Accreditation Procedure

Preparing for Accreditation

Visits are usually scheduled in the Spring. Full accreditation visits typically occur in two stages on an eight-year cycle. Stage 1 is a virtual visit, conducted through distance technology. Stage 2, scheduled approximately 4 – 6 weeks later, is designed as an on-site visit, but can occur as a virtual visit when circumstances do not allow for face-to-face meetings.

Schools are sent materials and instructions approximately 18-24 months before the visit, so that they can compile the Data Collection Instrument (DCI) and undertake a medical school self-study (MSS).

The school completes the Data Collection Instrument (DCI) within three or four months after it is received, so that it can be used as the basis for the medical school self-study (MSS). The dean appoints a self-study steering committee and subcommittees corresponding to the main sections of the DCI (e.g., Standards 1 to 12). Instructions are found in the Guide to the Institutional Self-Study. The faculty undergraduate accreditation lead (FUAL) contacts student leadership to discuss the organization of the Independent Student Analysis (ISA) process and a student ISA steering committee is formed. The DCI, MSS and ISA are sent to the CACMS Secretariat and to each member of the accreditation visit team three months before the accreditation visit.

The mini-DCI prepared for limited visits is completed in time for dispatch to the CACMS Secretariat and members of the visit team at least two months before the visit.

The Visit Team

Members of visit teams for a given year are appointed by the CACMS Secretariat approximately a year before the accreditation visit. Members composing the visit teams (see section above) are selected from a pool of medical practitioners and basic science and clinical educators, and educational researchers and administrators.

The visit team conducts an accreditation visit to verify and update information compiled in the school’s DCI, clarify any issues that are unclear, view the environment and facilities for learning first-hand, and meet with administrators, faculty members, and students. The team will meet with the dean to explain its purpose and gain input in a conference at the beginning of the accreditation visit, and typically meets with the dean and campus chief executive at the completion of the visit. The visit process, appointment of visit teams, visit report, and documents considered by CACMS in reaching accreditation decisions are explained in the CACMS Rules of Procedure.

The Independent Student Analysis

The guide to the Independent Student Analysis describes the important contribution students play in the accreditation process. Groups of students will be scheduled to meet with the visit team during the school’s accreditation visit.

The Accreditation Visit Report

The team secretary will collate written findings from each team member into a visit report that describes the program of education and accounts for the school’s compliance with each of the standards of accreditation as contained in the CACMS Standards and Elements. The preparation, review, and processing of visit reports, and the information considered for accreditation determinations are given in the CACMS Rules of Procedure.

CACMS Meetings

CACMS meets three times per year.

Accreditation Determinations

CACMS bases its accreditation determination on the visit report, supplemented as necessary by information contained in the DCI and the institutional self-study. Details of the deliberations of CACMS, acceptance of evidence, consideration of progress reports, and reporting of decisions are found in the CACMS Rules of Procedure.

The usual period of full accreditation is eight years. Schools may be asked to submit one or more status reports in the interval, to address steps taken to correct specific areas of noncompliance, or describe the results of program changes underway. Interim, focused visits may be scheduled when an on-site visit is deemed necessary. In some instances, the period of renewed accreditation is contingent upon review of a status report, or accreditation visit by a team of evaluators or the CACMS Secretariat. All of these matters are described in CACMS Rules of Procedure.

Appeal / Reconsideration Process

Schools (programs) may appeal CACMS actions affecting the accreditation status of the M.D. program. The reconsideration process consists of two steps: 1) review by an independent ad hoc review committee, and 2) CACMS review with or without an appeal hearing. The assignment of probationary status may be subject to reconsideration. Actions of CACMS subject to appeal include withdrawal of accreditation, denial of accreditation, or refusal to consider for accreditation. Detailed information for the procedures for reconsideration and appeal are given in Appendix B of the CACMS Rules of Procedure.

Complaints to CACMS

Policies and procedures for handling complaints to CACMS about institutional or program quality are given in the CACMS Rules of Procedure. Any person concerned about the quality of an undergraduate medical education program accredited by CACMS may contact the Secretariat to discuss lodging a complaint. Only those complaints will be investigated that, if substantiated, may constitute noncompliance with accreditation standards. CACMS will not intervene on behalf of a complainant regarding, for example, matters of admission, appointment, promotion, or dismissal of faculty or students. Information about guidelines and procedures for complaints is given in the CACMS Rules of Procedures.

Complaints about CACMS, its practices and standards, or the conduct of visits should be forwarded to the CACMS Secretariat.

Confidentiality of Information Related to Accreditation

CACMS will disclose to the public only the accreditation status of the school. Following action by CACMS, a “Letter of Accreditation” transmitting the accreditation decision and a copy of the visit report are sent by the CACMS Secretary to the president of the university (or the equivalent chief executive of the academic institution), with a copy to the dean of the medical school. The visit report and the letter transmitting the accreditation decision will be held confidential by CACMS. The final report may be disclosed by the medical school at its discretion.