1
AFMC Interim Accreditation Review Process 2014 Checklists
December 2014 Version
AFMC Checklists
Standard 1
MISSION PLANNING ORGANIZATION AND INTEGRITY
A medical school has a written statement of mission and goals for the medical education program, conducts ongoing planning, and has written bylaws that describe an effective organizational structure and governance processes. In the conduct of all internal and external activities, the medical school demonstrates integrity through its consistent and documented adherence to fair, impartial, and effective processes, policies, and practices.
Association of Faculties of Medicine of Canada
INTERIM REVIEW PROCESS
CopyrightThe Association of Medical Faculties of Canada (AFMC) 2014, all rights reserved. The AFMC Standards 1-12 Checklists are directly aligned with the corresponding CACMS Standards and Elements June 2014; the CACMS Data Collection Instrument (DCI) October 2014, the CACMS Guide to the Medical School Self-Study (MSS), December 2014, the CACMS Role of Students in the Accreditation of Medical Education Programs in Canada (ISA), and the CACMS Survey Report Guide. All AFMCmaterial may be reproduced for the non-commercial purpose of scientific or educational advancement.
STANDARD 1
ELEMENT RATING TABLE and ELEMENT EVALUATION FORMS
STANDARD 1: MISSION, PLANNING, ORGANIZATION AND INTEGRITY
A medical school has a written statement of mission and goals for the medical education program, conducts ongoing planning, and has written bylaws that describe an effective organizational structure and governance processes. In the conduct of all internal and external activities, the medical school demonstrates integrity through its consistent and documented adherence to fair, impartial, and effective processes, policies, and practices.
Medical School Self-Study Subcommittee
Standard 1 Element Rating Table
Standard 1 / Mission, Planning, Organization and IntegrityElement
1.1* / Strategic Planning and Continuous Quality Improvement
1.2 / Conflict of Interest Policies
1.3 / Mechanisms for Faculty Participation
1.4 / Affiliation Agreements
1.5 / Bylaws
1.6 / Eligibility Requirements
Label the number of the element using the following code.
Labeling Code / ColorStrength / *
Satisfactory
Satisfactory monitoring
Unsatisfactory
Note: If element 1.1 was rated as Satisfactory, the cell with the corresponding element number would be shaded light blue as shown above as an example.
The Association of Faculties of Medicine of Canada
interim accreditation survey review process
CACMS Element 1.1 Checklist
December 1, 2014
MEDICAL SCHOOL: DATE (mm,dd):
ELEMENT1.1 STRATEGIC PLANNING AND CONTINUOUS QUALITY IMPROVEMENT
A medical school engages in ongoing planning and continuous quality improvement processes that establish short and long-term programmatic goals, result in the achievement of measurable outcomes that are used to improve programmatic quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards.
YES / NO / REQUIREMENTS NOT FULLY MET
1.1 aThe medical school has a written statement of mission and vision for the medical education program.
The AFMC FMEC recommendations may be a useful resource.
1.1 bThe strategic plan is reviewed and revised at appropriate intervals.
1.1 cThe outcomes of the strategic plan are monitored to ensure that the strategic plan is effective.
1.1 dThe medical school engages in ongoing planning and continuous quality improvement that establish short and long-term programmatic goals.
1.1 eThe medical school monitors ongoing compliance with CACMS accreditation Standards and Elements and takes steps to maintain compliance.
1.1 f. Discussions with relevant individuals at the time this element was evaluated confirm that the requirements listed above are being met by the medical school.
RATING
☐Strength
☐Satisfactory
☐Satisfactory with a need for monitoring
☐Unsatisfactory
Evidence to support the above rating
Plans to address elements rated as Unsatisfactory or Satisfactory with a need for monitoring
The Association of Faculties of Medicine of Canada
interim accreditation survey review process
CACMS Element 1.2 Checklist
December 1, 2014
MEDICAL SCHOOL: DATE (mm,dd):
ELEMENT1.2 CONFLICT OF INTEREST POLICIES
A medical school has in place and follows effective policies and procedures applicable to board members, faculty members, and any individuals with responsibility for the medical education program to avoid the impact of conflicts of interest in the operation of the medical education program, its associated clinical facilities, and any related enterprises.
YES / NO / REQUIREMENTS NOT FULLY MET
1.2 aThere are conflict of interest policies and procedures that apply to the individuals noted in the element.
1.2 b The medical school informs the relevant individuals about these policies and procedures.
1.2 cThese policies and procedures address conflict of interest in each of the following areas:
i. research
ii. faculty with academic and teaching responsibilities
iii. commercial support for continuing professional development
1.2 d There are strategies for managing actual or perceived conflicts of interest in the operation of the medical education program, its associated clinical facilities, and any related enterprises.
1.2.e. Discussions with relevant individuals at the time this element was evaluated confirm that the requirements listed above are being met by the medical school.
RATING
☐Strength
☐Satisfactory
☐Satisfactory with a need for monitoring
☐Unsatisfactory
Evidence to support the above rating
Plans to address elements rated as Unsatisfactory or Satisfactory with a need for monitoring
The Association of Faculties of Medicine of Canada
interim accreditation survey review process
CACMS Element 1.3 Checklist
December 1, 2014
MEDICAL SCHOOL: DATE (mm,dd):
ELEMENT1.3 MECHANISMS FOR FACULTY PARTICIPATION
A medical school ensures that there are effective mechanisms in place for direct faculty participation in decision-making related to the medical education program, including opportunities for faculty participation in discussions about, and the establishment of, policies and procedures for the program, as appropriate.
