Accreditation Procedures

The Accreditation Cycle

University CPD offices are reviewed on an eight-year cycle. The accreditation process includes:

  • a full accreditation visit at year 0 (normally virtual)
  • an action plan, for all partially (PC) or noncompliant (NC) standards, within 12 months of the full accreditation visit
  • status reports at the 24, 48, and 72 month marks for standards that remain PC or NC
  • an activity audit at the 48 and 96 month mark, as is required from all university-based CPD offices, and, if applicable, at the 24 and 72 month marks, if they are found to be PC or NC for standard 3.2.
  • an Internal Quality Review at the 48-month mark
  • the next full accreditation visit at the 96-month mark

The CACME may require additional follow-up activities following the review of material submitted as part of the regular accreditation process.  This may entail a limited or full accreditation visit if CACME determines that the office is not in compliance with all accreditation standards.

Pre-Accreditation Visit Preparation

The Data Collection Instrument (DCI) report:

In addressing questions, those writing the report are encouraged to provide a 1-2 paragraph summary response to questions with some (limited) accompanying information, if necessary, to illustrate how the item is addressed in their unit. For example, reference to a business/strategic plan is a satisfactory way to provide the mission statement, unit objectives, organizational chart, financial statements, etc.

Schools being visited should submit their pre-visit materials directly to the visit team members and to the CACME Secretariat. Additionally the school should maintain a copy in their Office.

Selected examples of requested material (pamphlets, minutes, course reports, etc) should be sent to the visit team rather than exhaustive copies. Further examples should be available for inspection at the time of the accreditation visit.

The Accreditation Visit Team

The CACME Secretary will appoint two visit team members who will be provided with the DCI report at least eight weeks prior to the visit. The visit team members are selected according to their backgrounds and experience in CME and medical school affairs.

The accreditation visit is conducted over two days. During this time, the visit team meets with people in the Faculty of Medicine / Health Sciences (including the Dean), the CME/CPD office, and relevant hospitals and communities, who have any pertinent stakeholder role. The visit team members collect information as described in each standard.

The Accreditation Visit Report

Following the accreditation visit, the visit team members submit a report to CACME based on all the information collected, and a rating for each standard based the specified criteria for determining compliance. The accreditation visit report will be presented and discussed at the next CACME meeting, and a decision regarding accreditation will be duly made.

Accreditation Determinations

CACME bases its accreditation determination on the accreditation visit report. In the normal course of events, CACME does not review any of the primary documents submitted by the CME/CPD offices – it reviews only the accreditation visit report. However, CACME does have the option to review any documents in the course of their deliberations. It should be noted that the final decisions regarding accreditation are the sole responsibility of CACME. The team visit members are directed explicitly to refrain from making any recommendations.