Frequently Asked Questions

At the last full accreditation in 2014, the Committee on Accreditation of Canadian Medical Schools (CACMS) and the Liaison Committee on Medical Education (LCME) found that the MD program at the University of Alberta was compliant with all 132 accrediting standards, which resulted in a full and unqualified eight-year approval.

An interim accreditation site visit in March 2018 confirmed our compliance with all 12 standards and 96 elements and confirmed that the MD program was in an excellent position to start preparations for the Association of Faculties of Medicine of Canada (AFMC) mandated 2022 accreditation review cycle.

Accreditation is a peer-review, quality-assurance, quality-improvement process that ensures medical students receive the best education possible. The purpose of the Medical School Self-Study, the Data Collection Instrument (DCI) and the Independent Student Analysis that are part of the accreditation process is to promote self-evaluation and improvement. Institutional strengths can be identified and strategies can be put in place to ensure strengths are maintained. Any problems or issues requiring action can be addressed through this process.

As a process of evaluation, accreditation considers three general questions:

• Has the medical school clearly established its mission and goals for the educational program?
• Are the program's curriculum and resources organized to meet its mission and goals?
• 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?

The medical school self-study process and the resulting findings are central to these aims.

As part of the accreditation process, Canadian medical schools demonstrate compliance with 12 standards and 96 elements. The accreditation standards address items in the following categories:

• Standard 1: Mission, Planning, Organization, and Integrity
• Standard 2: Leadership and Administration
• Standard 3: Academic and Learning Environments
• Standard 4: Faculty Preparation, Productivity, Participation, and Policies
• Standard 5: Educational Resources and Infrastructure
• Standard 6: Competencies, Curricular Objectives, and Curricular Design
• Standard 7: Curricular Content
• Standard 8: Curricular Management, Evaluation, and Enhancement
• Standard 9: Teaching, Supervision, Assessment, and Student and Patient Safety
• Standard 10: Medical Student Selection, Assignment, and Progress
• Standard 11: Medical Student Academic Support, Career Advising, and Educational Records
• Standard 12: Medical Student Health Services, Personal Counselling, and Financial Aid Services

According to the CACMS Rules of Procedure the CACMS may grant one of the accreditation statuses listed below:

• Accreditation for an eight-year term: Typically the school completes status reports in followup.
• Accreditation with indeterminate term: The school will undergo a limited site visit within 24 months as a followup.
• Accreditation with shortened term: A full accreditation process will take place in less than eight years.
• Accreditation with warning: This is a confidential status and is not made publicly known. The school must create an Action Plan and, after approval of the plan, a followup limited site visit is scheduled within 13-15 months.
• Accreditation with probation: This status is publicly posted on the CACMS and LCME websites. The school must submit an Action Plan and after approval of the plan, the school will have a post-probation site visit. If the school does poorly at this visit, the school may have its accreditation withdrawn.
• Withdrawal of accreditation: This status is based on the determination that an accredited medical education program exhibits substantial enough deficiencies in compliance to raise concern whether graduates of the program are competent to enter the next stage of their training.

The MD program is required to submit three main sources of information as part of our accreditation process:

• Data Collection Instrument (DCI): a comprehensive questionnaire (446 questions) that compiles information required by CACMS on all aspects of the MD Program and the FoMD
• Independent Student Analysis (ISA): a student-led survey of all medical students that leads to a report with analysis and recommendations written by a student task force
• Medical School Self Study (MSS): a review of all available data by a steering committee made up of faculty, staff, and students

A summary report of the MSS will also be submitted that highlights the process, findings, and continuous quality improvement recommendations, compiled by the MSS Steering Committee.

The final documents are due by mid-July 2022, three months before our site visit.

While a program is unlikely to lose its 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.

Faculty, staff, and students will all be involved in the MD program accreditation process. From compiling data to sitting on sub-committees to participating in the site visit, there will be opportunities for many people to provide feedback and participate in the accreditation process.

Student engagement is a critical component of accreditation. Students provide their feedback through the Independent Student Analysis (ISA) and the subsequent report that is submitted on behalf of students. As well, students are valuable members of each of the six sub-committees and the steering committee. Students will also meet with the visiting committee and provide tours of our teaching and clinical sites during the site visit.

The CACMS website includes all relevant information about accreditation of Canadian medical schools, including documents outlining the accreditation process.

The University of Alberta accreditation website will be updated regularly with information and FAQs about the upcoming accreditation process.

The final documents for accreditation, including the Independent Student Analysis (ISA) report, the Data Collection Instrument (DCI), and the Medical School Self-Study (MSS) report, must be submitted by mid-July 2022, three months before the scheduled site visit.

• Will our accreditation include LCME?
• Is accreditation focused only on the undergraduate medical education (MD) program?

While the purpose of accreditation is to promote self-evaluation and improvement of the MD program, the accreditation process evaluates many aspects of the Faculty of Medicine & Dentistry overall, as well as the MD program specifically. About half the standards and elements look at the FoMD.

Between July 2021 and spring 2022, the sub-committees will evaluate whether the specific requirements for each element are being met by the medical school. The sub-committees will use data from the Data Collection Instrument (DCI) and the Independent Student Analysis (ISA) (where applicable) to evaluate each of the 96 elements based on the Medical School Self-Study (MSS) evaluation forms.

Using the data, the sub-committees assign one of three ratings to each element:

• Satisfactory
• Satisfactory with a need for ongoing monitoring
• Unsatisfactory

If an element is rated as "unsatisfactory" or "satisfactory with a need for ongoing monitoring," the sub-committee will provide quality improvement recommendations based on the data. The Oversight Committee and/or the MD program will work on implementing these recommendations.

The accreditation steering committee conducts the medical school self-study (MSS) and writes the final report that will be submitted as part of our final documentation in July 2022.

The steering committee is chaired by Dr. Ramona Kearney and includes all the sub-committee chairs, student and resident representatives, Faculty of Medicine & Dentistry (FOMD) faculty, and Alberta Health Services (AHS) leadership.

The accreditation sub-committees are responsible for analyzing the data for their standards and making recommendations for continuing quality improvement. The sub-committees will submit their reports to the steering committee for inclusion in the final medical school self-study report.

The sub-committees are made up of faculty, staff, and students. Each sub-committee is responsible for two accreditation standards.

• Sub-Committee 1: Standards 1 & 2
• Sub-Committee 2: Standards 3 & 5
• Sub-Committee 3: Standards 4 & 9
• Sub-Committee 4: Standards 6 & 7
• Sub-Committee 5: Standards 8 & 10
• Sub-Committee 6: Standards 11 & 12

All the raw data for the Data Collection Instrument (DCI) is available for steering committee and sub-committee members in the accred.med system. You can access accred.med using your CCID and password.

Each sub-committee and the steering committee also have a shared Google Drive with information, including:

• Committee orientation material
• CACMS Standards & Elements document
• MSS reports to be completed
• Accessing the DCI
• Meeting agendas & minutes
• Interim Accreditation 2018 MSS reports

Mistreatment may include anything from an unintended but hurtful remark to an intentional, repeated, impactful and targeted set of unprofessional behaviours. Mistreatment can occur between any two individuals and the power relationship between them often dictates how it is experienced, and what steps might be needed for a resolution. The actors, victims and witnesses of mistreatment may be any of students, faculty, administrative staff, interdisciplinary team members, patients, families and others.

All students and faculty are encouraged to become familiar with the MD program professionalism policy and the supervision of medical students on clinical rotations policy. The MD program monitors course and clerkship feedback, and it is our responsibility to respond to mistreatment when it is reported.