SITE VISIT REPORT GUIDE

FOR MEDICAL EDUCATION PROGRAMS

LEADING TO THE M.D. DEGREE

NOVEMBER 2015

FOR FULL ACCREDITATION SITE VISITS SCHEDULED IN 2015-2016

For further information, contact:

CACMS Secretariat

Committee on Accreditation of Canadian Medical Schools

Association of Faculties of Medicine of Canada

2733 Lancaster Rd, Suite 100

Ottawa, Ontario, Canada K1B 0A9

Phone: 613-730-0687Ext 225 Fax: 613-730-1196

Visit the CACMS website at:

Site Visit Report Guide

©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.

TABLE OF CONTENT

OVERVIEW OF THE ACCREDITATION PROCESS...... 1

  1. Purposes of accreditation...... 1
  2. Accreditation Standards...... 1

GENERAL STEPS IN THE ACCREDITATION PROCESS...... 1

  1. Completion of the DCI and Compilation of Supporting Documents...... 2
  2. Independent Student Analysis...... 2
  3. Medical School Self-Study Analysis and Report...... 3
  4. The Site Visit and Preparation of the Site Visit Report...... 3
  5. Accreditation Decisions and Follow-up...... 4

ASSISTANCE FROM THE CACMS SECRETARIAT...... 4

PREPARATION FOR THE SITE VISIT...... 4

SITE VISIT TEAM REPORT OVERVIEW...... 5

COMPONENTS OF THE SITE VISIT TEAM REPORT...... 5

  1. Title page...... 5
  2. Table of contents...... 5
  3. Memorandum...... 6
  4. Site Visit team composition...... 6
  5. Acknowledgement...... 6
  6. Disclaimer...... 6
  7. Final site visit team element rating summary table...... 7
  8. Summary of site visit team findings...... 7
  9. History of the school...... 8
  10. Accreditation history of the school...... 8
  11. Curriculum description...... 8
  12. Key parameters overview summary table...... 10
  13. Evaluation of the DCI...... 10
  14. Evaluation of the MSS...... 10
  15. Evaluation of the ISA...... 11
  16. Evaluation of the CGQ and AFMC GQ data...... 11
  17. Evaluation of elements by standard...... 11
  18. Appendices of the site visit report...... 11

SITE VISIT TEAM EVALUATION OF ELEMENTS...... 12

  1. Instructions...... 12
  2. Evaluation of Elements-Comment Field...... 12
  3. Rating the Elements ...... 13
  4. Completing the element rating tables, summary of findings and team

element rating summary table...... 14

  1. Exit conference with the dean...... 15
  2. Preparation of the final site visit report...... 15

Appendix AElement Evaluation Forms Standards 1-12

Appendix BSurvey Team Element Rating Summary Table

Appendix CCore Appendix

Appendix DPoints to be addressed in the Site Visit Exit Session

OVERVIEW OF THE ACCREDITATION PROCESS

  1. PURPOSES OF ACCREDITATION

Obtaining accreditation from the Committee on Accreditation of Canadian Medical Schools (CACMS) and the Liaison Committee on Medical Education (LCME) ensures that medical education programs are in compliance with defined standards. The accreditation process has two general and related aims: to promote medical school self-evaluation and improvement, and to determine whether a medical education program meets prescribed standards.

As a process of evaluation, accreditation seeks to answer three general questions:

  1. Has the medical school clearly established its mission and goals for the educational program?
  2. Are the program's curriculum and resources organized to meet the mission and goals?
  3. What is the evidence that the program is currently achieving its mission and goals and is likely to continue to meet them in the future?
  1. ACCREDITATION STANDARDS

The standards for accreditation of Canadian medical schools are contained in the publication CACMS Accreditation Standards and Elements (S&E).

Medical schools with site visits during the 2015-2016 academic year will use the June 2014 version of S&E. These standards have been widely reviewed and endorsed by the medical education community, including the organizations that sponsor the CACMS.

Medical schools are expected to achieve compliance with each of the 12 standards. Compliance with a standard will be based on satisfactory performance in the elements associated with the standard. See “Accreditation Decisions and Follow-up” below.

GENERAL STEPS IN THE ACCREDITATION PROCESS

Information provided by the medical school is analyzed in the context of accreditation standards by the medical schoolitself in its self-study,by the visiting site team, and lastlyby the CACMS. The general steps in the process are as follows:

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

2.Completion of the Independent Student Analysis (ISA) by the medical school’s students

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

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

5.Action on accreditation by the CACMS and the LCME.

Each of the steps is summarized below.

