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.
OVERVIEW DATA
The following tables will be completed by the AFMC Office of the Director of CAPER and VP Data and Analysis and provided to the medical school for verification. Subsequently the data will be provided to the CACMS Secretariat who will insert the tables into the Draft Site Visit Report and provide them to the team secretary approximately three months prior to the on-site visit. If relevant, the AFMC will update the tables with the most recent information provided by the medical school and they will be provided to the team secretary prior to the end of the on-site visit by the CACMS Secretariat.
NOTE: Data for tables 1.0-1 and 1.0-2 will be provided by the AFMC.Table 1.0-1 | Faculty and Enrollment / Source: AFMC CFQ
These data are from the AFMC Canadian Financial Questionnaire (CFQ) for the academic year (AY) of the program’s previous full site visit self-study, and for the academic year relevant to the current full site visit.
Data from the last full site visit report / AY 2017-18
Entering class size
Total medical student enrollment
Number of residents and fellows
Number of full-time basic science faculty
Number of full-time clinical faculty
Table 1.0-2 | Financial Overview / Source: AFMC CFQ
These data are from the AFMC Canadian Financial Questionnaire (CFQ) for the academic year (AY) of the program’s previous full site visit self-study, and for the academic year relevant to the current full site visit.
Revenue sources / Data from the last full site visit report / AY 2017-18
Visa student and trainee fees
University (excluding allied health and other programs)
Federal government
Provincial government
Practice plan/alternate funding plan/billing group
Hospital or health authority
Research awards, grants, and contracts
Research grant overhead funds
Gifts, donations and interest earned on endowments/investments
Other
Total revenues
NARRATIVE RESPONSE
a. Provide the month range of the fiscal year used by the medical school (e.g., July-June).
b. Provide a brief history of the medical school, noting key points in its development such as the development of any geographically distributed campuses, creation of parallel curricular tracks (e.g., longitudinal integrated clerkship), changes in the number of students in the program, and loss or addition of affiliated clinical sites.
SUPPORTING DOCUMENTATION
a. Maps of the medical school campus and its affiliated hospitals. Include a map illustrating the location of any geographically distributed campuses and sites used for longitudinal integrated clerkships. (Appendix 1 a)
1.1 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.
NARRATIVE RESPONSE
a. Provide the short and long-term goals of the medical education program.
b. Describe the process used by the medical school to establish its mission, goals and most recent strategic plan for the medical education program.
c. How often is the strategic plan reviewed and/or revised?
d. Describe how and how often the outcomes of the school’s strategic plan are monitored.
e. Describe how the medical school monitors ongoing compliance with CACMS accreditation Standards and Elements. Answer the following questions:
1. How often is compliance with CACMS Standards monitored?
2. What data sources are used?
3. How are the data reviewed?
4. How is follow-up implemented and improvement monitored?
SUPPORTING DOCUMENTATION
a. The strategic plan that includes the executive summary, the outcomes and how they will be measured and the estimated timeline for achievement of these outcomes. (Appendix 1.1 a)
1.1.1 SOCIAL ACCOUNTABILITY
A medical school is committed to address the priority health concerns of the populations it has a responsibility to serve. The medical school’s social accountability is:
a) articulated in its mission statement;
b) fulfilled in its educational program through admissions, curricular content, and types and locations of educational experiences;
c) evidenced by specific outcome measures.
SUPPORTING DATA
Table 1.1.1-1 | Populations that the Medical School has a Responsibility to Serve / Source: School-ReportedList the populations that the medical school has a responsibility to serve. Provide a short title in Column 1 and a brief description (e.g., geographic, linguistic). Add rows as needed.
School-identified population / Brief description
Table 1.1.1-2 | Specific Outcome Measures / Source: School-Reported
List the specific short-term and long-term outcome measures the school uses or will use as evidence that its social accountability is being fulfilled. Add rows as needed.
School-identified outcome measure / Short-term / Long-term
NARRATIVE RESPONSE
a. Describe how the medical school identifies the priority health concerns of these populations.
b. Describe how the social accountability commitment of the medical school is fulfilled through each of the following:
1. admissions process
2. curricular content
3. types and locations of educational experiences
c. Describe how and how often the specific outcome measures are monitored and the groups or individuals who review the results.
SUPPORTING DOCUMENTATION
a. The mission statement of the medical school with the words that articulate social accountability underlined. (Appendix 1.1.1 a)
1.2 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.
NARRATIVE RESPONSE
a. Place a “Y” for Yes or “N” for No next to each area in which the medical school or university has a faculty conflict of interest policy:
Conflict of interest policy / Y/NConflict of interest in research
Conflict of interest of faculty with academic and teaching responsibilities
Conflict of interest in commercial support of continuing medical education
b. Provide one example that illustrates how conflict of interest policies are being followed as they relate to faculty with academic and teaching responsibilities.
c. Describe how board members, faculty members and any individuals with responsibility for the medical education program are informed about the conflict of interest policies relevant to them.
