Systems of accreditation are frequently viewed by stakeholders (e.g. the public, health care administrators, policymakers) as effective mechanisms for ensuring the quality of basic medical education curricula and subsequent training programmes across the learning continuum. Accreditation can be defined as a process by which a designated authority reviews and evaluates, on a cyclical basis, an educational programme or institution using clearly specified criteria and procedures. A positive accreditation status is usually a governmental or professional body requirement, although in some instances the review is voluntarily requested by the administrators of the educational programme. To better elucidate the purpose and scope of accreditation activities, this section describes the current state of medical education accreditation in the USA and internationally. Next, literature is presented on the validity of accreditation systems, including associations between accreditation activities and doctor performance. Potential benefits and challenges that must be considered by an institution's administration in deciding whether to pursue an accreditation review are then outlined. Finally, because very little research in this field has been conducted to date, we discuss some of the unanswered questions concerning the value of accreditation, and highlight areas for further investigation.
Various organisations around the world accredit medical education and training programmes. In many countries, such as the majority in South America and some in Africa and Asia, accreditation organisations review higher education institutions as a whole. In other countries (e.g. Australia, Mexico, the UK), specialised agencies accredit specific professional education programmes, such as medicine. In some instances, multiple quality reviews are conducted by both types of agency. Accreditation authorities can be part of a country's government, such as an entity that is directly part of a ministry of education or health, or may be an independent body, the decisions of which are usually officially recognised at government level. Organisations can function at the provincial, national or cross-national (regional) level, and reviews can be mandatory or voluntary. An accreditation organisation's authority can be broad and encompass all medical education programmes in its jurisdiction, or be limited in scope, and cover only either public or private education programmes, institutions with a specific language of instruction, or institutions that meet certain other policy requirements.
Accreditation in the USA
In the USA, the Liaison Committee on Medical Education (LCME) is the nationally recognised accrediting authority for medical education programmes leading to the md degree in US and Canadian1 medical schools, and the Commission on Osteopathic College Accreditation (COCA) accredits schools granting the osteopathic (do) degree. The basic structures of the LCME and the COCA are functionally similar, although the LCME's accreditation standards are more expansive. A comparative analysis across the two sets of standards was conducted to determine if differences might affect the educational quality of md and do education, respectively. The authors found some variations, although they concluded that differences in accreditation standards are unlikely to be associated with any quality issues across the two professional degrees.
Graduate medical education (GME) is an essential part of the continuum of medical education in the USA. Upon graduation from medical school, doctors are eligible to apply for GME positions. Graduate medical education is frequently referred to as residency training, generally lasts 3–4 years depending on the area of specialisation, and is required to obtain a licence to practise medicine. Currently, the Accreditation Council for Graduate Medical Education (ACGME) is the overseeing body responsible for the quality assurance of allopathic GME, and the American Osteopathic Association (AOA) accredits osteopathic residency programmes. These organisations have recently announced that, as of 2015, there will be a single, unified accreditation system for GME programmes in the USA. The ACGME has identified six general competencies deemed essential for residency training: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism, and systems-based practice. Since the demarcation of these competencies, and the initiation of requirements for evaluating them, numerous investigations have attempted to measure their effectiveness. A meta-analysis of 56 studies reported mixed results, with the authors concluding that there was little evidence that most of the current measurement tools validly assessed the competencies independently of one another.
As of February 2013, the Directory of Organizations that Recognize/Accredit Medical Schools (DORA) maintained by the Foundation for Advancement of International Medical Education and Research (FAIMER) lists 104 countries with active systems of accreditation for basic medical education (out of 177 countries with currently operational medical schools). Of these countries, 42% (n = 44) have accreditation agencies that are specific to medical education, and 58% (n = 60) use agencies that accredit medical programmes as part of higher education institutions. It is important to note that the existence of an accreditation system in a country does not denote that all medical schools in that country are accredited, as the review is sometimes voluntary. In other cases, even where accreditation is mandatory, the system may be newly implemented or not yet fully operational.
Similar data regarding the global prevalence of medical education accreditation systems have been reported. A report based on a 1996 World Health Organization (WHO) survey of ministries of health and deans of medical schools indicated that almost two-thirds of medical schools were accredited by an external body, although detailed data describing these agencies or the various processes employed were not provided. Another global investigation of medical education accreditation found that although over half of all countries with medical schools have a national system of accreditation, the nature of the various authorities and levels of enforcement vary considerably. A study comparing medical education accreditation systems in nine developing countries located throughout the world concluded that the trend towards instituting robust quality assurance procedures was spreading to some developing countries, in which protocols similar to those used in the USA have been developed and implemented. Unfortunately, although the prevalence and characteristics of accreditation systems have been documented, there is relatively little evidence to quantify their utility with respect to improving education practices.