1. COMPLETION OF THE DCI AND COMPILATION OF SUPPORTING DOCUMENTS

The Dean designates a core team of faculty and staff to manage the aspects of the site visit preparation process. The faculty accreditation lead manages the data collection and self-study processes; the site visit coordinator typically manages visit logistics, and may assist with data collection.

The questions in the DCI are directly linked to specific elements. The absence of a document, data, and/or information specifically requested in the DCI will be taken by the site visit team and the CACMS to mean that the document, data, and/or information do not exist. While the self-study should consistently focus on data from a specific period of time i.e., the most recently completed academic year, the DCI should have been completed with all requested historical data. The time period covered by the data should be clearly indicated.

Because the DCI was likelyprepared nine months or more before the site visit, certain quantitative information must be updated prior to submission. The team will need current financial information, student enrollment data, updates on changes in the educational program, and any other significant new information. These updates should be made before the DCI is finalized and submitted (i.e., three months before the scheduled visit). The Association of Faculties of Medicine of Canada (AFMC) will update the financial information, student enrollment, faculty and resident numbers with the most recent information provided by the medical school. Schools are responsible for updating the responses to other questions, as needed.

2.INDEPENDENT STUDENT ANALYSIS

Students manage an independent review of the medical education program, student services and other areas of relevance to students following the guidelines described in the document entitled, The Role of Students in the Accreditation of Medical Education Programs in Canada. Normally students conduct their independent analysis (ISA) that is based on the results of a survey of all medical students while the DCI is being completed. The medical schoolmay provide logistical support and assistance in the implementation of the survey, and collection and analysis the data,however, planning for the student survey and the interpretation of the results are student responsibilities.

3. MEDICAL SCHOOL SELF-STUDYAND REPORT

The medical school self-study(MSS) process normally requires the time and effort of the medical school’s educational leadership, faculty members, students, administrative support staff and others associated with the medical school, its clinical affiliates, and, if relevant, its parent university. The MSS task force should be broadly representative of the constituencies of the medical school. It should, therefore, include some combination of the following: medical school senior and administrative leaders (academic, fiscal, managerial), department chairs and heads of sections, junior and senior faculty members, medical students, medical school graduates, faculty members and/or administrators of the general university, representatives of clinical affiliates, and trustees (regents) of the medical school/university. Additionally, the MSS task force could include graduate students in the basic biomedical sciences, residents involved in medical student education, and community physicians. Although the general guidelines about the composition of the task force should be followed, each school must make its own decisions about membership based on its specific environment and circumstances.

The MSS task force and its subcommittees are responsible for conducting the self-study. This process is described in detail in the CACMSGuide to the Medical School Self-Study. The subcommittees initially evaluate and rate each element assatisfactory, satisfactory with a need for monitoring or unsatisfactory(subcommittee reports). The self-study committeescite evidence from the DCI to support the rating assigned to each element. In addition, the evaluation forms include recommendations to address elements rated as unsatisfactory or satisfactory with the need for monitoring. The self-study subcommitteesalso identify elements as strengths if they believe that the medical school has achieved outcomes or uses a process that is worthy of emulation. The MSS task force analyzes the subcommittee reports, along with the supporting documentation and any new information such as the final ISA report and other data collected by the medical school, and produces thetaskforcereport with the final element evaluation forms.

The final Medical School Self-Study Report is submitted as part of the accreditation package three months prior to the site visit. Print copies of the individual subcommittee reports must be provided to the team in the team’s workroom during the visit, but should not be submitted with the accreditation package.

4. THE SITE VISIT AND PREPARATION OF THE SITE VISIT REPORT

Prior to the visit, the site visit team will review the materials submitted by the school in detail. At the time of the visit, the school will provide copies of these documents, as well as the individual self-study subcommittee reports, to the site visit team in print and electronic formats.

During the visit, the site visit team evaluates and rates each element based on evidence provided by the school and discussions with relevant individuals at the medical school. The site visit team makes neither recommendations nor decisions regarding the medical school’s compliance with accreditation standards ortheaccreditation status of the medical school. The former is the purview of the CACMS and the later is the purview of the CACMS and the LCME.

After the site visit, a draft site visit report will be prepared by the site visit team according to the format specified in thisguide. The site visit report evaluates each element based oninformation in the DCI, the MSS Report, the ISA, as well as information obtained by the team during the visit. The site visit report expresses the team’s judgment about the extent to which the medical school meets the requirements of each element, which will be rated as: 1) Satisfactory, 2) Satisfactory with a need for Monitoring, or3) Unsatisfactory.

The draft version of the report is subject to review by the CACMS Secretariat and the medical school prior to submission of the final report to the CACMS. Thesite visit reportdraft review process is described in detail later in this guide.