YES / NO / REQUIREMENTS NOT FULLY MET
1.3 a Faculty are voting members on the majority of standing committees in the medical school.
1.3 bThe process used to select faculty members for standing committees takes into account the need to have members whose perspectives are independent of departmental leadership and central administration.
1.3 c Faculty are made aware of proposed changes in the medical education program, its policies and procedures, and given an opportunity to provide input.
1.3 d There is at least one general faculty meeting each year (in person or virtual) where faculty are notified of the agenda and the outcomes of the meeting.
1.3 e The medical school uses an effective system to inform the faculty of important issues at the medical school.
1.3.f. Discussions with relevant individuals at the time this element was evaluated confirm that the requirements listed above are being met by the medical school.
RATING
☐Strength
☐Satisfactory
☐Satisfactory with a need for monitoring
☐Unsatisfactory
Evidence to support the above rating
Plans to address elements rated as Unsatisfactory or Satisfactory with a need for monitoring
The Association of Faculties of Medicine of Canada
interim accreditation survey review process
CACMS Element 1.4 Checklist
December 1, 2014
MEDICAL SCHOOL: DATE (mm,dd):
ELEMENT1.4AFFILIATION AGREEMENTS
In the relationship between a medical school and its clinical affiliates, the educational program for all medical students remains under the control of the medical school’s faculty, as specified in written affiliation agreements that define the responsibilities of each party related to the medical education program. Written agreements are necessary with clinical affiliates that are used regularly for required clinical learning experiences; such agreements may also be warranted with other clinical facilities that have a significant role in the clinical education program. Such agreements provide for, at a minimum:
a)The assurance of medical student and faculty access to appropriate resources for medical student education.
b)The primacy of the medical education program’s authority over academic affairs and the education/ assessment of medical students.
c)The role of the medical school in the appointment and assignment of faculty members with responsibility for medical student teaching.
d)Specification of the responsibility for treatment and follow-up when a medical student is exposed to an infectious or environmental hazard or other occupational injury.
e)The shared responsibility of the clinical affiliate and the medical school for creating and maintaining an appropriate learning environment that is conducive to learning and to the professional development of medical students.
f)Confirmation of the authority of the department heads of the medical school to ensure faculty and medical student access to appropriate resources for medical student education when those department heads are not also the clinical service chiefs at affiliated institutions.
YES / NO / REQUIREMENTS NOT FULLY MET
1.4 a The medical school has signed affiliation agreements with all clinical facilities at which medical students complete the inpatient portions of required clinical learning experiences including longitudinal integrated clerkships.
Affiliation agreements are not required for facilities that are used for clinical electives, or widely dispersed, purely ambulatory required clinical learning experiences (e.g., at an individual preceptor’s office). Note that all issues related to environmental hazards/injuries e.g., needle-stick injuries and the quality of the learning environment and student mistreatment need to be addressed at all locationsused for required clinical learning experiences.
1.4 b The affiliation agreements (which may include other associated formally endorsed documents e.g., addendum to the agreement)have explicit language as indicated in a-f in the element.
1.4 c An independent review of the relevant documents confirms that the requirements listed above are being met by the medical school.
RATING
☐Satisfactory
☐Satisfactory with a need for monitoring
☐Unsatisfactory
Evidence to support the above rating
Plans to address elements rated as Unsatisfactory or Satisfactory with a need for monitoring
The Association of Faculties of Medicine of Canada
interim accreditation survey review process
CACMS Element 1.5 Checklist
December 1, 2014
MEDICAL SCHOOL: DATE (mm,dd):
ELEMENT1.5 BYLAWS
A medical school has and publicizes bylaws or similar policy documents that describe the responsibilities and privileges of its dean and those to whom he or she delegates authority (e.g., vice, associate, assistant deans), department heads, senior administrative staff, faculty, medical students, and committees.
YES / NO / REQUIREMENTS NOT FULLY MET
1.5 a There are bylaws or similar policy documents that describe the responsibilities and privileges of the dean and those to whom he or she delegates authority (e.g., vice, associate, assistant deans), department heads, senior administrative staff, faculty, medical students and committees that are made known to faculty members.
1.5 b The bylaws or similar policy documents support an effective governance structure for the medical school.
1.5 c An independent review of the relevant documents confirms that the requirements listed above are being met by the medical school.
RATING
☐Satisfactory
☐Unsatisfactory
Evidence to support the above rating
Plans to address elements rated as Unsatisfactory or Satisfactory with a need for monitoring
The Association of Faculties of Medicine of Canada
interim accreditation survey review process
CACMS Element 1.6 Checklist
December 1, 2014
MEDICAL SCHOOL: DATE (mm,dd):
ELEMENT1.6 ELIGIBILITY REQUIREMENTS
A medical school ensures that its medical education program meets all eligibility requirements of the CACMS for initial and continuing accreditation and is either part of, or affiliated with, a university that has legal authority to grant the degree of Doctor of Medicine.
YES / NO / REQUIREMENTS NOT FULLY MET
1.6 a The medical school and its geographically distributed campuses are located in Canada.
1.6 b Students complete all required learning experiences in the medical school.
1.6 c The medical school is part of, or affiliated with, a university that has legal authority to grant the degree of Doctor of Medicine.
- 1.6 d Discussions with relevant individuals at the time this element was evaluated and an independent review of the relevant documentation confirm that the requirements listed above are being met by the medical school
RATING
☐Satisfactory
☐Satisfactory with a need for monitoring
☐Unsatisfactory
Evidence to support the above rating
Plans to address elements rated as Unsatisfactory or Satisfactory with a need for monitoring
Standard 1 Element Checklists