Frequently Asked Questions

Accreditation Overview

What is the MD program’s current accreditation status?

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.

What is the purpose of accreditation?

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.

What is being assessed through the accreditation process?

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
What are the possible outcomes of accreditation?

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.
What information is required for the accreditation process?

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.

What are the consequences of a negative accreditation status?

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.

Who is involved in our accreditation?

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.

Where can I find out more about accreditation and CACMS?

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.

What is the mock accreditation?
The mock accreditation, which is scheduled for Feb. 7-9, 2022, will provide faculty, staff, and students with an opportunity to go through a practice site visit with two mock accreditors. Meetings with the mock accreditors, as well as their feedback, will help us identify areas of strength and weakness and address those weaknesses prior to submitting our final documentation in July and our site visit in October.
Where can I find out more information about accreditation leading up to October 2022?
The University of Alberta accreditation website will be updated regularly with information and FAQs about the upcoming accreditation process. Information about accreditation will also be shared with faculty, staff, and students through regular email communications from the dean and associate dean, as well as FoMD newsletters.
What are the timelines for accreditation?
MD accreditation timeline overview
When are the accreditation documents due?

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.

What is the Accreditation Oversight Committee?
The Accreditation Oversight Committee includes the dean, vice dean of education, associate dean of the MD program, director of program quality and accreditation, and the chair of the steering committee. Together, the members of the oversight committee are working together to coordinate all aspects of the accreditation process.
What’s the difference between the medical school and the medical education program in the accreditation documents?
According to the CACMS lexicon, the medical school refers to the Faculty of Medicine & Dentistry at the University of Alberta and the medical education program refers to the MD program or the Office of Undergraduate Medical Education.

Site Visit

Will our site visit be in person?
CACMS will tell us in September 2021 whether our site visit will be held in person or virtually. The mock accreditation site visit will take place in the same format as the full site visit.
What happens during the site visit?
The site visit is the culminating event of the full accreditation process. The site visit is conducted by an ad hoc team of external reviewers. During the site visit, the visiting team will meet with groups from across the University, the FoMD, the MD program, and Alberta Health Services (AHS). During these meetings, the team will gather additional information on topics that were included in the Medical School Self-Study (MSS) report and try to gain understanding of the MD program’s compliance with CACMS standards and elements.
Who selects the site visiting team?
The ad hoc visiting team is selected by the CACMS Secretariat.
What does the site visiting team look for?
The site visiting team is looking for further information about a variety of topics that are included in the ISA and MSS reports. This additional information will help them gain deeper understanding of the MD program’s compliance with CACMS standards and elements.

Data Collection Instrument (DCI)

What is the Data Collection Instrument (DCI)?
The Data Collection Instrument (DCI) is a questionnaire that includes 446 questions related to each of the 12 standards and 96 elements. It includes data from the Independent Student Analysis (ISA), the Graduation Questionnaire (GQ), and other sources.
What happens to the information from the DCI?
The data from the DCI are used to inform the Medical School Self-Study (MSS) and the entire database will be submitted to CACMS and the site visiting team three months prior to the site visit.
What are the sources of information for the DCI?
The DCI is made up of information from a variety of sources, including the AFMC Graduation Questionnaire and the ISA, as well as FOMD and MD program documents (e.g. strategic plan, policies, course evaluation reports, etc.).
Who is responsible for collecting data for the DCI?
The director of program quality and accreditation is primarily responsible for gathering information for the DCI from a variety of sources, including leadership, faculty members, staff, and students.
What does “index year” mean?
The index year is the academic year that most of the DCI data will be based on. For the University of Alberta’s 2022 accreditation, the index year is the 2020-2021 academic year (July 1, 2020 to June 30, 2021).

Medical School Self-Study (MSS)

What is the Medical School Self-Study (MSS)?
The Medical School Self-Study (MSS) process brings together representatives of the medical school administration, faculty, student body, and other constituencies to collect and review data about the medical school and its educational program; assess the medical education program’s performance on accreditation standards and elements; identify areas that require improvement; and define strategies to ensure that any problems are addressed effectively.
What are the areas addressed by the MSS?
The MSS report summarizes the finding of the sub-committees and will include analysis of all 12 standards and 96 elements. The MSS also provides the medical school and medical education report with recommendations for quality improvement to address standards and elements that are deemed unsatisfactory or satisfactory with a need for monitoring.
When does the medical school self-study occur?
The self-study begins when the sub-committees start their work (summer 2021) and will continue through spring 2022. The steering committee will work from fall 2021 to late spring 2022 and ensure that the final self-study report is complete by mid-July, 2022.
How do the sub-committees and the steering committee determine the medical school’s performance?

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.

What is the accreditation steering committee? Who sits on the steering committee?

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.

What are the accreditation sub-committees?

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
I am a member of the steering committee or one of the sub-committees. How do I access information?

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

Independent Student Analysis (ISA)

Will the site visit team meet with students?
Yes! The site visiting team will meet with students from all four years of the program during lunch meetings. Students will also lead tours of our teaching and clinical sites for members of the site visiting committee.
What is the role of students in the accreditation process?
Students are a critical part of our accreditation process. In addition to the Independent Student Analysis (ISA) of the medical school conducted by students, students will also sit as members of the steering committee and the six sub-committees. As well, the site visiting team will meet with student representatives from all class years and will visit several clinical and teaching facilities with student guides. The final report of the site visiting team will include student perspectives gathered from a variety of sources, including the ISA report and survey data, the AFMC Graduation Questionnaire (GQ), and from student meetings. All of these perspectives will help the site visiting team determine the extent to which the medical school is compliant with accreditation standards and elements.
Why is it important to do well on our accreditation?
A program on probation must send written notification to all current students and applicants for admission that it has been placed on probation. A probationary status will affect the reputation of the program, and can negatively affect a student’s access to post-graduate training.
What is the Independent Student Analysis (ISA)?
The ISA survey and report provide a comprehensive picture of students’ perceptions of their medical education program. The ISA is completed independent of the medical school and the ISA report is one of the documents submitted to CACMS and the site visiting team by the program three months prior to the site visit.
What is the MD program’s policy about mistreatment?

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.

What happens to the ISA data and report after they are submitted to the MD program?
Data from the ISA will be included in the data-collection instrument and evaluated by the sub-committees and the steering committee as part of our Medical School Self-Study (MSS). The report will also be shared with the MD program so that recommendations can be part of our quality improvement process leading up to the site visit.
How were the ISA questions determined?
The ISA questions are determined by CACMS and are the same survey questions used by medical schools across the country for the ISA. Up to 10 additional questions can be added to the ISA survey and those are determined by the student group tasked with setting up the survey and sending it out.
What is the response rate we are hoping to achieve for the ISA?
CACMS recommends a response rate of 70 per cent for the ISA to demonstrate student engagement in the process and to ensure the validity of the data.