CCAC policy statement on: assessment panels

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This policy describes the work of CCAC assessment panels. It includes the mechanisms for selection of panel members, as well as information on the relationship between panels, institutions, the CCAC Assessment and Certification Committee and Council itself. This policy will direct panel members in undertaking assessments of institutional animal care and use programs, including the site visit and the preparation of the assessment report. It has also been prepared with a view to providing information to the institutions which participate in the assessment process.

The expertise of peers in developing CCAC guidelines and in conducting assessments is the foundation of the CCAC program. The purpose of the Assessment and Certification Program is to review all aspects of the care and use of animals in research, teaching and testing in an institution, to assess the procedures and facilities for animal care and use, to note and comment on any matters that may not be in accord with the CCAC's guidelines and policies and to report the panel's observations and recommendations to the CCAC Assessment and Certification Committee and to the institution. Assessment visits are the quality assurance system of the CCAC Assessment and Certification Program, and panel members should be supportive of the accomplishments of local animal care committee (ACC) members who work to implement CCAC guidelines on a day-to-day basis.

Assessment panels represent the Council as a whole, and all reports produced by assessment panels are finalized and approved by Council, through its Assessment and Certification Committee. Therefore, all questions and comments related to the assessment, or the assessment report, of any institution must be directed to the CCAC Secretariat, and not to individual panel members. In the event that a panel member is contacted regarding a specific assessment visit, s/he should immediately refer the matter to the CCAC Secretariat.

Both panel members and institutions are subject to the CCAC policy statement on: confidentiality of assessment information.

A. The Panel

  1. Panel Member Selection

    The assessment of institutions by the CCAC is conducted by panels of peers. Each CCAC assessment panel is composed of scientific members, including at least one veterinarian (generally a laboratory animal veterinarian), nominated by an Assessment Director, and of a community representative, normally nominated by the Canadian Federation of Humane Societies (CFHS). This representative should ideally be chosen from the community of the institution to be visited, in order to provide a local public perspective on the panel. All panel members must be chosen in a manner which will promote a fair and objective assessment of each institution's animal care and use program, according to the policies and guidelines of the CCAC. The Assessment and Certification Committee may be consulted during this process. The Assessment and Certification Committee will be informed by the CCAC Secretariat of the composition of each assessment panel at least one month, normally, before the assessment visit is to take place.

  2. Panel Member Removal

    1. The institution subject to assessment, or the CCAC Assessment Director, or the Chair of CCAC, may object to the nomination of a member of an assessment panel. The objection must be based on a reasonable apprehension that the nominated member will not be able to carry out his/her duties in accordance with CCAC guidelines and policies, including the CCAC Assessment Panel Policy and the CCAC policy statement on: confidentiality of assessment information.
    2. Any objection must be made in writing, must set out the reasons for the objection, together with any relevant documentation, and be delivered to the Assessment Director and to the individual named in the objection not less than 21 days prior to the initial meeting of the relevant CCAC assessment visit.
    3. An individual named in an objection will have seven days from the receipt of the objection to deliver a response to the Assessment Director. The response to an objection must be in writing and must set out the reasons for opposing the objection, together with any relevant documentation.
    4. Upon receiving an objection or a response to an objection, the Assessment Director will forward it immediately to the Assessment and Certification Committee. Following the reception of an objection, and any response to this objection, the Assessment and Certification Committee will consider and decide to sustain or dismiss the objection within seven days. There will be no appeals of the Assessment and Certification Committee decision.
    5. The objector and the individual named in the objection will be informed immediately of the Assessment and Certification Committee decision.
    6. In the event that the Assessment and Certification Committee sustains an objection, the individual named in the objection shall automatically cease to be a member of the assessment panel, and any pre-assessment documention shall be returned immediately to the Assessment Director. Any confidential information received by an individual who has been removed from an assessment panel must remain in confidence.
    7. An individual denied participation on one assessment panel shall not be excluded from nomination to other assessment panels.
    8. The Assessment Director may extend or abridge any of the time requirements set out in this procedure for panel member removal where, in the sole discretion of the Director, this is advisable. However, the person named in the objection will be given five days, normally, in which to respond to the Assessment Director.
  3. Duties of Panel Members

    It is important to note that panel members should not act as inspectors, but rather as unbiased, informed advisors to the local institutional ACC, directors of animal care, investigators and administration. Panel members should strive to implement the high standards of animal care and use which have been defined by other groups of peers at the Council level.

    1. The Assessment Directors

      As full-time employees of the CCAC, the Assessment Directors provide a measure of consistency between panels for the Assessment and Certification Program, and will assist other panel members in assuming their duties, in clarifying issues and in formulating recommendations.

