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PROFESSIONALISM COMMITTEE TERMS OF REFERENCE

MANDATE

This committee is a subcommittee of the Postgraduate Medical Education (PGME) Committee. The committee’s mandate is to review and adjudicate on professionalism concerns involving a resident or fellow, as per the Faculty of Medicine Policy on Professionalism (henceforth referred to as “Professionalism Policy”. The Postgraduate Professionalism Subcommittee (henceforth referred to as the “Committee”) reports to the Vice-Dean, PGME, or their designate, on the cases and the decisions.

MEMBERSHIP

The Vice-Dean of Postgraduate Medical Education (PGME) or designate will be a permanent member

* The Chair will vote only in the event of a tie.

QUORUM

Quorum will be four (4) voting members, one of which must be the Chair and one resident representative.

APPOINTMENT PROCESS

PGME office will invite interested parties to participate on the committee when a vacancy is identified. Candidates will be reviewed to ensure they are in good standing, and that no professionalism issues have been identified, prior to presenting candidates to PGEC for approval. Once approved, the PGME office will notify all candidates as to the outcome of the process.

FREQUENCY OF MEETINGS

• The Committee will meet to review and adjudicate when matters related to residents and fellows as respondents to professionalism complaints arise.
• It is expected that committee members will attend at least 75% of meetings that occur over the academic year.  Inability to attend the required percentage of meetings may result in removal from the committee by the Vice-Dean, PGME or designate.

CONFLICT OF INTEREST

A member of the Committee should recuse themself when dealing with a matter where the member:

• was materially involved in the completion of an evaluation; and/or
• made a recommendation and/or rendered a decision in the matter which is the subject of the complaint; and/or
• has a personal relationship with the resident or fellow.

Prior to considering any case, the Chair will disclose any conflict they have and require committee members to also declare any conflicts they may have. The Committee may also require a member to recuse themselves where the Committee determines that there could exist a reasonable apprehension of bias. All potential conflicts and concerns of bias will be reviewed by the Committee who will decide by vote if the declarations should result in the member recusing themselves from discussion.  These declarations and decisions will be noted in the official minutes of the Committee. 

FUNCTIONS OF THE COMMITTEE

At the request of the Vice-Dean PGME or delegate, in relation to a resident or fellow responding to professionalism complaints deemed at Level 2 or higher as per the Professionalism Policy, the Committee:

• Reviews and renders a decision on an investigation process.
• Reviews and when necessary, further investigates a complaint.
• Conducts a hearing for Level 3 complaints as per section 6 below.
• Renders a decision regarding the validity of a complaint.  Validity of a complaint speaks to the alleged events having occurred or not.
• Renders a decision on whether there was a violation of the Professionalism Policy related to a complaint.
• Determines a course of intervention and follow-up.
• Reports to the Vice-Dean, PGME or designate.

PROCESSES OF THE COMMITTEE

Professionalism database. For any new concerns the professionalism database will be consulted to determine if there is a prior history of professionalism concerns. 

Framework for Review of Complaints.

• The approach to review a professionalism complaint will include, but is not limited to, the following elements: 
  • a) confirm the complaint;
  • b) understand the context;
  • c) communicate and discuss in a mutually respectful manner;
  • d) encourage self-reflection;
  • e) agree on a plan for remediation, especially at Level 2 or higher;
  • f) document the interventions; and
  • g) construct a plan for follow-up.
• Confidentiality is maintained to the greatest extent possible, while allowing for necessary investigation and follow-up on complaints.

Communication of outcome  

• The resident or fellow, the Vice-Dean, PGME or designate, and the Program Director of the resident/fellow’s home program will be notified of the decision in writing. Consent is not required for sharing of information with these parties.

Review of a complaint

• The Committee is responsible for conducting the review of Level 2 complaints that are referred to the Committee by the Vice-Dean, PGME or designate, as well as conducting the review of all Level 3 complaints as per the Professionalism Policy.
   
• The Committee may seek the advice or assistance of a third party in its review and investigations of the complaint (e.g. Hospital Human Resources, University of Ottawa Human Rights Office).

Determining the intervention 

• The range of interventions is outlined in the Professionalism Policy, section 6.2.
• For Level 2 complaints, the Committee and the Program Director and Program Committee responsible for the resident or fellow will jointly create a plan for intervention and follow-up.
• For Level 3 complaints, the Committee determines a plan of intervention and follow-up, taking into consideration past cases, stakeholder input, the complainant’s input and the respondent’s input.

