2018 MD Program Accreditation Status Update

Since the last update on the progress toward the next accreditation for the Doctor of Medicine Program, the Accreditation Committee (AC) has reviewed all CACMS 12 Standards and 96 Elements for Compliance in order to update our documents, identify areas of strength and initiate change for gaps.

Some of the gaps are related to new Elements since 2015, including those covering Social Accountability, Professional & Leadership Development, Student Health & Patient Safety, and Clinical Learning Experiences. The AC review process has been important to identify policies, processes and actions to bring these Elements towards compliance. Other gaps are related to changes in our processes since 2015, which require updates to our documents and further review by the committee.

The process of review by the AC has been completed by teams of faculty, staff and students from the committee, with recommended updates to the Data Collection Instrument (DCI), which is the evidence of the School’s compliance with the Elements. As well, there have been more than 100 recommendations from the AC in the form of Action Templates which are shared with the relevant stakeholders of their particular elements.

Stakeholders span Admissions, Learner Equity & Wellness (LEW), Undergraduate Medical Education (UME) Program, Faculty Affairs (FA), and UME curricular renewal committees. Accreditation has a presence and voice on many of these stakeholders’ committees.

AC has been working closely with the Quality Committee to build and review cyclical monitors of performance related to the Elements, which will provide data on the status of these Elements. Examples of some monitors are: students’ observed history and physical examination rates by a clinical supervisor, evaluation response rates, and students’ immunization compliance rates.

With ongoing UME curricular renewal activities during the past two years, Accreditation has been an important stakeholder at the discussion table. CACMS permission was required to move forward with the curricular renewal process. As well, many of the AC recommendations and CACMS requirements have been used as guidelines for the curricular build. The positive spin-off of this Accreditation presence has been education of our faculty, staff and students about the Accreditation process and requirements.

During the past few months, AC has been reviewing progress on Elements which are internally rated as non-compliant (red) or compliance with monitoring (yellow) by the AC. There has been some progress in moving red and yellow elements to yellow and/or green. This progress review will continue into our next Interim Reviews scheduled for March 2019 and winter 2020.

Our first review will examine three quarters of the Elements including those for Admissions, LEW, FA, and some select non-curricular items in the UME Program. Given curricular renewal, the second review will be highly focused on curricular competencies, objectives, design and content, as well as evaluation, management, assessment, clinical supervision and student/patient safety. The review will examine our non-CBME curriculum and the CBME curriculum launching in September 2019.

The purpose of the interim reviews is to provide the School with a mid-point formative feedback on our progress with the CACMS Standards and Elements in preparation for the Full External Accreditation Review in 2023. Our first interim review will include two external reviewers, Dr. K. Busche from the University of Calgary and Dr. K. Beatty from the Northern Ontario School of Medicine. The review is planned to be virtual with a reduction in resources, use of videos and tele/videoconferencing such that the onsite review will only be half days each in Windsor and London with a focus on specific gaps identified by the reviewers. The review summary will be shared along with the prior 2015 CACMS Full External Accreditation Review and 2016 CACMS Progress Report. The second interim review is in the planning stages. In 2021, there will be formation of the Institution Self-Study Task Force (ISSTF) which will review the DCI and compliance with CACMS Standards and Elements in preparation for the 2023 Accreditation Site Visit.

For questions about the process, please contact:
Dr. K. Massey
Dr. M. Weir


From the Schulich UME Accreditation Team:


Kyle Massey, PhD (Adminstration Lead, UME Accreditation)

Dr. Michele Weir (Faculty Lead, UME Accreditation)

Dr. Gary Tithecott (Associate Dean, UME)

Dr. Jay Rosenfield (Vice Dean, Education)