Association of Faculties of Medicine of Canada and the Canadian Medical Association.

Guide for the Conduct of CACMS Accreditation Site Visits

Guide for the Conduct of CACMSAccreditation Site Visits

TABLEOFCONTENTS

GENERAL INFORMATION...... 4

Accreditation and the CACMS ...... 4

To Contact the CACMS Secretariat...... 4

FULL SITE VISITS...... 5

Overview of the Steps in a Full Accreditation Review...... 5

Site visit Team Size and Composition...... 6

Visit Structure...... 6

LIMITED SITE VISITS...... 7

OVERVIEW OF TEAM MEMBER FUNCTIONS...... 7

Team Chair...... 7

Team Secretary...... 8

Team Members...... 8

THE REPORT OF A SITE VISIT...... 8

Report Preparation and Review...... 8

Documents Related to the Accreditation Process...... 11

SITE VISIT LOGISTICS FROM THE PERSPECTIVE OF THE SITE VISIT TEAM...... 12

Suggested Schedule for a Full Accreditation Site Visit...... 12

Suggested Schedule for a Limited Accreditation Site Visit...... 12

Expense Report Processing...... 12

CACMS Travel Reimbursement Policy...... 13

MEDICAL SCHOOL RESPONSIBILITIES...... 13

Roles of Medical School Participants in the Accreditation Process...... 13

Visit Preparation and Logistics...... 14

Completion and Submission of Pre-Visit Materials and Updates...... 15

Student Involvement...... 16

The Site Visit...... 16

APPENDIX A: MODEL VISIT SCHEDULE FOR A FULL ACCREDITATION SITE VISIT...... 19

APPENDIX B SITE VISIT TEAM MEMBER DUTIES...... 32

APPENDIX C: TYPICAL TIMELINE FOR A FULL ACCREDITATION REVIEW...... 38

APPENDIX D: POINTS TO BE ADDRESSED IN THE EXIT CONFERENCE...... 40

APPENDIX E: WRITING ASSIGNMENT TEMPLATE...... 44

GENERALINFORMATION

The purpose of this document is to provide site visit teams and medical schools with a summary of the steps in preparing for and conducting a CACMS site visit. Sections of the document provide this information from a variety of perspectives (e.g., the site visit team in general, specific team member roles, the medical school), so the reader should select the sections that are most relevant. The document is a synthesis of other information available on the CACMS webpage at: Consult the site for the most recent information.

ACCREDITATION AND THE CACMS

Accreditation is widely used in higher education. It serves the important purpose of assuring the public, government agencies, and professional groups that educational programs and institutions meet or exceed nationally accepted standards of quality for educational process and student outcomes. Accreditation by the CACMS servestwopurposes:1)todetermineifamedicaleducationprogramisinsubstantial compliancewithaccreditationstandardsand2)topromoteprogramimprovement.

The CACMS is sponsored by the Canadian Medical Association (CMA) and the Association of Faculties of Medicine of Canada (AFMC) and accredits M.D.-granting medical education programs in Canada.

TO CONTACT THECACMS SECRETARIAT

The Secretariat consists of two professional members (a Secretary and an Assistant Secretary), one accreditation manager, and one accreditation specialist. EnquiriesshouldbesenttotheCACMS at:

Secretary

Committee on Accreditation of Canadian Medical Schools

c/o Association of Faculties of Medicine of Canada

2733 chemin Lancaster Road, Suite 100

Ottawa, ON K1B 0A9

613-730-0687, ext. 225

E-mail communications and general enquiries to the CACMS Secretariat should be sent to the CACMS electronic mailbox at .

The members of the CACMSSecretariat welcometheopportunitytorespondtoquestionsandcomments.

FULLSITE VISITS

Overview of the Steps in a Full Accreditation Review. Full accreditation of all the elements of the 12 CACMS Standards, culminating in a full site visit, typically occur on an eight-year cycle and consist of the following steps:

1.Completion by the school of the data collection instrument (DCI) and compilation of supporting documents.

2.Analysis of data from the Independent Student Analysis (ISA), the most recent graduation questionnaires, and the DCI, narrative responses and appendices, by Medical School Self-study (MSS) subcommittees and task force, development of self-study reports for each standard, and compilation of these updated reports into a final Medical School Self-Study (MSS) Report.