CONDUCT OF HEARING

The Committee will meet to review Level 2 complaints referred by the Vice-Dean PGME or designate and all Level 3 complaints.

The meeting will be chaired by the Chair of the Committee. If the Chair is in conflict or is considered to be biased, an alternate Chair will be selected by the Chair.

The Committee will decide any issue as to procedure or evidence at the hearing.  

Third party advice, assistance, written statements, or affidavits may be collected prior to the hearing.

At least 10 calendar days prior to the hearing, the Respondent (resident or fellow subject of the complaint) will be provided with the evidence collected by the Committee to date and will be given an opportunity to respond in writing five (5) calendar days before the scheduled hearing.

The Respondent will be invited to the hearing 10 calendar days in advance and may attend with their representative if they wish. The representative is there as a support person and will not speak on behalf of the respondent during the proceeding.

At the commencement of the meeting, the Chair will summarize the procedure for the meeting and reaffirm the allocated time provided for the meeting among the complainant, the respondent, appropriate witness(es) and written statements.

The complainant and the respondent will be interviewed separately. 

The respondent will present after which the members of the Committee will be given the opportunity to question the respondent. The respondent will be given the opportunity to make brief closing statements.

The Committee may have to deliberate on the evidence and formulate a decision at a later date.

Summary minutes of the meeting will be taken by a member of the Committee and will be reviewed by the Chair within 5 calendar days. Once the summary minutes have been reviewed and approved by the Chair, they will be distributed to members of the Committee for review and comment.
 

DECISION OF THE MEETING

The Committee may in assessing the evidence on a standard of balance of probabilities:

• Find the details of the complaint valid;
• Find some of the details of the complaint to be valid;
• Find the alleged incident in the complaint to be unsubstantiated at this point and further investigations are needed; or
• Find the alleged incident in the complaint to be unsubstantiated and no further investigations are needed.

The Committee will, if there is a determination that the complaint is valid, determine whether there was a violation of the Professionalism Policy.

The decision of the Committee will be by a show of hands and will be determined by a majority of the voting members present.

The Chair will vote only in the event of a tie.

The decision of the Committee will be recorded in the meeting minutes of the Committee. Individual votes will not be recorded.

The Committee will determine the appropriate course of action, which may include but are not limited to, additional monitoring, referral to services (e.g. Ontario Medical Association Physician Health Program), remediation, probation, suspension or dismissal. 

NOTICE OF DECISION AND REASONS

• The Chair will draft a letter outlining the Committee’s decision and reasons for the decision within 5 business days of the meeting and will send to the Committee members for feedback giving them an additional 5 business days to reply to the Chair with comments. 
• The Chair will finalize the letter and send it to the respondent and the respondent’s home Program Director within 20 business days of the Committee’s meeting.
• Copies of the letter will also be sent to the Vice-Dean PGME.
• The complainant is provided information on the process and follow up as appropriate.

MINUTES

The minutes of any meeting will include the date and time of the meeting, those present, a brief summary of the meeting, and the Committee’s decision and reasons.

REPORT TO THE PGEC

The Chair of the Committee will prepare an annual written report for the Vice-Dean PGME, summarizing the activities of the Committee and its decisions, without disclosing the name(s) of the respondents or complainants involved. The report may also propose any general recommendations to improve professionalism within the Faculty.

APPEAL OF COMMITTEE’S DECISION

The respondent may appeal the decision of the Postgraduate Professionalism Committee to the Faculty Council Appeals Committee.

CONFIDENTIALITY

The documents provided to the Committee at meetings shall be retained by the Chair of the Committee.

All deliberations of the Committee and all information received by the Committee shall be confidential except for such disclosure as is necessary for the Committee’s investigations and reports.

All committee members must acknowledge that all discussions, documents, and correspondence, regardless of their manner of transmission, are deemed confidential and must always remain confidential. All information received and transmitted must be handled in accordance with the University of Ottawa’s policy 117. Items may be requested via the University of Ottawa’s Access to Information and Privacy Office, in accordance with policy 90.

EQUITY, DIVERSITY, AND INCLUSION (EDI):

The University of Ottawa aspires to promoting a work environment that fully represents the diversity of Canada’s population. As a result, it is committed to applying equity principles to enrich discussion, decisions, and outcomes of committees to support our EDI mandate.

REFERENCES:

1.Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007 Nov;82(11):1040-8. PubMed PMID: 17971689. Epub 2007/11/01. eng.

