Accreditation Overview

Accreditation News


Mock accreditation helped focus efforts

The college hosted a mock accreditation visit February 5-8, 2017, in preparation for its full accreditation visit later this year. External reviewers were Dr. Tom Marrie, former dean at both the University of Alberta and Dalhousie who guided both schools off probation, and Dr. Cam Enarson from University of North Carolina, who has done 37 full accreditation visits over his career. 

The mock, which provides a dress rehearsal, as well as a fact finding mission and reality check, has never been done before at the college but has become standard practice at all Canadian medical schools over the last three years. It helps inform where to focus efforts in the months leading up to the actual visit.

What next?

Immediately after the mock, work began to prepare for the full visit. A plan is in place and people have been identified to lead all areas of work. Highlights of work being completed are as follows:

  • The college’s Data Collection Instrument must be updated and submitted by June 19, 2017
  • Accreditation elements have been categorized as critical, urgent and high priority and will be focused on in that order
  • An Accreditation Executive Team is meeting three times a week to discuss and update progress
  • Two main project areas have been identified: Quality Undergraduate Medical Education (UGME) Program and Quality Accreditation Visit
  • Within the Quality UGME Program project, seven focus areas and leads for each have been identified

Accreditation visit dates set

From October 29 to November 2, 2017, the College of Medicine will have a full accreditation visit for its Undergraduate Medical Education (UGME) program.

The Committee on Accreditation of Canadian Medical Schools (CACMS), in conjunction with the Liaison Committee on Medical Education (LCME) in the United States, ensures Canadian medical faculties' MD programs meet quality standards. Each school undergoes a full on-site assessment visit every eight years. On October 16, 2015, the UGME program was returned to full accreditation until March 2018 after having been placed on accreditation with probation status in 2013.

Work in preparation for the 2017 visit has begun on multiple fronts, overseen by an Accreditation Steering Committee. Work on a Data Collection Instrument started in the fall of 2015, and is ongoing. Medical students completed a student survey—with a 90 per cent participation rate—as part of an Independent Student Analysis (ISA). More information on the results of the ISA and student survey will be provided next week.

Many of our faculty, staff, residents and medical students are participating on six accreditation subcommittees, which began meeting in mid-May. They are reviewing and rating a full range of UGME program information as part of the Medical School Self-study (MSS) process. More information on the composition and work of the subcommittees will be provided in the coming weeks.

A mock accreditation visit is set for February 5-8, 2017, and provides a ‘dry’ run of the formal accreditation visit for the college, further ensuring the accreditation standards will be met and the formal visit will be well coordinated.

Finally, be sure to watch for details of an accreditation launch party being planned for September.

Overview of UGME Accreditation Process

Obtaining accreditation from the Committee on Accreditation of Canadian Medical Schools (CACMS) and the Liaison Committee on Medical Education (LCME) ensures that medical education programs are in compliance with defined standards.

The accreditation process has two general aims: to promote medical school self-evaluation/continuous quality improvement and determine whether a medical education program meets prescribed standards.

The standards for accreditation of Canadian medical schools are contained in the CACMS publication CACMS Accreditation Standards and Elements (S&E)

 The CACMS accreditation standards have been formatted and organized into 12 overarching standards with 93 elements. 

The 12 accreditation standards are:

  • Standard 1: Mission, Planning, Organization, and Integrity;
  • Standard 2: Leadership and Accreditation;
  • Standard 3: Academic and Learning Environments;
  • Standard 4: Faculty Preparation, Productivity, Participation, and Policies;
  • Standard 5: Educational Resources and Infrastructure;
  • Standard 6: Competencies, Curricular Objectives, and Curricular Design;
  • Standard 7: Curricular Content;
  • Standard 8: Curricular Management, Evaluation, and Enhancement;
  • Standard 9: Teaching, Supervision, Assessment, and Student and Patient Safety;
  • Standard 10: Medical Student Selection, Assignment, and Progress;
  • Standard 11: Medical Student Academic Support, Career Advising, and Educational Records;
  • Standard 12: Medical Student Health Services, Personal Counseling, and Financial Aid


The general steps for the medical school in the accreditation process are as follows:

1. a. Completion of the Data Collection Instrument (DCI).

b. Simultaneous completion of the Independent Student Analysis (ISA).