    2. The Panel Chair
      1. should be prepared to lead discussions with the active participation of other members of the panel, at initial and summary meetings;
      2. should work towards achieving a consensus by panel members on all issues related to the assessment, in collaboration with the Assessment Director.
    3. All Panel Members
      1. should be familiar with CCAC's guidelines and policies;
      2. should understand the reason and basis for the CCAC Assessment and Certification Program;
      3. should carefully read and become familiar with the pre-assessment documentation supplied by the institution;
      4. should review the information on approved protocols provided in the Animal Use Data Form (AUDF), which is included in the pre-assessment documentation; a panel member wishing to examine a full protocol must contact the Assessment Director before the visit. Panel members should use the information reported in the AUDF, the Terms of Reference for Animal Care Committees, the minutes of ACC meetings and a few selected protocols to evaluate the ways in which the local ACC functions and approves protocols. It is not the role of panel members to examine the merits of all protocols;
      5. should be respectful and collegial in discussions with members of the institution;
      6. should be as calm and quiet as possible when near animals, recognizing that any unfamiliar intrusions into animal rooms can disturb the animals, and thus should respect any reasonable institutional concerns regarding intrusions into animal rooms or procedures;
      7. should be prepared to discuss with the institutional ACC and individual investigators the procedures used on animals, as well as the use of standard operating procedures (SOPs);
      8. should be prepared to take sufficient notes to contribute to a meaningful report;
      9. should understand that much of the information received by members during an assessment is privileged and its confidentiality should be respected, as discussed above;
      10. should understand that any difficulties pertaining to any aspect of the assessment and report should normally be resolved through discussions within the panel but difficulties which cannot be resolved through the panel chair or Assessment Director, should be directed to the Chair of the CCAC Assessment and Certification Committee. If difficulties are still unresolved, the matter can be brought to the attention of the CCAC Chair.

B. Pre-assessment Meeting

All panel members are required to meet at a convenient time prior to the visit to review the goals of the assessment, the institution's pre-assessment documentation, the results of the previous assessment and any other issues related to the visit.

C. Initial Meeting

The time of the initial meeting is usually stated in the information package provided prior to the site visit and therefore the panel should be present at the appointed time.

The initial meeting is usually held with the ACC and other senior institutional representatives, as well as senior animal care personnel (the names and titles of these individuals should be recorded). Panel members are introduced, including notification of their departmental and institutional affiliations.

The chair of the panel or the Assessment Director should briefly outline the CCAC's mandate and purpose of the visit, and draw attention to the five major aspects of the CCAC's Assessment and Certification Program, as indicated on the Assessment Summary Sheet (Appendix A).

The following points should be briefly reviewed (the information should normally be contained in the pre-assessment documentation) and any specific concerns discussed.

  1. Overview of the institution's research and/or teaching mandate as it pertains to animal use; new programs and/or elimination of programs.
  2. Review of the implementation of previous CCAC recommendations.
  3. Changes since previous assessment:
    1. personnel: animal care and use;
    2. physical plant;
    3. other changes.
  4. Animal care committee - modus operandi:
    1. documentation:
    2. Terms of Reference;
    3. Animal use protocol form;
    4. Minutes of committee meetings.
  5. protocol review process and frequency of ACC meetings;
  6. ACC site visits of animal facilities and written accounts thereof.
  • Current animal use:
    • review projects: protocols;
    • meet with or arrange to meet with investigators/teachers during site visit;
    • scientific merit review mechanisms for non-peer reviewed and contract research projects.
  • Qualifications and continuing education programs for:
    • animal care and research technicians;
    • investigators and teachers;
    • ACC members;
    • courses offered on the care and use of animals within the institution.
  • Occupational health and safety program.
  • Veterinary supervision and care.
  • Provision for animal care: weekends, holidays, after hours.
  • Security of facilities and crisis management program.
  • Concerns of the institution (regarding animal care, CCAC programs, etc.).

D. Site Visit

During the site visit, panel members should not hesitate to ask any question concerning any aspect of animal care or use. Discussion with investigators/teachers is highly encouraged.

Panel members should be particularly attentive to:

  1. Animal facilities maintenance:
    1. animal housing - physical plant, ventilation, environmental and temperature control, lighting, caging, pens, ancillary equipment, noise;
    2. sanitation - general organization, cleaning procedures, waste disposal, vermin control, porous or damaged surfaces, storage facilities;
    3. security of facilities - access during and after working hours;
    4. safety measures within facilities - unprotected electrical fixtures, slippery floors.
  2. Animal care and management practices:
    1. husbandry - food, water, bedding, identification (cage cards), records (animal care and use records, particularly for surgical procedures, and controlled substance logs) provision for special care, and standard operating procedures, particularly for pre-, peri- and post-operative care;
    2. health monitoring practices and special husbandry practices;
    3. biosafety considerations;
    4. environmental enrichment program.
  3. Veterinary care program:
    1. reception of animals; quarantine and isolation; conditioning;
    2. prevention, diagnosis, treatment and control of animal disease (sentinel programs); regular care and emergency availability;
    3. species separation;
    4. anesthesia and analgesia;
    5. surgery and post-operative care, including records;
    6. euthanasia;
    7. training of technicians, students, teachers and investigators.
  4. Experimentation involving hazardous agents and protocols of particular invasiveness (CCAC Categories D and E).