3.Visit by an ad hoc site visit team and preparation of the site visit team report for review by the CACMS.

4.Action on accreditation by the CACMS and LCME.

The CACMSSecretariat establishes the visit dates approximately 15-18 months before thesite visit. Pre-visit documents, including the Data Collection Instrument (DCI) and instructions for theMedical School Self-study (MSS), are available on the CACMS webpage around that time. School personnel work over a period of several months to provide the information requested in the DCI. The DCI is used to inform theMSS. The school will submit its completed DCI, MSS Report, and other materials to site visit team members and the CACMS Secretariat office three months before the visit.

During the visit, the team meets with medical school educational and academic leadership, faculty members and students and will develop a list of its findings that relate to specific elements. See Appendix A for a model full visit schedule.

At the completion of the site visit, the team’s summary findings will be reported orally to the dean and the university chief executive on the final day of the visit and a written copy of the team findings related to the elements will be provided to the dean. These initial findings will be revised during the process of review of the visit report. The visiting team makes neither recommendations nor decisions regarding the medical school’s accreditation status; the determination of accreditation status is the purview of the CACMS and the LCME.

After the visit, a draft report is prepared by the visiting team according to the format specified in the Site Visit Report Guide. The report evaluates the information in the DCI, the MSS Report, the ISA, as well as information obtained by theteam during the visit, and presents the team's findings from the visit. The visit report will include the team’s judgment about findings related to elements, which will be rated as: 1) satisfactory, 2) satisfactory with a need for monitoring, and 3) unsatisfactory. See the Site Visit Report Guide on the CACMS webpage( for definitions of these terms. After having been reviewed by the CACMS Secretariat and the medical school dean, the report is submitted to the CACMS for its study at the next regularlyscheduled meeting. The CACMS will develop the final list of findings related to the elements and judge compliance with accreditation standards, determine the status of accreditation of the medical education program, and identify any requirements for follow-up.

SiteVisit Team Size and Composition. TheCACMSSecretariatisresponsibleforappointing the members of site visitteams. Theteamforafull accreditationsite visitofamedicaleducationprogramtypicallyconsistsoffive to six membersdrawnfromapoolofexperiencedmedicaleducators andphysician practitioners,including professionalmembersof the CACMS,toensureconsistencyinthe evaluationprocess.

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 school and compiles the site visit report. The remaining team members will include an LCME-designated member whenever possible; a student member when possible; and a “faculty fellow”. The team may include an observer.

Thefacultyfellowtypically has not been on a full sitevisit previouslyandhasbeendesignatedby hisorherschooltogainhands-onexperience before the schoolbeginsitsownself-studyprocess; the ‘faculty fellow” is a full member of the team, evaluates assigned elements and contributes to the site visit report. The observer is also designated by his or her school or by another organization with an interest in accreditation, but does not participate in the work of the team or the report.

In appointing full site visit teams, the CACMS Secretariat will make all reasonable efforts to balance the team in terms of accreditation experience, gender, professional expertise, practitioner/educator status, and familiarity with the type of medical school being visited.

The LCME appointees to CACMS site visit teams are invited to attend CACMS team preparation workshops. At a minimum, LCME appointed team members are briefed by the CACMS Secretariat on any differences between the CACMS and the LCME site visit processes and variations in accreditation elements.

VisitStructure.Fullsite visitstypically are three and one-half days in duration and beginlateonSundayafternoon and end on Wednesday. The visit beginswithateamcaucus,followed by ameetingwiththedean. Duringthevisit,theteamwillmeetwiththosepersonsorgroupswho can provide or verify information,includingfaculty,students,administrators,andrepresentativesof clinical affiliates.Whilemeetingswithfacultymembersandstudentstypicallytake placewithoutthepresenceofinstitutionalleaders,thedean’sparticipationisappropriateduringtheteam’smeetingswithprogramadministrators,especiallyregardingfinancesandrelationshipswith clinicalaffiliates. Theteamwillsuccessivelydevelopandrefineitslistofsummaryfindings,beginning atthearrivalteamcaucusandcontinuingduringworkingsessionseacheveningandpriortotheexit conferences.