PGME EVALUATION SUBCOMMITTEE TERMS OF REFERENCE

MANDATE:

The Evaluation Subcommittee is a standing committee of the Postgraduate Education Committee (PGEC) that is responsible for reviewing Program recommendations for trainees in academic difficulty and requiring formal remedial action, including recommendations from the Program for extension of training, reassessment/reclassification, remediation, probation and dismissal.  The Subcommittee ensures that relevant policies are adhered to, and fair process is provided for trainees and programs.

MEMBERSHIP:

The Vice-Dean of Postgraduate Medical Education (PGME) or his designate will be a permanent member and will act as the Chair (ex-officio voting member).

QUORUM:

Quorum is achieved with attendance of the Chair and four voting members, one of which must be a trainee.

APPOINTMENT PROCESS:

PGME office will invite interested parties to participate on the subcommittee when a vacancy is identified. Candidates will be reviewed to ensure they are in good standing, and that no professionalism issues have been identified, prior to presenting candidates to PGEC for approval. Once approved, the PGME office will notify all candidates as to the outcome of the process.

FREQUENCY OF MEETINGS:

The subcommittee will meet monthly from September to June and ad hoc at the request of the Chair.   It is expected that subcommittee members will attend at least 75% of scheduled meetings.  Failure to attend the required percentage may result in removal from the subcommittee.

SUBCOMITTEE DECISIONS:

On behalf of the Faculty Postgraduate Medical Education Committee (PGEC):

• To review the Policy for the Assessment of Postgraduate Trainees at least once annually and suggest recommendations for revision as required.
• Ensure that PGME regulations and policies have been adhered to by the Program, and that trainees have had a fair process when identified as having academic difficulty.

At the request of the Assistant Dean, PGME, to review the cases of trainees in academic difficulty where there are recommendations from the Program for remedial action, including extension of training, reassessment/reclassification, remediation, probation and dismissal.  The review may include the evaluation of the trainee’s academic, behavioral, ethical and professional performance in the program, or the evaluation/recommendation from an independent process.

PROCEDURES:

1.   Relevant documents requiring review by subcommittee members are provided via secure portal to ensure confidentiality for the trainee.  Any written submission provided to the RPC by the resident may be included in the documents provided.

2.   Each subcommittee meeting will start with a discussion about conflict of interest and allow members to declare any such conflict to determine suitability to remain in the meeting

3.   If both resident subcommittee members are excluded from deliberations due to a potential conflict of interest, the Chair will seek a temporary resident replacement from PARO to maintain resident representation on the subcommittee.  

4.   The Chair will invite the Program Director or delegate to present to the subcommittee when any new remedial plans are being proposed involving a trainee.  Invited Program Director or delegate will provide background and answer questions regarding their own specific trainee(s).  and then recused from subsequent subcommittee discussions. 

5.   Subcommittee decisions are determined by a vote of members present.  The Chair will only vote in the case of a tie.

6.   The subcommittee may accept (ratify) or deny (fail to ratify) the Program recommendation.  If the Program’s recommendation is denied, the subcommittee will define an alternate plan which will be binding on the program and the RPC. The subcommittee may also make recommendations for modifications to plans proposed by the Program. 

7.   The Program Director, with the resident copied, will be informed of the decision by a letter within 10 business days of the subcommittee meeting.

REPORTING:

The committee reports to the Assistant Dean, PGME.

Minutes / Related Documents:

Minutes and related documents, if required will be filed and maintained by the PGME office.

CONFLICT OF INTEREST:

Subcommittee members must state a perceived conflict of interest to the subcommittee, at the beginning of the meeting. The subcommittee will discuss and determine if one exists, and if so, will ask the subcommittee member to recuse themselves from any discussion and / or decision making.  If the Chair of the subcommittee declares a conflict of interest, an interim chair from the faculty membership of the subcommittee will be appointed by the Assistant Dean, PGME.

CONFIDENTIALITY:

The subcommittee shall meet in camera.  All subcommittee members must acknowledge that all discussions, documents and correspondence, regardless of their manner of transmission, are deemed confidential and must remain confidential at all times. All information received and transmitted must be handled in accordance with the University of Ottawa’s policy 117. Items may be requested via the University of Ottawa’s Access to Information and Privacy Office, in accordance with policy 90.

EQUALITY, DIVERSITY, AND INCLUSION (EDI):

The University of Ottawa aspires to promoting a work environment that fully represents the diversity of Canada’s population. As a result, it is committed to applying equity principles to enrich discussion, decisions, and outcomes of committees to support our EDI mandate.

