STANDARD 1 ELEMENT RATING TABLE and ELEMENT EVALUATION FORMS. Survey Team Standard 1 Element Rating Table

Transcription

1 STANDARD 1 ELEMENT TABLE and ELEMENT EVALUATION FORMS STANDARD 1: MISSION, PLANNING, ORGANIZATION AND INTEGRITY A medical school has a written statement of mission and goals for the medical education program, conducts ongoing planning, and has written bylaws that describe an effective organizational structure and governance processes. In the conduct of all internal and external activities, the medical school demonstrates integrity through its consistent and documented adherence to fair, impartial, and effective processes, policies, and practices. Survey Team Standard 1 Element Rating Table Standard 1 Mission, Planning, Organization and Integrity Element 1.1 Strategic Planning and Continuous Quality Improvement 1.2 Conflict of Interest Policies 1.3 Mechanisms for Faculty Participation 1.4 Affiliation Agreements 1.5 Bylaws 1.6 Eligibility Requirements Label the number of the element using the following code. Labeling Code Color Strength * monitoring Note: If element 1.1 was rated as, the cell with the corresponding element number would be shaded green as shown above as an example. Standard 1 Survey Team Element Rating Table and Evaluation Forms Page 1 of 8

2 Standard 1 Summary of Findings The following is the Summary of Survey Team Findings for Standard 1 that are linked to elements rated as Strengths (S*), with a need for Monitoring (SM) or (US). The findings are listed in order by the number of the element. Delete elements rated as satisfactory. Element Rating S*, SM, US Standard 1 Mission, Planning, Organization, and Integrity 1.1 Strategic Planning and Continuous Quality Improvement 1.2 Conflict of Interest Policies 1.3 Mechanisms for Faculty Participation 1.4 Affiliation Agreements 1.5 Bylaws 1.6 Eligibility Requirements Note: See Survey Team Evaluation of Elements section D of the Survey Report Guide regarding the formulation of findings. Standard 1 Survey Team Element Rating Table and Evaluation Forms Page 2 of 8

3 1.1 STRATEGIC PLANNING AND CONTINUOUS QUALITY IMPROVEMENT A medical school engages in ongoing planning and continuous quality improvement processes that establish short and long-term programmatic goals, result in the achievement of measurable outcomes that are used to improve programmatic quality, and ensure effective monitoring of the medical education program s compliance with accreditation standards. 1.1 a The medical school has a written statement of mission and vision for the medical education program. 1.1 b The strategic plan is reviewed and revised at appropriate intervals. 1.1 c The outcomes of the strategic plan are monitored to ensure that the strategic plan is effective. 1.1 d The medical school engages in ongoing planning and continuous quality improvement that establish short and long-term programmatic goals. 1.1 e The medical school monitors ongoing compliance with CACMS accreditation Standards and Elements and takes steps to maintain compliance. 1.1 f Review of the documentation related to this element and discussions with relevant individuals at the time of the onsite survey visit confirm, that the requirements listed above are being met by the medical school. Strength with a need for monitoring Standard 1 Survey Team Element Rating Table and Evaluation Forms Page 3 of 8

4 1.2 CONFLICT OF INTEREST POLICIES A medical school has in place and follows effective policies and procedures applicable to board members, faculty members, and any individuals with responsibility for the medical education program to avoid the impact of conflicts of interest in the operation of the medical education program, its associated clinical facilities, and any related enterprises. 1.2 a There are conflict of interest policies and procedures that apply to the individuals noted in the element. 1.2 b The medical school informs the relevant individuals about these policies and procedures. 1.2 c These policies and procedures address conflict of interest in each of the following areas: i. research ii. faculty with academic and teaching responsibilities iii. commercial support for continuing professional development 1.2 d There are strategies for managing actual or perceived conflicts of interest in the operation of the medical education program, its associated clinical facilities, and any related enterprises. 1.2 e Review of the documentation related to this element and discussions with relevant individuals at the time of the onsite survey visit, confirm that the requirements listed above are being met by the medical school. Strength with a need for monitoring Standard 1 Survey Team Element Rating Table and Evaluation Forms Page 4 of 8