2.    DCI, ISA and most recent graduation questionnaires are analyzed by the Medical School Self-study (MSS) Task Force and its subcommittees as they prepare their self-study report.

3.    CoM UGME program is visited by an ad hoc survey team.

4.    CoM UGME program receives a decision on accreditation by the CACMS and LCME.

In the ISA process, medical students will carry out their own review of the UGME program, student services, and other areas of relevance to students.  Planning for the student survey and the interpretation of the results is a student responsibility as outlined in the CACMS publication: The Role of Students in the Accreditation of Medical Education Programs in Canada


In October 2015, after reviewing the report of the survey team from the May 2015 Limited Site Survey, CACMS and the LCME voted to continue full accreditation of the University of Saskatchewan MD degree program. The decision is a strong endorsement of the excellent quality of the MD program.

We are pleased to announce that CACMS and the LCME found the MD Program to be compliant with all accrediting standards, resulting in full and unqualified approval.

The full accreditation will take place October 29 to November 2, 2017.


 The medical school self-study task force and its subcommittees are responsible for conducting the self-study.  The project as a whole should be guided by the faculty accreditation lead. Each subcommittee should review and analyze the ISA, the most recent graduation questionnaires, and the DCI data, narrative responses and appendices for the elements to which they have been assigned. In the majority of cases, the relevant documentation to evaluate the element has been requested in the DCI itself. The subcommittees carry out the first evaluation and rating of elements, provide evidence to support the rating, and develop plans with timelines to address areas of unsatisfactory performance. This process is described in more detail later in the guide. Subsequently, the task force analyzes the subcommittee reports, along with the supporting documentation and any new information, and revises as appropriate the individual subcommittee element ratings.  The task force updates the evidence to support the rating and the final plans to address elements where performance is unsatisfactory and elements requiring monitoring. The task force creates the final self-study report that includes a summary of the elements that are strengths of the medical school and elements that require attention to ensure ongoing or future compliance with accreditation standards, and to improve the quality of the educational program and medical students’ experiences.  The components of the self-study report are described in detail later in this guide.

The medical school self-study report, the ISA, the most recent graduation questionnaires and the completed DCI with its appendices need to be submitted to the survey team three months prior to the survey visit as described on the CACMS website.


Preparation for Fall 2017 visit

Preparations are already underway for the next full Undergraduate Medical Education Program accreditation visit, expected Fall 2017.  In preparation, the College of Medicine will undergo a process of self-evaluation and self-study.  In the course of conducting our self-study, the college will bring together representatives of the medical school administration, faculty, student body, and other stakeholders to accomplish three specific requirements: 

  1. Collect and review data about the medical school and its educational program
  2. Identify both medical school strengths and areas that require improvement
  3. Define strategies to ensure that the strengths are maintained and any problems are addressed effectively

Current Status as of October 16, 2015

Effective October 16, 2015, the Undergraduate Medical Education Program at the University of Saskatchewan’s College of Medicine is returned to full accreditation for an extended period, to March 2018. 

Accreditors will return for the next full accreditation visit in fall 2017, several months later than originally anticipated.  Since 2011, the college has committed to investing much hard work and energy to address long-standing accreditation issues. 

The outcome of returning to full accreditation, for an extended period of time, is an indication from our accreditors that changes underway in the college are delivering the intended results.  As we turn our focus towards preparing for the fall 2017 visit, we are mindful the accreditation process is about continuous quality improvement. 

We remain steadfast in our pledge to provide quality medical education to students in communities across Saskatchewan. A strong provincial College of Medicine benefits the people of Saskatchewan by serving as a cornerstone to our provincial healthcare system.

Read the full summary here.

Read the October 23, 2015 article in On Campus News


Accreditation Summary
This document is a summary version of the official letters of transmittal received from CACMS/LCME in  October 2013 and  March 2014.

May 15, 2015

Students, Residents, Staff and Colleagues,

I  am writing to share a very brief update on this week’s UGME accreditation visit.  As you know, a site survey team from our accrediting body, CACMS/LCME, was in Saskatchewan from Sunday until earlier today.  The team was assessing the College of Medicine’s progress on 13 standards of accreditation that were previously identified as non-compliant or in need of monitoring.

