Accreditation FAQs

What are the possible accreditation statuses and follow-up options?

As per CanERA (Canadian Excellence in Residency Accreditation), there are two possible accreditation statuses: Accredited Program; and, Accredited Program on Notice of Intent to Withdraw Accreditation.

Each residency program is also awarded a required follow-up based on their identified areas for improvement (AFIs). These follow-up options include:

  • Next Regular Accreditation Review: The program has demonstrated acceptable compliance with the standards, and timelines for the next review follow the established accreditation cycle for the Schulich School of Medicine and Dentistry. Programs should conduct continuous quality improvement intiatives throughout the cycle. 
  • Action Plan Outcomes Report (APOR): There is one (or more) significant area(s) for improvement impacting the overall quality of the program which requires follow-up prior to the next regular accreditation review, and which can be evaluated via submission of evidence from the program. Follow-up will take place two-years after the regular accreditation review.
  • External Review: There is one (or more) significant area(s) for improvement impacting the quality of the program which requires follow-up prior to the next regular accreditation review, and which can be best evaluated through external peer reviewers. Factors that may suggest the need for follow-up by external review include (but are not limited to): persistence of the AFI(s); the nature of the AFI(s); concerns with the program's and/or institution's oversight of the program's continuous quality improvement. 

An Accredited Program on Notice of Intent to Withdraw Accreditation will always require a follow-up by external review. A program may be put on notice if there are major and/or continuing concerns which call into question the educational environment and/or integrity of the residency program and its ability to deliver high quality residency education. It may also be put on notice if the program has failed to complete and submit the required accreditation follow-up by the deadline, after notifications and reminders. 

What is the difference between AFI-2Y and AFI-RR?

Areas for improvement (AFIs) will be highlighted in an accreditation review. If a requirement is labelled as AFI-2Y, it must be addressed prior to the next regular accreditation review in 2027. Typically, evidence of addressing an AFI-2Y will occur through the submission of an Action Plan Outcome Report (APOR) or an external review within two years following the regular onsite survey.

An AFI-RR must be addressed prior to the next regular accreditation onsite survey.

How should our program respond to previous AFIs?

The response to previous areas for improvement (AFIs) differs depending on whether a program has a follow-up via Action Plan Outcome Report (APOR). Non-APOR programs are required to respond to both AFI-RR and AFI-2Y in the "AFIs" tab of CanAMS. Only narrative responses are required, as it is expected that evidence of actions taken and outcomes will be evaluated by the surveyors through the internal/external review itself, either in interviews or in documents attached in the instrument, or both. 

For programs with follow-up by APOR, only a response to AFI-2Y is required. How best to address each AFI-2Y is at the discretion of the residency program, with guidance and support from the PGME Office. However, information submitted for the APOR must describe (via narrative and/or documentation) both: 1) action(s) taken to address each AFI, and 2) evidence of the outcomes of the action(s) taken. The level of detail must be sufficient that the accreditation committee has enough information to evaluate whether or not the AFI-2Y has been fully addressed. 

What is the School doing to ensure each program meets each accreditation standard?

Schulich Medicine & Dentistry Postgraduate Medical Education (PGME) conducts internal reviews of all programs throughout the regular review cycle at least once. PGME follows-up with each program at the 6- and 12-month mark after an internal review to support the program on its progress for each identified area for improvement.

In addition, the PGME Office collects confidential resident reports every two years from each program to determine adherence to the accreditation standards from the residents' perspective. Actions taken will occur on a case by case basis depending on the report contents.

PGME is available for regular consultation to support any program with program evaluation and continuous improvement. Please contact Lindsay Curtis (lindsay.curtis@schulich.uwo.ca) for more information.