Internal Reviews

All residency and AFC programs go through the internal review process. This multi-year process takes place within the 8-year accreditation cycle and begins approximately 3 years after the on-site external accreditation survey. It continues until all residency and AFC programs are reviewed at least once, and any necessary follow-up activities (e.g., progress reports, focused internal reviews, etc.) are completed. The internal review cycle also includes a review of the PGME (i.e., the “Institution”) by external faculty.

Internal Review Committee (IRC)

Chaired by the Assistant Dean, PGME, the IRC is a subcommittee of the Postgraduate Medical Education Committee (PGMEC) and is responsible for conducting the internal reviews of accredited residency and area of focused competence (AFC) programs. The IRC assists the Chair in planning, overseeing, and carrying out the internal review process while adhering to the Internal Review policies and procedures. Membership includes current and past program directors, individuals who have conducted reviews for the accrediting colleges, and residents. Terms of Reference »

IRC Structure

The Postgraduate Medical Education Committee (PGEC) leads the Internal Review Committee (IRC), which in turn leads the ad-hoc IRC Internal Review Teams (the Lead Surveyor (an IRC member), the PD Surveyor (a peer PD), and the Resident Surveyor).

Program Improvement

In accordance with the institutional accreditation standards set by the Canadian Residency Accreditation Consortium (CanRAC), the PGME office, on behalf of the Dean of the Faculty of Medicine and Dentistry, is responsible for overseeing the continuous quality improvement of its residency programs and AFC fellowship programs (hereby referred to as training programs). The following standard in the General Standards of Accreditation for Institutions with Residency Programs apply: 

8.2: The postgraduate dean and postgraduate education committee continuously identify, monitor, and address issues affecting residency program quality.

The principles for program improvement that guide PGME’s internal review and follow-up after accreditation review of its training programs are outlined in the PGME Training Program Improvement Policy.

Learn more about Continuous Quality Improvement for programs as it relates to learning environments »

Process for Program Improvement after an Internal Review

The following process is outlined in the PGME Training Program Improvement: Internal Review Procedure.

Date Coordination
PGME coordinates dates for each Programs’ Internal Review
Team Assembly
IRC Chair assembles review teams for each review
Documentation Submission
The Programs submits documentation and prepares for the review
Internal Review
The Programs undergo an Internal Review
After Internal Review
PGME collates AFIs from all programs and identifies the commonest AFIs
To systemically address common AFIs, PGME educates programs, develops templates and guidance documents for programs to implement improvements, and monitors adherence of improvement
Regular Review- or APOR-status programs submit annual progress reports
Programs with a mock accreditation status of Regular Review or APOR must submit annual progress reports on how they are correcting the AFIs. Depending on the AFIs, the PGME Associate and Dean, and others, may need to meet regularly with the Program Director.
PGME Associate and Assistant Deans work with External Review +/- NOI-status programs
For Programs with a mock accreditation status of External Review +/- NOI, the PGME Associate and Assistant Dean, and typically others within the University or health authorities, will work with the program and use whatever resources are required and attainable to effect improvements in the AFIs and regularly review progress

Process for Program Improvement after an Accreditation Review

The following process is outlined in the PGME Training Program Improvement: Follow-up after Accreditation Review Procedure.

Prior to Accreditation Review
PGME Associate and/or Assistant Dean prepares the Program Director for the review
During the Accreditation Review
PGME coordinates the review with the relevant accreditation college
After the Accreditation Review

PGME Associate and Assistant Dean reviews the results with the Program Director and develops a plan to correct the AFIs with a process that depends on the follow-up status

If follow-up by regular review...
PGME Associate Dean and others regularly touch base with the program to monitor progress
If follow-up by APOR...
PGME Associate Dean organizes a focused internal review of the program with input from relevant program constituents to address the AFIs
If follow-up by External Review +/- NOI...
PGME Associate Dean and others have multiple meetings with the Program Director and other program constituents, using whatever resources are needed and attainable, to resolve the AFIs and prepare for the external review