Accreditation and Reviews

An accreditation survey occurs once every six years and the College reviews whether a program is being administered according to the Standards outlined in the RCPSC Blue Book.  A survey primarily assesses the process and apparent resident satisfaction.  The RCSPC Grey Book clearly describes the process, consequences, and terminology in detail.

One year before the survey:

  • The Head of the Accreditation Service will contact the PG Dean to set the date for the survey.  Usually the Head will meet with Program Directors and the PGME Office several months before the survey to review the process.
  • For a Program Director, the survey is a performance review.  The process begins with the preparation of a pre-survey questionnaire that asks you to describe how you are addressing the RCPSC Blue Book Standards.
It is worth, early in your term, filling out a pre-survey questionnaire as an excellent method of critically reviewing your program and knowing what the College will expect from you in a 'real' survey.  At the very least, look at the one filled out by your predecessor for the last survey to get an idea of what is required.  

Ask your Department to keep the data usually required for a pre-survey questionnaire (which is challenging to collect as the survey approaches) on hand and up-to-date (such as a yearly update of faculty and resident publications and grant listings, staff demographics, etc).  This will save hours of work as the deadline approaches.

Six months before the survey:
  • Complete the pre-survey questionnaire.  Identify your program's strengths and weaknesses.  For a small program of under five residents, it will take at least a month to prepare this document and for a larger program, it can take several months.
On the day of the survey:
  • Your program will be reviewed by a surveyor who will ask you to clarify aspects of your program, and will tour your facility.  The surveyor will meet with you, your RPC, your residents, and other teaching faculty.  A thorough surveyor will ask to review the minutes of previous RPC meetings, a selection of residents’ dossiers, evidence of regular in-training evaluation, rotational goals and objectives, and program evaluation.  This process will take three to four hours for a small program and can take several days for a very large one with several sites of training.
The surveyor will report to the survey team that night and will meet with you the following morning to discuss the team’s recommendations to the Accreditation Committee.  Approximately six weeks later, you will receive the surveyor's written report, to which you respond, and a final decision will then follow.

The surveyor is particularly interested in the perceptions of the residents and whether your program has addressed problems identified at the last survey.   Even a lot of recent paper will not disguise five years of absent process or progress.  Every program has problems but the presence of chronic deficiencies that have been present over several surveys will compromise your program’s status.

A survey is a nerve-wracking time for a Program Director but it can be a powerful tool for change.  Sometimes criticism on a survey of less than full approval may be the only way a department or institution will pay attention to a problem you have been struggling with for years.

The Internal Review is expected to occur between on-site surveys and is an excellent way of reviewing your program.  It is organized by the PGME office and is like a mini-survey.  Consider it practice for the real thing, and use it to identify and remediate problems.  The results of these reviews are not forwarded to the College unless the program is new or has been inactive.  The PGME office has developed an excellent website for Internal Reviews which will guide you through the process.

If you have the opportunity, become a surveyor. This is a great way to understand what is expected of a program, and to get fresh insights and ideas for your own program.