FAQs about UME Accreditation

FAQs about UME Accreditation

Spotlight on Accreditation

Spotlight on Accreditation

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What is an accreditation standard?

The accreditation requirements are divided into 12 Standards, which are further subdivided into 94 elements. A full list of these is found at the CACMS website.

  1. Standard 1 Mission, planning, organization, and integrity

    1.1 Strategic planning and continuous quality improvement

    1.1.1 Social accountability

    1.2 Conflict of interest policies

    1.3 Mechanisms for faculty participation

    1.4 Affiliation agreements

    1.5 Bylaws

    1.6 Eligibility requirements

  2. Standard 2 Leadership and administration

    2.1 Senior leadership, senior administrative staff and faculty appointments

    2.2 Dean’s qualifications

    2.3 Access and authority of the dean

    2.4 Sufficiency of administrative staff

    2.5 Responsibility of and to the dean

    2.6 Functional integration of the faculty

  3. Standard 3 Academic and learning environments

    3.1 Resident participation in medical student education

    3.2 Community of scholars/Research opportunities

    3.3 Diversity programs and partnerships

    3.4 Anti-discrimination policy

    3.5 Learning environment

    3.6 Student mistreatment

  4. Standard 4 Faculty preparation, productivity, participation, and policies

    4.1 Sufficiency of faculty

    4.2 Scholarly productivity

    4.3 Faculty appointment policies

    4.4 Feedback to faculty

    4.5 Faculty professional development

    4.6 Governance and policy-making procedures

  5. Standard 5 Educational resources and infrastructure

    5.1 Adequacy of financial resources

    5.2 Dean’s authority/Resources

    5.3 Pressures for self-financing

    5.4 Sufficiency of facilities and equipment

    5.5 Resources for clinical instruction

    5.6 Clinical instructional facilities/Information resources

    5.7 Security, student safety and disaster preparedness

    5.8 Library resources/Staff

    5.9 Information technology resources/Staff

    5.10 Resources used by transfer/Visiting students

    5.11 Study/Lounge/Storage space/Call rooms

    5.12 Required notifications to the CACMS

  6. Standard 6 Competencies, curricular objectives and curricular design

    6.1 Program and learning objectives

    6.2 Required patient encounters and procedures

    6.3 Self-directed and life-long learning

    6.4 Outpatient/Inpatient experiences

    6.4.1 Context of clinical learning experiences

    6.5 Elective opportunities

    6.6 Service-learning

    6.7 Currently, there is no element 6.7

    6.8 Education program duration

  7. Standard 7 Curricular content

    7.1 Biomedical, behavioral, social sciences

    7.2 Curriculum across the life cycle

    7.3 Scientific method/Clinical/Translational research

    7.4 Critical judgment/Problem-solving skills

    7.5 Societal problems

    7.6 Cultural competence and health care disparities

    7.7 Medical ethics

    7.8 Communication skills

    7.9 Interprofessional collaborative skills

    7.10 Professional and leadership development

  8. Standard 8 Curricular management, evaluation, and enhancement

    8.1 Curricular management

    8.2 Use of program and learning objectives

    8.3 Curricular design, review, revision/Content monitoring

    8.4 Evaluation of program outcomes

    8.5 Medical Student feedback

    8.6 Monitoring of required patient encounters and procedures

    8.7 Comparability of education/Assessment

    8.8 Monitoring time spent in educational and clinical activities

  9. Standard 9 Teaching, supervision, assessment, and student and patient safety

    9.1 Preparation of resident and non-faculty instructors

    9.2 Faculty appointments

    9.3 Clinical supervision of medical students

    9.4 Assessment system

    9.5 Narrative assessment

    9.6 Setting standards of achievement

    9.7 Timely formative assessment and feedback

    9.8 Fair and timely summative assessment

    9.9 Student advancement and appeal process

    9.10 Student health and patient safety

  10. Standard 10 Medical student selection, assignment, and progress

    10.1 Premedical education/Required coursework

    10.2 Final authority of admission committee

    10.3 Policies regarding student selection/Advancement and their dissemination

    10.4 Characteristics of accepted applicants

    10.5 Technical standards

    10.6 Content of informational materials

    10.7 Transfer students

    10.8 Currently, there is no element 10.8

    10.9 Visiting students

    10.10 Currently, there is no element 10.10

