Internal Reviews

Programs must use their CanAMS profile to provide:

• Narrative responses
• Supporting documentation
• Evidence related to accreditation standards

For many programs, content from the previous accreditation cycle will already be populated in CanAMS and only requires updates.

Updates should reflect:

• Quality improvement initiatives
• Standards updates
• Previous accreditation feedback
• Program changes

Important

• Save responses regularly using the “Save” button
• All documentation must be uploaded at least 8 weeks before the review

Use the “AFIs” tab in CanAMS to complete narrative responses for your program’s previous Areas for Improvement. Although this tab is not currently visible to internal reviewers, the PGME Office will share your responses with reviewers before the review.

Please include responses for both:

• AFI-2Y
• AFI-RR

Only narrative responses are required — supporting evidence documents do not need to be attached, as they will already be included within the instrument. If you would like reviewers to reference a specific document, include the file name within your narrative response.

Additional guidance an preparatory resources will be provided by PGME once your review date is confirmed.

At least 3 weeks before the review date, programs must submit:

• RPC meeting minutes (previous 2 years)
• Competence Committee meeting minutes (previous 2 years)
• Resident files

Files may be submitted through:

• OneDrive
• Teams

The PGME Office coordinates the Residents’ Report.

Process

1. PGME sends the template to the Program Administrator
2. The Program Administrator distributes it to residents
3. Residents submit the completed report directly to PGME

Important

• Reports must not copy program leadership
• Reports remain confidential
• Reports are not shared with the program

Deadline

Residents’ Reports must be submitted at least 8 weeks before the review.

Programs must ensure the following participants are available during the review day, either in person or virtually:

• Program Director
• Teaching faculty
• Residency Program Committee (RPC) members
• Competence Committee (CC) members
• Program Administrator
• Department/Division Chair
• Current residents/trainees

Participation may occur:

• In person
• By videoconference
• By teleconference

The review team includes:

• Faculty member from another discipline (Chair)
• Program Director from another discipline
• Resident representative from another discipline

At minimum 2 weeks before the review, the PGME Office provides reviewers with:

• Access to the program’s AMS profile
• Review agenda and participant list
• General accreditation standards
• Specialty-specific standards and training requirements
• Previous accreditation survey report
• Sample interview questions
• Internal Review Report template

Reviewer Expectations

Reviewers must:

• Review all materials at least 1 week before the review
• Submit questions or clarification requests to the PGME Office

At least 1 week before the review, reviewers also receive:

• RPC minutes from past two years
• Competence Committee minutes from past two years
• Resident files via OneDrive

The Internal Review Team interviews key stakeholders and evaluates the program against accreditation standards.

Review Activities

Reviewers will:

• Review program documentation in the AMS
• Examine supporting files and meeting minutes
• Conduct stakeholder interviews with Program Director, Teaching faculty, Residency Program Committee (RPC) members, Competence Committee (CC) members, Program Administrator, Department/Division Chair, Current residents/trainees of the program
• Assess compliance with accreditation requirements

For each requirement, reviewers select:

• Meets requirement
• Area for improvement

Detailed feedback is expected for:

• Requirements identified as areas for improvement
• Positive program practices and strengths
• Feedback on requirements rated “does not meet”must reference specific accreditation indicators 

Reviewer Considerations

Reviewers should:

• Encourage open feedback
• Ensure all participants can contribute
• Stay on schedule throughout the day

The report must include:

• Program strengths
• Areas for improvement
• Recommendations
• Identify the specific accreditation indicator(s) if not met
• Leading practices or innovations

Detailed feedback should be provided for all identified improvement areas. 

Once drafted:

1. The Chair circulates the report to Faculty and Resident review team members
2. Reviewers provide feedback and input
3. The finalized report is submitted to PGME

The report must be submitted no later than 2 weeks after the review date.

The PGME Office will remove Internal Review Team access to the program’s AMS instrument profile once the review is complete. The Internal Review Subcommittee (IRC) reviews the IR Team Chair's report approximately 1–4 months after the review. The IRC:

• Reviews findings and recommendations
• Makes final decisions
• Provides program recommendations

The finalized report is then sent to:

• Program Director
• Program Administrator
• Department/Division Chair

Programs are encouraged to share findings with:

• Residents
• Faculty
• RPC members
• Other stakeholders

Programs will receive a follow-up chart outlining:

• Areas for improvement
• Planned actions and timelines

The PGME Office and IRC will monitor progress at:

• 6 months
• 12 months following receipt of the Decision Letter and Internal Review Report.

A summary of internal review findings may also be presented periodically to the PGME Committee by the IRC Chair or Associate Dean, PGME.

Internal Review Reports are considered internal University documents. Reports and results:

• Are not shared with the Royal College or CFPC for residency program reviews
• Do not affect accreditation status

However, internal review reports must be available to institutional accreditation survey teams to support assessment of the University’s internal review process.