PGY-1 RESIDENCY ALLOCATION COMMITTEE (PRAC) TERMS OF REFERENCE

MANDATE:

APPEALS PROCESS

If a program does not agree with the recommendations, a notice of appeal must be submitted in writing by the Program Director no later than ten (10) business days following receipt of the annual PGY-1 allocation report. The written notice must include the reason(s) for submitting an appeal.

In the event that a program might be adversely affected by a revised decision due to another program’s appeal, the Vice-Dean will invite the affected program’s Director to meet with the Committee as well.

The Committee meets with the Program Director(s) appealing the recommendations. Only the Program Directors are permitted to meet with the Committee.

FINAL RECOMMENDATIONS

PGY-1 Residency Allocation Committee shall meet on an as needed basis to finalize the recommendations.

Final recommendations concerning residency allocation are presented for information only at the June PGEC meeting; a copy shall be sent to the Department Chairs and the Dean. Once presented, no further opportunities to modify the recommendations will be permitted.
 

REPORTING:

The committee will report to the PGEC.

MINUTES / RELATED DOCUMENTS:

Minutes and related documents, if required will be filed and maintained by the PGME office.

CONFLICT OF INTEREST:

If a member of the PGY-1 Residency Allocation Committee assumes a position of Program Director in an active PGY-1 entry program, Department Chair or Division Head, the individual will be asked to step down as a member of the subcommittee.

Committee members must state a perceived conflict of interest to the committee, at the beginning of the meeting. The committee will discuss and determine if one exists, and if so, will ask the committee member to recuse themselves from any discussion and / or decision making.

CONFIDENTIALITY:

All committee members must acknowledge that all discussions, documents, and correspondence, regardless of their manner of transmission, are deemed confidential and must remain confidential at all times. All information received and transmitted must be handled in accordance with the University of Ottawa’s policy 117. Items may be requested via the University of Ottawa’s Access to Information and Privacy Office, in accordance with policy 90.

EQUALITY, DIVERSITY, AND INCLUSION (EDI):

The University of Ottawa aspires to promoting a work environment that fully represents the diversity of Canada’s population. As a result, it is committed to applying equity principles to enrich discussion, decisions, and outcomes of committees to support our EDI mandate.

ACCREDITATION SUBCOMMITTEE TERMS OF REFERENCE

MANDATE:

The Accreditation Subcommittee is a standing committee of the Postgraduate Education Committee (PGEC) that is responsible for reviewing all internal accreditation documents and maintaining the overall standards of the University Internal review process.

MEMBERSHIP:

The Accreditation Subcommittee has fifteen (15) members.  The Director of Accreditation chairs the subcommittee.
Membership for other committee members is for a three-year term, renewable twice. 
Membership is as follows:

It is expected that Subcommittee members will attend/participate at least 75% of scheduled meetings.  Failure to participate in the minimum number of meetings will result in removal from the Subcommittee.

QUORUM:

Quorum is set at six (6) members in attendance including the Subcommittee Chair or his/her delegate.

APPOINTMENT PROCESS:

PGME office will invite interested parties to participate on the committee when a vacancy is identified. Candidates will be reviewed to ensure they are in good standing, and that no professionalism issues have been identified, prior to presenting candidates to PGEC for approval. Once approved, the PGME office will notify all candidates as to the outcome of the process.

FREEQUENCY OF MEETINGS:

The Subcommittee shall meet at least four (4) times a year and additionally as required.  Communication with the Faculty PGEC will be on an as needed basis for issues that arise.

SUBCOMMITTEE DECISIONS:

N/A

CONFLICT OF INTEREST:

A Subcommittee member must not participate in the review of his/her own academic program.  The Subcommittee member must declare a conflict of interest when their program’s review is to be discussed or in specific situations where the member plays an important role in the program that is to be discussed. The member will refrain from adding written commentary on the documents under review, and if appropriate, leave the meeting during the program’s discussion.

Committee members must state a perceived conflict of interest to the committee, at the beginning of the meeting. The committee will discuss and determine if one exists, and if so, will ask the committee member to recuse themselves from any discussion and / or decision making.

FUNCTIONS OF THE SUBCOMMITTEE:

1. Review all accreditation preparatory and mandated internal reviews, and progress reports, and make recommendations regarding individual programs as necessary.
2. Report to the Vice-Dean, PGME or designate, and to the PGEC on issues that arise as they pertain to standards of accreditation of the RCPSC and CFPC.  The Director of Accreditation will convey at a minimum, an annual report to the full membership, but may report at additional meetings should the need arise.
3. Assume responsibility for the overall standards of the PGME Internal Review process and make recommendations as necessary to the PGEC.
4. Ensure reports generated by review teams are of high quality.
5. Provide feedback to review teams on the quality of the reports.
6. Provide faculty development and support on accreditation-related activities.