    10.11 Student assignment

  11. Standard 11 Medical student academic support, career advising, and educational records

    11.1 Academic advising

    11.2 Career advising

    11.3 Oversight of extramural electives

    11.4 Provision of the medical student performance record

    11.5 Confidentiality of student educational records

    11.6 Student access to educational records

  12. Standard 12 Medical student health services, personal counseling, and financial aid services

    12.1 Financial aid/Debt management counseling/Student educational debt

    12.2 Tuition refund policy

    12.3 Personal counseling/Well-being programs

    12.4 Student access to health care services

    12.5 Providers of student health services/Location of student health records

    12.6 Student health and disability insurance

    12.7 Immunization requirements and monitoring

    12.8 Student exposure policies/Procedures


Who is the accreditation external review team and what is their role?

CACMS assembles a site visit team that includes the dean of another medical school, a representative from LCME, a medical student and at least two faculty members from other universities.

The team meets with educational leadership, staff, students, residents and faculty to clarify information and learn if the school actually follows its policies and procedures. The team sends a report to CACMS, which meets to decide the accreditation status of the school.  

See the Guide for Conduct of CACMS Accreditation Visits for more details


What is the role of CSM faculty, students and staff during the accreditation site visit?

Staff and faculty connected directly to the provision of undergraduate medical education will be expected to be aware of the policies and procedures relevant to their work and provide evidence that the policies and procedures are followed. For example, the Medical Teaching Unit (MTU) clinical preceptors should be aware of work hour restrictions (Element 8.8, Clerkship Work Hours)  as well as the educational objectives (Element 6.1, The Big Ten Graduation Educational Objectives)


What are the possible outcomes regarding accreditation status?

  1. 1

    Accreditation for an eight-year term. The school completes status reports in follow-up of elements that are rated as satisfactory with monitoring or unsatisfactory.

  2. 2

    Accreditation with indeterminate term. The school will have a follow-up limited site visit within 24 months.

  3. 3

    Accreditation with shortened term. A full accreditation will occur in less than eight years.

  4. 4

    Accreditation with warning. The school must create an Action Plan and, if this plan is approved, a follow-up limited site visit is scheduled within 13 - 15 months.

  5. 5

    Accreditation with probation. This status is not confidential and is publicly posted on the CACMS and LCME websites. The school must submit an Action Plan. If the Plan is accepted, the school will have a post-probation site visit. If the school does poorly at this visit, the school may have its accreditation withdrawn.

  6. 6

    Withdrawal of accreditation.

Every school is asked by CACMS for some follow-up after a site visit. Our goal is to maintain accreditation and to only be expected to provide status reports.

While a program is unlikely to have accreditation withdrawn accreditation following a survey and site visit, a probationary or warning status may have a significant and lasting impact on the program.
Adverse accreditation findings affect the institution’s reputation, including its place in national and international rankings, and may have a negative impact on the institution’s development activities.
 
A program on probation must send written notification to all current students and applicants for admission that it has been placed on probation.
 
In order to apply for and enroll in a post-graduate training program (residency) in Canada and/or the United States, students must have graduated from a Doctor of Medicine (MD) program accredited by the CACMS and LCME. Maintaining accreditation is therefore essential to ensuring that MD program graduates can continue their training beyond the MD level.


What are the benefits of accreditation?

  • The provision of national standards of educational quality
  • The quality assurance process requires us to assess and improve our undergraduate educational program
  • Knowledge that we are providing the same quality of education as other medical schools across Canada

Contacts

Dr. Marcy Mintz
UME Accreditation director
mjmintz@ucalgary.ca

Gretchen Greer
UME Accreditation coordinator
greerg@ucalgary.ca