From my perspective, this survey went very smoothly (despite the unplanned fire alarm on Monday) and the survey team commented on the many courtesies and accommodations extended during their stay.  Personally, I was particularly impressed with the turnout and engagement demonstrated by our faculty, students and partners in both Saskatoon and Regina.  The high level of participation is inspiring. 

As I’ve said before, we will not be informed of the outcome until later this fall, and I will not speculate on the findings.  I will however commit to sharing with the entire college community the official letter of transmittal once it has been received, likely in late October.

I want to extend my sincere appreciate to Dr. Sheila Harding, Dr. Athena McConnell, Kevin Siebert, Darla Wyatt and the entire UGME leadership group for making this visit happen – your teamwork has been truly impressive.  As with any survey, there were several on-site requests for additional documentation, and our team rose to the occasion, responding with ease.  Thank-you for making us all look good!

Congratulations to our students who have finished writing exams – I will see you for your Convocation Ceremony and Graduation on June 4th.  Best of luck to the first and second year classes as you continue with exams.  And to our JURSIs, I hope I will see many of you on your Family Medicine rotations over at West Winds.  I also understand the Admissions Committee is ready to send out Letters of Offer beginning on Friday, so we’ll have 100 new UGME students to welcome.

Thank-you again to everyone who helped in making this visit a great success.  More importantly, thank-you all for your daily efforts on behalf of the College of Medicine and our students. 

Enjoy your long weekend!


May 6, 2015

College of Medicine learners, faculty and staff,

Beginning this Sunday, the College of Medicine will host a much-anticipated UGME accreditation visit. 

As you know, our undergraduate medical education (UGME) program has been on probation since November 2013, after previous accreditation visits noted deficiencies with 13 of the 139 accreditation standards for Canadian medical schools.  As a college, we have been preparing for months, and I am confident we are ready to demonstrate significant progress since our last visit in March 2013.

The four member Survey Team from the Committee on Accreditation of Canadian Medical School (CACMS) and the Liaison Committee on Medical Education (LCME) will be in Saskatchewan from May 10-13, and will make stops in both Saskatoon and Regina.

The purpose of this limited site survey is to review eight standards that were previously determined to be non-compliant, and five standards that were described as compliant with a need for monitoring.  These 13 standards are explained further in the  Accreditation Decision Summary, and complete accreditation information is available  You can also watch for an article on our preparations that will be published in On Campus News this Friday. 

We won’t know the results of this visit until fall 2015.  I don’t want to speculate on the outcome, but I will remind everyone that accreditation is an eight-year cycle. When a program is on probation, it’s common for accreditors to complete two survey visits before changing a program's status.  Our next full accreditation visit will happen in 2017, so given the timing, it would be unusual to have a second limited survey take place before the full survey in 2017.

Regardless of the outcome, I do want to publicly appreciate the work of our department heads, the entire UGME office, Kevin Siebert, Darla Wyatt, and of course Drs. Harding and McConnell.  I know they’ve been living accreditation for the last number of weeks, and their efforts have not gone unnoticed.


On a related note – congratulations to our friends and colleagues in the School of Physical Therapy on your successful Master of Physical Therapy program accreditation!  Truly outstanding news that reinforces why I refer to the School as a ‘gem’ within the college. 

As always, my door is open, and I welcome the chance to hear from you directly.



Read the  April 2015 Accreditation Summary.  
This document is a summary version of the official letters of transmittal received from CACMS/LCME in October 2013 and  March 2014.

April 10, 2015

College of Medicine learners, faculty and staff,

I'm writing today to share details about the college's upcoming UGME accreditation visit.  

The four member Survey Team from the Committee on Accreditation of Canadian Medical School (CACMS) and the Liaison Committee on Medical Education (LCME) will be in Saskatchewan from May 10-13, and will visit both Saskatoon and Regina.

The purpose of this limited site survey is to assess the progress we've made since the last visit in March 2013, which resulted in the program being placed on probation in November 2013. Specifically, the Survey Team will review eight standards that were previously determined to be non-compliant, and five standards that were described as compliant with a need for monitoring.  These 13 standards are explained in further detail at (link - updated accreditation summary document).

