Standards and Planning

Accreditation Standards

Accreditation Planning

The PGME Office and the Associate Dean, PGME are responsible for compliance with the accreditation standards pertaining to all postgraduate programs and the PGME Office. One mechanism in exercising this oversight is by way of the internal review process. All residency programs and Area of Focused Competence (AFC) training programs at Memorial University are examined by way of an internal review process. This multi-year process takes place within the 8-year accreditation cycle and begins approximately 3 years after the on-site survey. It continues until all residency and AFC programs are reviewed at least once, and any necessary follow-up activities (e.g., action plan outcome reports, external reviews, follow-up reviews, written reports, resident reports) are completed. The internal review cycle shall also include an Institutional review (ie. of the PGME Office) by external faculty.

Internal Review Oversight Committee (IROC)

The internal review process is overseen by the Internal Review Oversight Committee (IROC), a subcommittee of the Postgraduate Medical Education Committee. Customized reports on internal review findings are provided to Disciplines and sites throughout the accreditation cycle. The IROC has a mandate to support educational excellence and accreditation compliance through organizing, reviewing and providing recommendations based on all residency program reviews, carried out under the auspices of the PGME Office.

All IROC members, individually and collectively, will approach matters that come before the Committee in such a way that the interests of the Faculty of Medicine take precedence over the interests of any of its constituent parts, should those interests conflict or appear to conflict. This Committee is intended to complement existing University resources which address matters of PGME Accreditation and to foster collaboration on such matters relating to the PGME. This Committee is not intended to act as a substitute, duplicate or alternate forum to address issues over which other areas of the University have specific jurisdiction.

Internal Review Process

  1. Residency program will collaborate with the Faculty Lead, Accreditation to develop and distribute their schedule for an internal review in accordance with the accreditation cycle timelines.

  2. PGME IROC will instruct the residency program under review of the format of the internal review, based on CanAMS, as appropriate.

  3. The residency program under review completes and compiles all necessary documentation that is to be reviewed by the review team. Documentation includes but is not limited to:
    a. CanAMS instruments,
    b. Residency Program Committee agendas – most recent, two (2) years;
    c. Overall and rotation specific goals and objectives mapped to CanMEDS/CanMEDS-FM competencies;
    d. Curriculum map;
    e.Templates of all assessment forms (and a narrative document outlining their role in the assessment program);
    f. Residency program policies and all (sub) committee terms of reference;
    g. Evidence of programmatic quality assurance and quality improvement processes within the program should be highlighted explicitly;
    h. Other documents as requested to be reviewed – e.g. resident files and assessments.

  4. The review team conducts their review of the program and completes a written Internal Review Report describing the strengths and weaknesses of the residency program and highlight any specific areas in need of further attention. If further review or follow-up is required, it will be highlighted explicitly, with a recommended timeline.

  5. The Internal Review Report is sent for review by the IROC within 10 working days.

  6. The IROC will formulate a transmittal letter to accompany the Internal Review Report for the residency program highlighting the findings of the review team and outlining expectations around an action plan.

  7. The Associate Dean, PGME, will meet with the individual Program Director and the Discipline Chair of the residency program and discuss the findings and action plan.

    This plan may be shared with senior management of the Faculty of Medicine.