5. ACCREDITATION DECISIONS AND FOLLOW-UP

The sitevisit report is reviewed by the CACMS at its next regular meeting (in September, January, or May), at which time the element ratings are finalized and a formulated decision about the program’s accreditation status and follow-up is made. Subsequently this formulated decision will be reviewed by the LCME at its next regularly scheduled meeting (October, February or June) and a final CACMS/LCME decision on the accreditation status and follow-up will be determined.

ASSISTANCE FROM THE CACMS SECRETARIAT

Site visit team members are encouraged to attend the preparation sessions available toteam membersscheduled for upcoming visits. These include an individual site visit team“Secretariat Call” to assist the team in preparing for the visit, and an annual preparation session at the Canadian Conference on Medical Education (CCME). These sessions provide general information about accreditation, updates on new procedures or changes to CACMS Standards and Elements and give participants an opportunity to discuss specific issues with members of the Secretariat. Designated site visitteam members will automatically receive invitations to these events. Site visit team secretaries and chairs are encouraged to contact the CACMS Secretariat by email or phone, before, during and after the visit for assistance with questions or problems as they arise.

PREPARATION FOR THE SITE VISIT

The team secretary will inform team members of their assigned elements and discuss the process of element evaluation. Minimally, each team member should review the Medical School Self-Study Evaluation forms, and the DCI data, narrative responses and appendices for the elements to which they have been assigned. The relevant questions from the Canadian Graduation Questionnaire (AAMC CGQ), the AFMC Graduation Questionnaire (AFMC GQ) and the ISA pertaining to a specific element are provided in the DCI for that element. Prior to the visit, following the instructions provided in this guide, each team member should complete in draft form the evaluation of elements and summary of findings specifically assigned to them based on the documentation provided by the school. The team member should contact the team secretary if additional information is needed from the school to permit the evaluation of an element. During and after the site visit, the element evaluation forms shouldbe revised as appropriate based on any new information and discussions with the relevant individuals during the visit. If not submitted by the end of the site visit, the final element rating table and element evaluation rating forms aresent to the team secretary within 7-10 days after the visit. The team must use this guide when evaluating the elements assigned to them. The team secretary must use the sitevisit report template included in this guide, and the tables provided by the CACMS Secretariat, to ensure consistency across site visit reports.

SITEVISIT REPORT OVERVIEW

The report of an accreditation visit is the formal record of the team’s findings related to the elements of accreditation standards. It serves as the primary source of information for accreditation decisions by the CACMS and the LCME. Team members will have reviewed the school’s material before the visit. Updates or corrections made to the DCI after the accreditation package has been submitted (3 months before the visit) will be bundled and sent to the team so that they may be incorporated into the visit schedule. The team may also request information from the school if the information in the DCI is incomplete or unclear. While onsite, the team may also review additional information, such as the self-study subcommittee reports and other relevant documentation.

Each site visit team member must take the utmost care to ensure that all element ratings are fully explained and documented, and that all the assigned elements are evaluated. The site visit report is based on information contained in the DCI,informationupdates providedto the team and discussions with medical school representatives during the visit.

There may be casesin which the self-study may not accurately portray prevailing circumstances or may express greater optimism about the existing state of affairs than seems evident to the team. Team members should validate the information in the DCI and the bases of conclusions drawn by the MSS Task Force. Because some of this information may have been compiled as long as a year before the accreditation visit, it is important to note whether major areas of concern have been addressed and whether any new concerns recently have emerged.

COMPONENTS OF THE SITE VISITREPORT (* Items will be provided by the CACMS Secretariat Office)

  1. TITLE PAGE*
  1. TABLE OF CONTENTS*
  1. Memorandum
  2. Site Visit Team Composition*
  3. Acknowledgement
  4. Disclaimer
  5. Final Site Visit Team Element Rating Summary Table
  6. Summary of Site Visit Team Findings
  7. History of the School*
  8. Accreditation History of the School*
  9. Curriculum Description
  10. Key Parameter Overview Summary Table (last full visit vs visit)*
  11. Evaluation of the DCI
  12. Evaluation of the MSS
  13. Evaluation of the ISA
  14. Evaluation of the CGQ and AFMC GQ
  15. Evaluation of Standards 1-12
  16. Core Appendix
  17. Supplemental Appendix
  1. MEMORANDUM

TO:Committee on the Accreditation of Canadian Medical Schools

FROM:The Secretary of the ad hoc Site Visit Team That Visited

[Name of School] on [Dates]

RE:Report of the Site Visit Team

On behalf of the ad hoc CACMS Site Visit Team that visited the [Name of School] on [Dates], the following report of the team’s findings is provided.