E. Summary Meetings

  1. Panel Meeting (in camera)

    Prior to reconvening with the institutional ACC and officials, the panel will meet to discuss any concerns resulting from the visit and to finalize the verbal presentation of recommendations to the institutional representatives; the use of the Assessment Summary Sheet may be useful at this time.

  2. Final Meeting with Institutional Representatives

    The final meeting should not only include the panel's observations, but also detail any problem that should receive immediate attention. Commendatory remarks and recommendations should also be made at this time.

    The verbal report should emphasize the more important recommendations that will be contained in the final, written report. The reasons for the recommendations to be made should be outlined at this time. The Major and Serious recommendations (see definitions in Section Fc), as well as potential ways and means of addressing these recommendations, should be discussed.

F. The Assessment Report

The panel will meet following each day of assessment to dictate its findings and recommendations.

Based on the preliminary report by the panel, a draft written report is prepared by the CCAC Secretariat. The draft report is circulated to panel members and to the members of the CCAC Assessment and Certification Committee for their comments and approval; the final report is then forwarded to the institution by the CCAC Secretariat and copies are sent to the panel members. The time frame for this is normally ten weeks, in order for the Assessment and Certification Program to remain effective and credible.

Each institution is asked to provide comments on its assessment visit to the Assessment and Certification Committee through the Assessment Visit Questionnaire, in order to assist the committee in pursuing its goal of improving the Assessment and Certification Program.

The senior administrative officer of the institution shall be requested to provide an implementation report in writing to CCAC within six months for Regular recommendations, within three months for Serious recommendations, and within a suitably short time frame for any Major recommendations (the time frame will be specified by the CCAC depending on the subject of the recommendation). Th(ese)is implementation report(s) will be circulated to assessment panel members and to the Assessment and Certification Committee for information and comment. The CCAC, through its Assessment and Certification Committee, will then assign a status to the institution, based on the implementation report(s).

Occasionally a panel member may have a serious concern which is not shared by the rest of the panel, despite attempts to arrive at a consensus (as described in point A 3. c) x)). In an extreme situation, that member may submit a minority report, a copy of which must be forwarded to the Assessment and Certification Committee which will ensure that it is sent to the institution together with the final assessment report. The institution will not be required to respond to a minority report.

Where it may seem advisable, a panel may decide to submit a letter to the senior administrative officer concerned, drawing attention to a matter(s) which is considered to require immediate attention, and which has resulted in a Major or Serious recommendation, prior to the submission of the full, formal report. A copy of any such letter will be attached to the full assessment report.

The Council is responsible for notifying the granting agencies of institutions that are in Non-compliance with CCAC guidelines.

The assessment report should be concise, and contain the following while avoiding unnecessary descriptive passages.

  1. General Remarks:
    1. report on initial meeting with ACC and executive officers;
    2. comment on the ACC and its effectiveness, and the adequacy of the animal care program;
    3. outline other matters discussed, if pertinent;
    4. outline laudatory comments as well as concerns.
  2. Site Visits:
    1. describe these by their administrative or geographical units where possible;
    2. indicate what action, if any, has been taken on specific recommendations for that unit contained in the previous report;
    3. avoid focusing on small or unimportant details;
    4. include observations on apparent inefficient use of facility and/or questionable practices which seem likely to affect standards of animal care;
    5. commend excellence where it exists;
    6. comment on discussions with investigators/teachers, particularly on favorable techniques and those that exhibit a high degree of sensitivity and concern for the animals they use;
    7. comment on matters of special concern in the treatment of animals.
  3. Recommendations:

    Categorize the recommendations according to the following definitions:

    1. Major: Apply to deficiencies in an animal care and use program that demand immediate appropriate action by the institution and where failure to take such action would further jeopardize animal welfare and could place the institution in a status of Non-compliance;
    2. Serious: Apply to deficiencies in an animal care and use program that must be addressed expeditiously in order for the institution to comply with CCAC guidelines. The institutional actions taken, or planned, in response to these recommendations must be specified in an implementation report to the CCAC within three months of receipt of the CCAC report;
    3. Regular: Apply to lesser deficiencies in the animal care and use program that must be addressed, but that normally can be accommodated within the routine program. Such recommendations should be implemented prior to the next scheduled assessment; The institutional actions taken, or planned, in response to these recommendations must be specified in an implementation report to the CCAC within six months of receipt of the CCAC report;
    4. Minor: Apply to changes aimed at enhancing an already acceptable or even commendable animal care and use program;
    5. Commendatory: Apply to excellent conditions, practices or personnel in an animal care and use program.

G. Acknowledgement

The credibility of the entire CCAC Assessment and Certification Program is dependent upon the performance of its assessment panels. The Canadian Council on Animal Care is deeply appreciative of its panels' contribution of time and effort in helping to fulfil the mandate of the CCAC.

 

Revised March 1999