VisitstypicallyconcludeonWednesdayafternoonafterexitconferenceswiththedeanandtheuniversity chiefexecutive(orhisorherdesignee). Generally,theteammeetsprivatelywiththedeanatboththe entranceandexitconferences,althoughthedeanmayincludeotherswithadvancenoticetotheteam. At theexitconferenceswiththedeananduniversitychiefexecutive(orhisorherdesignee),theteamchair willsharethesummaryofthesite visitteam’sfindings.Theteamchairwillprovideacopyoftheteam’s findingstothedeanattheendoftheexitconferencewiththedean.Theteamchairwillemphasizeto both thedeanandtheuniversitychiefexecutivethatthe site visitteam'ssummaryreportrepresentsapreliminarystatementoffindingsforconsiderationby theCACMS.Theteam’sfindingsarenot,therefore, forwidespreaddissemination at this point.

LIMITEDSITE VISITS

Limitedsite visitsusuallyinvolvethree or fourteammembers: chair, secretary, LCME-appointed member whenever possible, and one additional member for a minimum of a three team members. A student member joins the team whenever possible. The team may also include a faculty fellow or an observer. The visitsarefocusedonpreviouslycitedelements that were identified as unsatisfactory or satisfactory with a need for monitoringand,therefore, areshorterinduration. TeammembersgenerallyarriveonSundayforateamcaucusandentrance conferencewiththedean,asinafullsite visit. Limitedsite visitstypicallyconcludeonTuesdayafternoondependingonthenumberandtype of elementstobereviewed. There are exitconferenceswiththedeanandtheuniversitychiefexecutive(orhisorherdesignee), as in a full site visit.

Insteadofthe complete DCIandMSSpreparedforfullsite visits, the school prepares asmaller DCI (mini-DCI) customized to collect information necessary to address each of the elements requiring follow-up. A limited site visit does not require an ISA however, information from and about students may be required depending on the elements under review. Instructions forpreparingthe mini-DCI aresenttotheschool by theCACMSSecretariataboutsixtoeightmonthsbeforethevisit. Theschoolisexpectedtosendthe completedmaterialstothelimited site visitteammembersandtotheCACMSSecretariat officeabout six weeks priortothevisit.

The limited site visit may involve meetings with university administrators, faculty members, students, and representatives of affiliated institutions among others, as needed to address the elements being followed-up during the site visit. The site visit team report preparedfollowing a limited site visit is focused on conveying the team’s findings on the elements previously identified as unsatisfactory or satisfactory with a need for monitoring. Additional elements may be identified by the team as unsatisfactory or satisfactory with a need for monitoring as a result of the limited site visit. The report of a limited site visit has a similar format to that of a full site visit report with the exception that it is focused on a reduced number of elements.

OVERVIEW OF TEAM MEMBER FUNCTIONS

More detailed information about the roles and responsibilities of site visit team members is contained in Appendix B.

TeamChair.Duringthevisit,thechairmakesintroductionsandexplainsthepurposeofthe site visit. He or she conducts the entranceconference with the dean andleadsthediscussionsasthesite visitteamworkstodevelopitsfindingsaboutthe extent to which the medical school meets the requirements of accreditation elements. Thechairreportstheteam'sfindingsto the dean anduniversity executiveattheconclusionofthesite visit.

TeamSecretary.For both full and limited site visits, the team secretary works with the school’s faculty accreditation lead (see Medical School Responsibilities in this document for the definition of faculty accreditation lead) to finalize the visit arrangements, including the site visit schedule, and ensures that team members have their specific assignments for the visit and all necessary materials. The site visitteam secretary is responsible for oral and written communication with the school, other team members, and the CACMS Secretariat. All team contact with the school should be through the team secretary. The team secretary is responsible for completing the site visit report from the element evaluation formsprepared by eachteam member.

Team Members.Teammembers,includingthefacultyfellow for full site visits,preparefortheirassigned elements byreviewingtherelevant portions of the DCI MSS Reportand the ISA indepth. Theyshouldcontacttheteamsecretaryiftheybelieve thatpertinentinformationismissing from the materials submitted by the schooloris ambiguous.Duringthesite visit,teammemberswillbe responsibleforleadingthediscussioninthesessionsdevotedtotheirassignedelements. Teammembersare encouragedtobringportablecomputerstofacilitatereportpreparation. Itisexpectedthatallteam memberswillbe present for the opening team caucus and remaintoparticipateintheexitconferencesonthefinaldayofthevisit.