In preparation for the May visit, we have now submitted to CACMS/LCME our  completed Briefing Book, which contains the required background material and information on each standard under review.  It is available for reading at (link to PDF of BB).

I am confident that since March 2013, the College of Medicine has made significant progress on many fronts.  Stable, permanent leadership is now in place.  More importantly, the college has brought together a team of people, including the vice dean, associate and assistant deans, and key administrators, to fully support the planning and delivery of our undergraduate medical education program, and our students.  

To help ensure the visit runs smoothly in May, a mock run-through of the various meetings will be conducted Monday April 20, Tuesday April 21 and Wednesday April 23.  Details on both the mock and actual visit will be provided to all involved parties as the survey schedule is finalized.  Thank-you for holding these times in your calendar and being flexible as the dates and times have shifted.

We will not be informed of the results of our May visit until fall 2015.  I do not want to speculate on the outcome, but I do want to reiterate that accreditation is an eight-year cycle.    When a program is on probation, it is common for accreditors to complete two survey visits before changing the program's status.  Our next full accreditation visit is due in 2017, so given the timing, it would be unusual to have a second limited survey take place before the full survey in 2017.  

You can expect another update from me early in May, following my return from Western University.  As I have said before, accreditation is a form of self-regulation, and so I'm heading to Ontario next week to lead the full survey team for Western's accreditation.  

In the meantime, I want to acknowledge the efforts of the department heads and the entire UGME office in preparing for this visit.  Thank-you for all of your hard work.  We owe special gratitude to Dr. Athena McConnell and Dr. Sheila Harding for their leadership and expertise in this regard, and also to Kevin Siebert for his diligence and ability to pull it all together.  I know how much time and energy this assignment demanded of departments and people, and I deeply appreciate your efforts.



June 26, 2014
We have received verbal approval from CACMS/LCME on our action plan, as presented on April 15, 2014.  We continue to prepare for our limited survey visit, and our task at hand is to carry out the tasks described in the action plans, with the goal of demonstrating compliance.

April 15, 2014
As requested, a second Action Plan to address four specific standards was submitted to CACMS and LCME today.  It will be considered for approval by the respective accreditation committees at their upcoming meetings.

View our April 2014  Accreditation Action Plan

February 28, 2014
We have received verbal approval from CACMS/LCME on our Action Plan, as presented on December 20, 2013.  The accreditors have now requested a second Action Plan to address four specific standards.  It is due by April 15, 2014.

January 7, 2014
Our University of Saskatchewan College of Medicine Action Plan was submitted to CACMS and LCME on December 20, 2013. It will be considered for approval by the respective accreditation committees at their meetings as follows:  CACMS January 23-24, 2014 and LCME February 25-27, 2014. 

View our December 2013 Accreditation Action Plan 

Friday October 18, 2013

To the College of Medicine community,

Further to the information disseminated on October 4, I am writing to share with you the formal letter of transmittal from CACMS/LCME.  I want to reiterate that the College of Medicine remains fully accredited as we work to address the specific standards outlined in the letter. We do not intend to request a consideration of this decision. We will instead focus our attention and resources on addressing the identified issues.

To facilitate free exchange of information and ideas, three Town Hall meetings will be held as follows:  (Videoconferencing has been requested for West Winds as well.)

  • Tuesday, November 5, 1700-1830  (from SaskTel Theatre in Saskatoon; via videoconference to Regina General Hospital Auditorium)
  • Tuesday, November 12, 1700-1830  (from Regina General Hospital Auditorium; via videoconference to HSB E1130)
  • Wednesday, November 13, 1700-1830  (from SaskTel Theatre in Saskatoon; via videoconference to Regina General Hospital Auditorium)

As we work through this process, you can expect regular progress reports. You may submit feedback  and suggestions to There will be a Secretariat visit from CACMS/LCME in early December 2013, to provide consultative assistance in the development of the  Action Plan. The Action Plan must be submitted to CACMS/LCME by the end of December.