5 1.3 MECHANISMS FOR FACULTY PARTICIPATION A medical school ensures that there are effective mechanisms in place for direct faculty participation in decision-making related to the medical education program, including opportunities for faculty participation in discussions about, and the establishment of, policies and procedures for the program, as appropriate. 1.3 a Faculty are voting members on the majority of standing committees in the medical school. 1.3 b The process used to select faculty members for standing committees takes into account the need to have members whose perspectives are independent of departmental leadership and central administration. 1.3 c Faculty are made aware of proposed changes in the medical education program, its policies and procedures, and given an opportunity to provide input. 1.3 d There is at least one general faculty meeting each year (in person or virtual) where faculty are notified of the agenda and the outcomes of the meeting. 1.3 e The medical school uses an effective system to inform the faculty of important issues at the medical school. 1.3 f Review of the documentation related to this element and discussions with relevant individuals at the time of the onsite survey visit confirm, that the requirements listed above are being met by the medical school. Strength with a need for monitoring Standard 1 Survey Team Element Rating Table and Evaluation Forms Page 5 of 8

6 1.4 AFFILIATION AGREEMENTS In the relationship between a medical school and its clinical affiliates, the educational program for all medical students remains under the control of the medical school s faculty, as specified in written affiliation agreements that define the responsibilities of each party related to the medical education program. Written agreements are necessary with clinical affiliates that are used regularly for required clinical learning experiences; such agreements may also be warranted with other clinical facilities that have a significant role in the clinical education program. Such agreements provide for, at a minimum: a) The assurance of medical student and faculty access to appropriate resources for medical student education. b) The primacy of the medical education program s authority over academic affairs and the education/ assessment of medical students. c) The role of the medical school in the appointment and assignment of faculty members with responsibility for medical student teaching. d) Specification of the responsibility for treatment and follow-up when a medical student is exposed to an infectious or environmental hazard or other occupational injury. e) The shared responsibility of the clinical affiliate and the medical school for creating and maintaining an appropriate learning environment that is conducive to learning and to the professional development of medical students. f) Confirmation of the authority of the department heads of the medical school to ensure faculty and medical student access to appropriate resources for medical student education when those department heads are not also the clinical service chiefs at affiliated institutions. 1.4 a The medical school has signed affiliation agreements with all clinical facilities at which medical students complete the inpatient portions of required clinical learning experiences including longitudinal integrated clerkships. 1.4 b These agreements have explicit language as indicated in a-f in the element. 1.4 c Review of the documentation related to this element confirm that the requirements listed above are being met by the medical school at the time of the onsite survey visit. with a need for monitoring Standard 1 Survey Team Element Rating Table and Evaluation Forms Page 6 of 8

7 1.5 BYLAWS A medical school has and publicizes bylaws or similar policy documents that describe the responsibilities and privileges of its dean and those to whom he or she delegates authority (e.g., vice, associate, assistant deans), department heads, senior administrative staff, faculty, medical students, and committees. 1.5 a There are bylaws or similar policy documents that describe the responsibilities and privileges of the dean and those to whom he or she delegates authority (e.g., vice, associate, assistant deans), department heads, senior administrative staff, faculty, medical students and committees that are made known to faculty members. 1.5 b The bylaws or similar policy documents support an effective governance structure for the medical school. 1.5 c Review of the documentation related to this element confirm that the requirements listed above are being met by the medical school at the time of the onsite survey visit. Standard 1 Survey Team Element Rating Table and Evaluation Forms Page 7 of 8

8 1.6 ELIGIBILITY REQUIREMENTS A medical school ensures that its medical education program meets all eligibility requirements of the CACMS for initial and continuing accreditation and is either part of, or affiliated with, a university that has legal authority to grant the degree of Doctor of Medicine. 1.6 a The medical school and its geographically distributed campuses are located in Canada. 1.6 b Students complete all required learning experiences in the medical school. 1.6 c The medical school is part of, or affiliated with, a university that has legal authority to grant the degree of Doctor of Medicine. 1.6 d Review of the documentation related to this element and discussions with relevant individuals at the time of the onsite survey visit confirm, that the requirements listed above are being met by the medical school. with a need for monitoring Standard 1 Survey Team Element Rating Table and Evaluation Forms Page 8 of 8