THE REPORT OF A SITE VISIT

REPORT PREPARATION AND REVIEW

Confidentiality of Information. Informationabouttheschool,whethercontainedinthe DCI, the ISA and MSS Report,orobtainedonsite,is consideredconfidentialandmustnotbedisclosedtootherparties. Aconfidentialitystatementisincluded intheCACMSSecretariat’smailingtothe site visitteam;thisstatementmustbesignedandreturnedbefore thevisit. Team members should hold the team findings confidential. Eitherattheendofthesite visitorafterreviewingthereport,teammembers shoulddisposeof materialsrelatedtothe site visitinawaythatensures it remains confidential. Documents or correspondence notneededforthe site visitreportcanbeleftwiththeschoolattheconclusionofthevisit. Afterreviewingthe draft site visit report,teammembersshoulddestroyanyremainingdocuments, includingthe draft report,relatedtothe accreditationsite visit.

TimelineforCompletingtheSite VisitReport.Thefollowingchartgivestheimportantdeadlinesfor completionoftheSite visitreport. Detailedexplanationsfollowthischart.

ContentandCompilation oftheSite VisitReport.ThereportshouldbeorganizedaccordingtotheSite Visit ReportGuide,availableontheCACMSwebpage: visitteam’ssummary findingsmustbeamplysupportedby documentation intheelement evaluation forms andthecore appendix and information obtained onsite and included in the supplemental appendix.

PreparingtheDraftSite VisitReport.To ensure prompt consideration of the medical education program’s accreditation status, it is essential that the draftsite visit report be completed as quickly as possible. Team members should submit the element evaluation forms for their assigned standardsto the team secretary within seven to ten days following the visit, if not by the visit’s conclusion. The draftsite visit report should be completed bytwo-four weeks after the visit. The team secretary should send a copy of the draft report (including the core and supplemental appendices) to the CACMS Secretariat for review. The CACMS Secretariat will communicate with the team secretary about the draft site visit report’s organization, format, internal consistency, and thoroughness in evaluation of all of the elements and summary of team findings(for a full site visit) and in providing sufficient documentation related to each finding.

UponreceivingthecommentsfromtheCACMSSecretariat,theteamsecretaryshouldmakeanyneeded revisions;sendtherevisedsite visitreporttotheteammembers. Teammembersshouldensurethatthereportaccurately representstheirfindingsand the consensusassessment of the team. After review by the team and any subsequent revisions (approximately four-six weeks following the visit), the team secretary sends the draft site visit report totheCACMS Secretariat who will forward it to the dean of the medical school. In acovermemo to the deanaccompanyingthereport, the CACMS Secretariat will requestthat the dean reviewthereportandreturncommentswithin 10workingdaystotheSecretariat who will forward to the teamsecretaryfor considerationandfinalrevision. Thedeanwill beinstructedtochecktheteam’s reportforfactualerrors and concerns about tone. No new information may be provided by the dean that was not included in the DCI, the MSS Report,the ISAor provided to the team during the site visit. After considering feedback from the dean, the secretary in consultation with the team chair and other team members as needed,revises the draft as they deem appropriate and submits the final version of the report to the CACMS Secretariat. The CACMS Secretariatthen sends the final version of the report to the dean at the time it is submitted by the team secretary. Ifthedeancontinues to have concerns about thetone of the report or the process of the visit,heorshemaywritealettertotheCACMS SecretariatforinclusionintheCACMS’considerationoftheschool’saccreditationstatus as described in detail later in this documents and in CACMS Rules of Procedure.

Timeline for the submission of the Final Version of theSite VisitReport.Instructions for preparing and submitting the final report are available in the Site visit Report Guide. The CACMS meets in the early part of September, January, and May. The final site visit reportmustbereceivedbythe CACMSSecretariatnolaterthansixweeks before the next scheduled CACME meetingtoallowadequatetimeforreviewby CACMSmembers. TheCACMSSecretariatshouldbepromptlynotifiediftheteamsecretary anticipatesanydelaysinprovidingthefinalreport.

Notice of CACMS/LCME Action. During the CACMS meeting, membersreviewthesite visitreport(andcorrespondencesubmittedby thedean)andwill develop the final element ratings and list of findings and judge compliance with accreditation standards, determine the status of accreditation of the medical education program, and identify any requirements for follow-up.