PROCEDURES:

1. The Director of Accreditation, along with the Vice Dean, PGME or designate, set an eight (8) year schedule that outlines the timing of internal reviews for all RCPSC and CFPC training programs at the University of Ottawa.  It is expected that during the time between full external reviews of all University of Ottawa postgraduate programs (conducted by the RCPSC and CFPC every eight years), each program will be subject to at least one full internal review as per the Royal College or CFPC accreditation format.  Programs may also be subjected to additional preparatory reviews as deemed necessary.  At the discretion of the Director of Accreditation, Assistant Dean, and/or Vice-Dean, programs may be subjected to an increased level of scrutiny including, but not necessarily, additional internal reviews, particularly if programs are scheduled for an Action Plan Outcomes Report (APOR) or External Review.
2. Reviewers are assigned to reviews by the Accreditation Program Administrator with oversight by the Director.  Internal reviews are conducted by two (2) Physician Faculty members and one (1) Postgraduate trainee from the Faculty of Medicine, University of Ottawa.  In most cases, the more experienced faculty reviewer will be designated as the Lead Reviewer by the Accreditation Program Administrator and will be the primary author of the report.
3. The Subcommittee is responsible for reviewing all internal review reports and providing formative feedback to the review teams.  Report documents can be accessed by Subcommittee members in a secure digital environment.  Comments and/or track changes will be used by members to ask for clarity or provide feedback in the draft report.  The Director is responsible for summarizing the comments/changes before returning the report to the review team for revisions.  Quarterly, the Subcommittee will meet to ensure that program reports are meeting the General Standards of Accreditation as set out by the RCPSC and CFPC.  Feedback regarding any program deficits will be provided by the Director of Accreditation to the Vice-Dean and Assistant Dean after each internal review, and each Program Director and Department Chair will have access to the report to guide programmatic change.

EXPECTED TIMELINES FOR INTERNAL REVIEWS:

1.  The Accreditation Program Administrator receives the data from the CanAMS (Accreditation Monitoring System) from the program at least one (1) month prior to the review.
2. The Director of Accreditation, Vice Dean, PGME and Assistant Dean, PGME have approximately one (1) week to review and provide commentary on the information submitted.
3. The program has approximately one (1) week to make final edits before re-submitting the final documentation to the Accreditation Program Administrator.
4. Review team members receive access to the program’s documentation two (2) weeks prior to the review date.  The draft report must be submitted within two (2) weeks following the survey visit.
5. Formative feedback on the quality of the report and all requests for clarification from the Accreditation Subcommittee are provided back to the review team within 10 days.
6. All final edits by the Lead Reviewer are asked to be re-submitted within ten (10) days.
7. Once the report has been approved by the Director of Accreditation and/or the Assistant or Vice-Dean, PGME, the final report is sent to the Program Director and the responsible Clinical Department Chair.
8. The Accreditation Program Administrator will process the reviewers’ remuneration for completion of the review and the final report. 
9. Reviewers must submit an invoice to [email protected] and [email protected] to indicate to whom the funds should be paid.

CONFIDENTIALITY:

All committee members must acknowledge that all discussions, documents and correspondence, regardless of their manner of transmission, are deemed confidential and must remain confidential at all times. All information received and transmitted must be handled in accordance with the University of Ottawa’s policy 117. Items may be requested via the University of Ottawa’s Access to Information and Privacy Office, in accordance with policy 90.

EQUITY, DIVERSITY, AND INCLUSION (EDI):

The University of Ottawa aspires to promoting a work environment that fully represents the diversity of Canada’s population. As a result, it is committed to applying equity principles to enrich discussion, decisions, and outcomes of committees to support our EDI mandate.

POSTGRADUATE EDUCATION COMMITTEE TERMS OF REFERENCE

MANDATE:

The Faculty Postgraduate Education Committee is a standing committee of the Faculty of Medicine that coordinates Postgraduate Education in all recognized programs be they:

1. Royal College of Physicians and Surgeons of Canada  Residency Training Programs
2. Canadian College of Family Medicine Residency Training Programs

MEMBERSHIP:

The Vice-Dean of Postgraduate Medical Education (PGME) or designate will be a permanent member and will act as the Chair (ex-officio voting member).