A note with respect to the last paragraph in this transmittal letter:  In the Spring of 2013, a third party complaint submitted to CACMS/LCME about facilities and information resources in Saskatoon raised questions about standards MS-37 (study and lounge space, and personal storage space) and ER-7 (clinical instructional facilities and information resources). In light of recent upgrades to the St. Paul’s Hospital Library and the opening of E Wing in the Health Sciences Building, CACMS/LCME requested that additional information be obtained by surveying relevant student groups in Saskatoon, for submission by December 1, 2013. Brief surveys will be conducted for this purpose in the weeks ahead.


Sheila Rutledge Harding, MD, MA, FRCPC
Associate Dean, Medical Education 
College of Medicine, University of Saskatchewan

Read the  Summary Version of the formal letter of transmittal from CACMS/LCME (October 2013)

Friday October 11, 2013

To the College of Medicine Community:

As you know, we have received verbal notice that the accreditation status of the MD Program, determined at their recent meetings by the Committee on Accreditation of Canadian Medical Schools (CACMS) and the Liaison Committee on Medical Education (LCME), is “accreditation with probation”. Detailed instructions about the required response will follow in a transmittal letter that we expect to receive by the end of October. In the meantime, this is what we know now:

  • Of the 10 standards under scrutiny during the March 2013 visit, six are now considered either “in compliance” (ED-8, ED-41, ER-4 and MS-37) or “in compliance with need for monitoring” (ED-30, ED-31, ED-44 and MS-32) – the latter designation may be used when compliance with a standard is new and relatively untested, or is at risk because of other events. ED-9 was added to the monitoring list – it pertains to the implementation of a new curriculum.
  • Of the original 10 standards, four (IS-9, ED-2, ED-3 and ED-24) are still considered noncompliant, and a further two areas of noncompliance have been identified (IS-11 and ED-25A). The attached document provides the details of these six standards, along with the findings of the survey team from March 2013.

This outcome was fully predictable: IS-9 was first cited in 2009, and has remained problematic through limited visits in 2011 and 2013, despite the warning that followed the 2011 visit.

We understand we now have two years to fully address these issues. Much work has already been done in recent months in anticipation of this outcome. Immediate next steps are as follows:

  •  We will be required to develop an Action Plan (again, the details will be in the forthcoming transmittal letter) for submission to LCME/CACMS by the end of December 2013, for approval at their January 2014 meetings.
  •  Development of the Action Plan includes a Secretariat Consultation, wherein a Secretariat representative from each of the two accreditation bodies will come in early December to review the plan in person with those most responsible for its implementation.
  •  Arrangements are being made for two or three cross-site Town Hall meetings in early November  to provide additional information to the CoM community, answer questions, and gather input for the Action Plan.
  •  We will also create a web page to enable ready access to the transmittal letter and to gather suggestions for inclusion in the Action Plan.

It will be my responsibility to collate and edit the Action Plan document, with input from others as appropriate to the standards in question and the instructions in the transmittal letter. I hope to make use of the Accreditation Working Group of the Dean’s Advisory Committee to be my sounding board as I develop the Action Plan.

Finally, it is important to note that the March 2013 survey team did not find fault with the overall adequacy of the current educational program. Preliminary information from the MCCQE1 exam in the Spring of 2013 suggests that the performance of our students is on the rise, contrary messaging notwithstanding.  I urge all faculty, residents, and staff to be cognizant of the substantial impact of this situation on our students, and to continue to provide them with a sound educational program, accompanied by lots of support and encouragement. Thank you.

Sheila Rutledge Harding, MD, MA, FRCPC
Associate Dean, Medical Education
College of Medicine, University of Saskatchewan 

Friday October 4, 2013

College of Medicine community,

I am writing to inform you that earlier today (Friday October 4, 2013), I received a phone call from Dr. Genevieve Moineau, President and CEO of the Committee on the Accreditation of Canadian Medical Schools (CACMS).  This call was a courtesy to our school to inform me that our accreditation status has been discussed at the most recent meetings of CACMS/LCME. 

As you know, the College of Medicine is fully accredited, but has been on Warning of Probation since July 2011.  Although the call today from Dr. Moineau is not official, she informed me that our Undergraduate Medical Education program will be placed on Accreditation with Probation.  I want to reiterate, that despite this news today, our college will continue to remain fully accredited.  An official letter of transmittal detailing this decision is expected later this month.   

I will communicate further once I have received further information. 

Lou Qualtiere,
Acting Dean