More Information

Our Process - General Overview

The regular accreditation cycle is an 8-year cycle which includes a peer review external site visit, 2-year follow up external reviews, and/or Action Plan Outcomes Reports (APOR) where needed, institution-led internal reviews mid-cycle, as well as continuous monitoring and improvement including regular documentation, self-assessments and data collection. 

Peer Review Site Visits – These reviews happen once every 8 years. Peers from across Canada are recruited by CanERA (surveyors). The surveyors begin by reviewing documents that have been updated on the Canadian Accreditation Management System (CanAMS) by the program and then conduct a review of the program through a series of confidential meetings with appropriate stakeholders. These reviews are usually in person, on site. The surveyors then make recommendations as to what the status of the program should be. The recommendation is taken to the respective accreditation committee for a final verdict. A program can be placed in one of the following categories: 

  • Accredited program with Follow up by Regular Review
  • Accredited program with Follow up by APOR (within 2 years)
  • Accredited program with Follow up by External Review (within 2 years)
  • Accredited program with Notice of Intent to Withdraw; with Follow up by External Review (within 2 years)

At the university of Calgary our next Regular Site Review is planned for 2030.

On Site Visit

2-year Follow up Reviews –

  • APOR – This takes place only through document review on CanAMS, without an actual visit
  • External Review - These reviews are similar to the regular site reviews but can take place virtually as well. The RCPSC conduct a full review of the program, while the CFPC conduct a focused review only on identified areas for improvement (AFIs)

 

2 Y - Follow Up

Internal Reviews – these reviews are completed as part of the regular accreditation process and is a mandated activity at the institution level. It serves as a continuous quality improvement initiative to support programs in identifying their strengths and areas for improvement. Our Internal Reviews will be planned for 2026-2028

  • Action Plan development and Implementation – The internal review will result in a set of action plans that the programs will work on towards improvement. 
Internal Reviews

Continuous monitoring and improvement – the QI and Accreditation portfolio is in the process of developing an approach for programs to maintain accreditation readiness through a series of: 

  • Regular self-assessments, documentation and check ins
  • Ongoing data collection points to inform decision making and resource allocation

Our Timeline

QI and Accreditation Cycle

CQI Framework

CQI Cycle
  • Data: Use range of data (such as Exit, PGY 1, PGY 3 surveys, Accreditation Standard mock & internal reviews, Health Checks, Teacher Assessments, PA & PD Surveys, Patient Safety incidents)
    • Possible sources: Medsis stats, Deferrals/Accommodations, Workshop completion, DRS stats, CaRMS, finance patterns
  • QI and Accreditation Committee: Use data to identify trends and focus areas. Make recommendations to Strategic Advisory Committee (SAC)
  • SAC: Review themes and recommendations, and suggest solutions and action plan for approval at PGME committee meeting
  • PGME Committee (PGMEC): Review solutions and approve next steps
  • Relevant Subcommittee/Portfolio: Solutions put into action by relevant group.