There are 2 types of PGEC meetings:
1. Executive – representation from the departments noted in the table below.  All Program Directors are welcome to join any Executive meeting, even if not a member of Executive.
2. Full – includes all members of the PGEC Executive (as noted below) and all Residency Training Program Directors (or their delegate).

Guests from affiliated organizations will be invited to meetings as needed at the discretion of the Chair. (non voting)

APPOINTMENT PROCESS:

PGME office will monitor the membership to ensure turnover as appropriate noted above.

FREQUENCY OF MEETINGS:

The PGEC Executive will meet 10 times per year from September to June. Four (4) of these meetings will be held to include the entire contingent of Program Directors (or delegates) and will be known as the PGEC Full meeting.

It is expected that PGEC Executive members will attend all PGEC (Full and Executive) meetings and all other residency program directors attend all PGEC Full Meetings. Non-executive members are invited to attend any and all PGEC Executive meetings.

QUORUM:

The quorum for PGEC Executive and PGEC Full meetings shall be at least 1/3 of the total number of voting members or such greater number of members as the PGEC may determine.

FUNCTION:

• Admissions and Registration:
  • Ensure appropriate admissions criteria and procedures are established for all levels of residency training programs.
  • Ensure that appropriate conditions of enrollment are in place, whether these conditions are local or provincial requirements (i.e. PRP, AVP, PEAP, immunization, licensure, and medico-legal liability coverage)
• Evaluation with respect to: 
  • Established Standards of Accreditation according to the RCPSC and CFPC and maintaining an effective Evaluation Policy and Promotions policy
• Monitoring of programs.

Administer an Accreditation Subcommittee for the purposes of:

• Preparing for the on-site Accreditation visits from the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada, as well as the Liaison Committee on Medical Education (LCME) Faculty Accreditation visit. Ensuring that Educational Sites meet Standards of Accreditation.
• Conducting Internal Reviews and the review and approval of reports.
• Ensuring that Educational Sites meet Standards of Accreditation.

ACCOUNTABILITY:

• The PGEC is accountable to the Dean and the Faculty Council of the Faculty of Medicine.

The PGEC is also accountable to report, as necessary, to:

• the Royal College of Physicians and Surgeons of Canada
• the College of Family Physicians of Canada
• subcommittees

SUBCOMMITTEES:

• The PGEC may establish Subcommittees as are necessary to implement policies and procedures as listed above. Terms of reference are to be determined by each Subcommittee and approved by the PGEC.
• Chairs or delegates of these Subcommittees will report to the PGEC on an annual basis.
• Subcommittees include:
• Evaluation Subcommittee
• Professionalism Subcommittee
• Accreditation Subcommittee
• PGY1 Residency Allocation Subcommittee (PRAC)
• Competency-Based Medical Education (CBME) Subcommittee

RECOGNITION:

It is recognized that the University of Ottawa, Faculty of Medicine, has agreements with each hospital defining their affiliation with the University. It is recognized that the affiliated hospitals through the Ontario Teaching Hospitals (OTH) represent the teaching hospitals and the University of Ottawa for the purposes of negotiating non-academic terms and conditions related to residents with the Professional Association of Residents of Ontario (PARO). For matters pertaining to their employment status, residents are responsible to their employer.

Committee Decisions:

• Decisions rendered are not appealable.

Minutes / Related Documents:

• Minutes and related documents, will be filed and maintained by the PGME office

CONFLICT OF INTEREST:

Committee members must state a perceived conflict of interest to the committee, at the beginning of the meeting. The committee will discuss and determine if one exists, and if so, will ask the committee member to recuse themselves from any discussion and / or decision making.

CONFIDENTIALITY:

All committee members must acknowledge that all discussions, documents and correspondence, regardless of their manner of transmission, are deemed confidential and must remain confidential at all times. All information received and transmitted must be handled in accordance with the University of Ottawa’s policy 117. Items may be requested via the University of Ottawa’s Access to Information and Privacy Office, in accordance with policy 90.

EQUALITY, DIVERSITY, AND INCLUSION (EDI):

The University of Ottawa aspires to promoting a work environment that fully represents the diversity of Canada’s population. As a result, it is committed to applying equity principles to enrich discussion, decisions, and outcomes of committees to support our EDI mandate.