SUPPORTING DOCUMENTATION
a. Policies and procedures intended to prevent or address financial or other conflicts of interest including recusal from discussions or decisions if a potential conflict occurs among governing board members, university administrators and medical school academic and educational leaders (dean, vice-dean, department chairs, and other relevant positions), and senior administrators (e.g., Chief financial officer), and faculty. (Appendix1.2 a)
1.3 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.
SUPPORTING DATA
Table 1.3-1 | Standing Committees / Source: School-ReportedList all major standing committees of the medical school and provide the requested information for each, including whether members are all appointed (A), all elected (E), or whether the committee has both appointed and elected members (B), and whether the committee is charged with making recommendations (R), is empowered to take action (A), or both (B).
Committee / Reports to / Total voting members / Total faculty voting members / Membership selection
(A/E/B) / Authority (R/A/B)
NARRATIVE RESPONSE
a. Summarize how the selection process for faculty committees ensures that there is broad faculty input into the governance process. How are individuals whose perspectives are independent from that of departmental leadership or central administration included? Note whether committees include elected members or members nominated or selected through a faculty-administered process (e.g., through a “committee on committees”).
b. Describe how faculty are made aware of policy and other types of changes that require faculty comment and how such input from faculty is obtained. Describe some opportunities for faculty to provide such input over the previous three years.
c. List the number and type of general faculty meetings held during the past academic year. Indicate whether these meetings were held in-person and/or by audio/visual conference. Describe the means by which faculty were made aware of meeting agendas and outcomes.
d. Describe any mechanisms other than faculty meetings (such as written or electronic communications) that are used to inform faculty about issues of importance at the medical school.
1.4 AFFILIATION 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) assurance of medical student and faculty access to appropriate resources for medical student education
b) primacy of the medical school’s authority over academic affairs and the education/assessment of medical students
c) 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) 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
Definition taken from CACMS lexicon- Required clinical learning experience: A subset of required learning experiences that take place in a health care setting involving patient care that are required of a student in order to complete the medical education program.These required clinical learning experiences may occur any time during the medical educational program.
SUPPORTING DATA
Table 1.4-1 | Affiliation Agreements / Source: School-ReportedFor each inpatient clinical teaching site or regional health authority used for required clinical learning experiences, provide the page number in the current affiliation agreement and highlight the passages containing the following information:
a. assurance of medical student and faculty access to appropriate resources for medical student education
b. primacy of the medical school’s authority over academic affairs and the education/ assessment of medical students
c. 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. 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
Add rows as needed for each campus / teaching site / regional health authority.
Campus / Clinical teaching site or
regional health authority / Date agreement signed / Page number(s)
(a) Access to resources / (b) Primacy of program / (c) Faculty appointments / (d) Environmental hazard / (e) Learning environment
SUPPORTING DOCUMENTATION
a. The signed/executed affiliation agreement for each clinical teaching site at which students complete the inpatient portions of required clinical learning experiences including integrated longitudinal clerkships. This does not include clinical teaching sites only used for electives or selectives. (Appendix1.4 a)
Note: Each affiliation agreement should be saved as a separate document and named according to the following convention:
Appendix_1.4_a1_sitename or regional health authority,
Appendix_1.4_a2_sitename or regional health authority,
Appendix_1.4_a3_sitename or regional health authority, etc.
1.5 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.
Definition taken from CACMS lexicon- Senior administrative staff: Individuals in high-level positions responsible for the operation of the medical school e.g., finances, information technology, and facilities.
NARRATIVE RESPONSE
a. Provide the date of the most recent revision of the bylaws or similar policy documents that apply to the medical school.
b. Describe the process for changing bylaws or similar policy documents, including the individuals and groups that must approve changes.
c. Briefly describe how the bylaws or similar policy documents are made available to the faculty.
SUPPORTING DOCUMENTATION
a. The table of contents of the faculty bylaws or similar policy documents that apply to the medical school, and the link to the electronic document. (Appendix1.5a)
1.6 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.
* Details are found in the CACMS Rules of Procedure.
Definition taken from CACMS lexicon- University: The university or universities of which the medical school is a part.
NARRATIVE RESPONSE
a. Place a “Y” for Yes or “N” for No next to each of the eligibility requirements for accreditation by the CACMS
Eligibility requirement / Y/NThe medical school and its geographically distributed campuses are located in Canada
Students complete all required learning experiences at the medical school
The medical school is part of, or affiliated with, a university that has legal authority to grant the degree of Doctor of Medicine
b. Provide the name of the university of which the medical school is a part of, or is affiliated with, that has the legal authority to grant the degree of Doctor of Medicine in Canada.
CACMS DCI – Standard 1 (AY 2018-2019) Page 12