Committee and Approval Details

PROGRAM ADMINISTRATORS' EXECUTIVE COMMITTEE TERMS OF REFERENCE

MANDATE:

Acts as a liaison and change agent by providing valuable feedback and ideas for process improvement and implementation of new tools. Collaborates with the PGME office when decisions need to be made. Represents the PAs when discussing process matters with PGME Office, as well as in providing updates and news to PDs via PGEC meetings. Provides collaborative support, orientation, and essential knowledge pertaining to the Program Administrator (PA) role in medical education. Assists with the planning of the PA retreat, suggests ideas for professional development and provides updates at the general assemblies.

MEMBERSHIP:

The PA Executive Committee is made up of a core group of approximately 10 Program Administrators with representation from all 5 affiliated partner hospitals working in postgraduate medical education at the University of Ottawa, plus at least 1 representative from the PGME Office.

APPOINTMENT PROCESS:

The recruitment process is carried out at any time during the academic year. A call for nominations will be done at the spring PGME Administrators’ assembly. 

Members are expected to accept assignments involved in the planning of the professional development workshops and creation of ad-hoc working groups or sub-committees.

MEMBER ELIGIBILITY:

To be eligible for membership on the committee, the individual must be the designated Postgraduate Program Administrator for an accredited CCFP or RCPSC residency program at the University of Ottawa.  There may only be one representative per program on the committee.

QUORUM:

Quorum is achieved when the majority of committee members are present / adjudicate on the decision.

FREQUENCY OF MEETINGS:

The chair approves all scheduled meeting dates.  Meeting length is one hour. These meetings occur a minimum of four times a year (with additional meetings as required) between September and June of every year.  The organization of the meeting is the responsibility of the Chair with assistance of the PGME Manager or other PGME staff.

ATTENDANCE:

All Committee members are required to participate in at least 75% of the scheduled meetings, and are expected to participate in the professional development curriculum planning. If attendance is much lower or nil, the Chair will contact the member and confirm membership interest.

ACCOUNTABILITY:

The PA Executive Committee is accountable to the PGME Office and all program administrators and program directors at the University of Ottawa.

SUB-COMMITTEES:

All sub-committees will be chaired by a member of the PA Executive.  The number of sub-committees will be determined on an annual basis according to the PA Executive Objectives for that year. Professional Development activities are the exception as no separate sub-committee exists, rather these activities are coordinated by the main PA Executive Committee.

Any PA from the larger General Assembly group is eligible to participate on a sub-committee, they do not have to be a member of the PA Executive. 

CONFLICT OF INTEREST:

Committee members must state a perceived conflict of interest to the committee, at the beginning of the meeting. The committee will discuss and determine if one exists, and if so, will ask the committee member to recuse themselves from any discussion and / or decision making.

CONFIDENTIALITY:

All committee members must acknowledge that all discussions, documents and correspondence, regardless of their manner of transmission, are deemed confidential and must remain confidential at all times. All information received and transmitted must be handled in accordance with the University of Ottawa’s policy 117. Items may be requested via the University of Ottawa’s Access to Information and Privacy Office, in accordance with policy 90.

EQUALITY, DIVERSITY, AND INCLUSION (EDI):

The University of Ottawa aspires to promoting a work environment that fully represents the diversity of Canada’s population. As a result, it is committed to applying equity principles to enrich discussion, decisions, and outcomes of committees to support our EDI mandate.

CLINICAL FELLOWSHIP COMMITTEE TERMS OF REFERENCE

GENERAL PROVISIONS:

The Faculty’s Clinical Fellowship Committee (CFC) is a committee of Postgraduate Medical Education (PGME) that coordinates Faculty of Medicine Post-Residency Fellowship Education in all recognized programs.

It must be clearly understood that each Fellowship program must have a designated Fellowship Director.

A fellow is defined as a clinical trainee in postgraduate medical education undertaking an unaccredited fellowship or a fellowship in an Area of Focused Competence (AFC) post-residency.

MEMBERSHIP:

Membership to the CFC include:

• Vice-Dean, PGME (Chair)
• Assistant Dean, PGME (ex-officio)
• Dean, Faculty of Medicine (ex-officio)
• Operations Manager, PGME (ex-officio)
• One representative from each of the following clinical departments and schools:

1. Anesthesiology
2. Emergency Medicine
3. Epidemiology, Public Health and Preventative Medicine
4. Family Medicine
5. Innovation in Medical Education
6. Laboratory Medicine
7. Medicine
8. Obstetrics and Gynecology
9. Ophthalmology
10. Otolaryngology
11. Pediatrics
12. Psychiatry
13. Radiology
14. Surgery
    1. The Program Director of each AFC program
    2. Two Clinical Fellow Representatives
    3. One Program Administrator Representative

Guests may be invited to meetings, as required and at the discretion of the Chair (non-voting).

MEETINGS:

The CFC will meet a minimum of four (4) times per year, from September to June.

Quorum for CFC meetings shall be at least 1/3 of the total members or such greater number of members as the CFC may determine.

FUNCTIONS OF THE COMMITTEE:

1. Admissions and Registration

   • Ensure appropriate admissions criteria and procedures are established for all postgraduate fellows.

   • Ensure appropriate conditions of enrollment are in place, whether these conditions are local or provincial requirements (e.g. Pre-Entry Assessment Program, English Language Requirements).

2. Evaluation

   • Standards around assessment for all fellowship programs as well as Royal College Standards for the AFC programs.

   • Maintaining an effective Evaluation Policy and Promotions policy.
   • Monitoring of programs.

3. Accountability.

   • The CFC is accountable to the Vice-Dean, PGME.

SUBCOMMITTEES:

The CFC may establish Subcommittees as are necessary to implement policies and procedures as listed above. Terms of reference are to be determined by each Subcommittee and approved by the CFC. Chairs or delegates of these Subcommittees report to the CFC on an annual basis.

RECOGNITION:

It is recognized that the Faculty of Medicine, University of Ottawa, has agreements with each hospital defining the hospital’s affiliation with the University.

POSTGRADUATE COMPETENCY-BASED MEDICAL EDUCATION SUBCOMMITTEE TERMS OF REFERENCE

MANDATE:

The competency-based medical education (CBME) subcommittee is an advisory subcommittee of the Postgraduate Education Committee (PGEC) and is accountable to the Vice-Dean, Postgraduate Medical Education, Faculty of Medicine. This subcommittee is responsible for the overall oversight and strategic planning for the implementation of Competence By Design (CBD) in the RCPSC programs at the University of Ottawa as well as ensuring that there is overall alignment in our CFPC programs with the Triple C curriculum.

FUNCTIONS OF THE SUBCOMMITTEE:

The CBME subcommittee will adhere to the mission and policies of the Faculty of Medicine. It is responsible for strategic planning in all areas related to CBME at the University of Ottawa, including but not limited to:

• Identifying and prioritizing needs (perceived and unperceived), actions and activities relevant to readiness for, fidelity with, and the intended outcomes of CBME implementation,
• Identifying resources / technology infrastructure that will enable the successful adoption of CBME at 91��ɫ.
• Identifying common needs across programs and users of Elentra, and prioritizing enhancements, changes, and new system developments.
• Suggesting support strategies for faculty, learners, and administrative staff.

• Proposing new policies and/or policy changes as needed to support competency based medical education.
• Proposing and overseeing program evaluation of CBME implementation

MEMBERSHIP:

QUORUM:

Chair and 50% of the subcommittee members.

APPOINTMENT PROCESS:

PGME office will invite interested parties to participate on the committee when a vacancy is identified. Candidates will be reviewed to ensure they are in good standing, and that no professionalism issues have been identified, prior to presenting candidates to PGEC for approval. Once approved, the PGME office will notify all candidates as to the outcome of the process. 

FREQUENCY OF MEETINGS:

The subcommittee will meet at least 4 times per year.

ATTENDANCE OF MEETINGS:

It is expected that subcommittee members will attend at least 75% of scheduled meetings. Failure to attend the required percentage of meetings will result in removal from the subcommittee.

SUBCOMMITTEE DECISIONS:

Decisions rendered are not appealable.

REPORTING: 

The committee will report to the PGEC on an ad hoc basis.

MINUTES / RELATED DOCUMENTS:

Minutes and related documents, if required will be filed and maintained by the PGME office.

CONFLICT OF INTEREST:

Committee members must state a perceived conflict of interest to the committee, at the beginning of the meeting. The committee will discuss and determine if one exists, and if so, will ask the committee member to recuse themselves from any discussion and / or decision making. 

CONFIDENTIALITY:

All committee members must acknowledge that all discussions, documents and correspondence, regardless of their manner of transmission, are deemed confidential and must remain confidential at all times. All information received and transmitted must be handled in accordance with the University of Ottawa’s policy 117. Items may be requested via the University of Ottawa’s Access to Information and Privacy Office, in accordance with policy 90.

EQUALITY, DIVERSITY, AND INCLUSION (EDI):

The University of Ottawa aspires to promoting a work environment that fully represents the diversity of Canada's population. As a result, it is committed to applying equity principles to enrich discussions, decisions and outcomes of committees to support our EDI mandate.