Validity of accreditation
Although there has been a recent worldwide focus on the overseeing of medical education quality assurance, there is limited published research demonstrating that accreditation activities are related to the ultimate goal of producing more highly skilled doctors, who, in turn, provide better patient care. The lack of research related to the value of accreditation is likely to reflect a number of methodological factors applicable across educational fields.[11, 12] For example, in medical education specifically, in many countries all programmes are accredited (usually based on the same criteria), which precludes within-country comparisons of performance of students or graduates from accredited and non-accredited programmes. In terms of the outcomes (e.g. performance on national licensing or specialty board certification examinations) of students who have attended schools in various countries or regions with or without accreditation systems, criteria such as admission standards, resources available to students and curriculum factors may differ widely across schools, making comparisons based solely on isolated accreditation variables difficult, and potentially biased. Here, more qualified students may simply choose to attend accredited institutions that are perceived to offer a better education. Most importantly, valid outcome measures (e.g. test results, disciplinary actions) that are comparable across schools, or practice settings, are not commonly available, or only available for a subset of students or graduates.
Despite these methodological difficulties, some investigations have shown that accreditation activities may improve medical education, at least in terms of the performance of students. In a study of Mexican and Philippine citizens seeking Educational Commission for Foreign Medical Graduates (ECFMG) certification, first-attempt pass rates on all components of the required US Medical Licensing Examination (USMLE) series were higher for individuals who had attended accredited medical schools, compared with their peers who had attended non-accredited schools. In another study of the performance of all graduates of international medical schools who took the USMLE Step 2 clinical skills (CS) examination during the 5-year (2006–2010) study period, accreditation was positively associated with the Step 2 CS first-attempt pass rate. The odds of a student or graduate of an accredited school passing Step 2 CS on his or her first attempt were 2.4 times greater for individuals from Caribbean medical schools, and 1.1 times greater for individuals from all other (non-Caribbean) medical schools, than the odds of a student or graduate from a non-accredited school passing the examination on the first attempt.
Although these studies include some data showing a positive association between accreditation activities and student success on examinations, additional markers of quality, including performance on other examinations taken later in the career (e.g. board certification) and actual patient care data are required. Without these, it is difficult to know whether accreditation processes have an appreciable, long-term impact on education programmes and, hence, the quality of those who graduate and eventually practise medicine. Given the many limitations of cross-sectional investigations, future work in this field should also include longitudinal studies for specific schools pre- and post-accreditation. Schools that can confirm marked increases in student performance on examinations, or other quality measures, after making the improvements required by an accreditation review may yield additional evidence to support the utility of rigorous quality assurance activities such as accreditation.
In addition to gathering data on the effects of the existence of accreditation systems, it is also important to investigate the components of accreditation, such as the specific standards used and protocols employed, that may enhance the quality of the education process. Whereas previous investigations focused on describing the existence and some general characteristics of accreditation systems, only a few studies, to our knowledge, have compared or assessed the effectiveness or appropriateness of the specific medical education standards used to make accreditation decisions.[16-18] Additional data demonstrating best practices in the development and implantation of protocols, and supporting the psychometric characteristics of the tools used to assess the effectiveness of the standards employed, are necessary to support the perceived value of accreditation as a means of assuring the quality of education programmes and fostering continued excellence. Unfortunately, until clear evidence is found linking accreditation activities and outcomes (e.g. patient care), it cannot be assumed that one type of system, mechanism or element of quality assurance is superior to another.
Although there is evidence, albeit limited, to support the value of accreditation of basic medical education programmes, some benefits of these systematic reviews may be manifest despite limited data showing marked improvement in student outcomes. For example, schools that are subject to a review are forced to prepare for the exercise, usually beginning many months, or years, in advance. Schools must examine their own quality assurance systems and determine their compliance with internal rules and regulations. They must ensure that all necessary policies have been created, disseminated and implemented. Even if a school does not ultimately pass the official accreditation assessment, it is likely to have made significant positive efforts to meet the requirements of the external review. Therefore, although this is difficult to quantify, the education programme should improve, thus producing more qualified graduates who are more likely to possess the knowledge and skills required for the delivery of effective patient care.
Accreditation decisions made by agencies around the world are usually considered credible and are accepted by stakeholders as meaningful and trustworthy. Nevertheless, because of a lack of transparency in the process, variability in methodology, or other issues related to a lack of standardisation across schools, the decisions can sometimes appear capricious and arbitrary. In order to address the need for a globally accepted system for ensuring the quality of accreditation systems themselves, the World Federation for Medical Education (WFME), in conjunction with FAIMER, has formulated policies and procedures for the recognition of agencies accrediting medical schools, an endeavour in meta-accreditation. Necessary documents and instruments have been created, and the system of recognition has been piloted with a regional accrediting agency in the Caribbean, the Caribbean Accreditation Authority for Education in Medicine and other Health Professions (CAAM-HP). Given that accreditation standards can vary by region, and can be applied with more or less rigour, it is important that organisations that provide accreditation services are subject to some sort of formal review. Without this, the comparability of accreditation decisions will be difficult to judge, making it even more problematic to ascertain the educational impact of any quality assurance initiatives.
Incentives for accreditation (cost/benefit)
Although accreditation systems do not exist in many countries and regions, and may be voluntary, there are frequently incentives in place to encourage medical education programmes to undergo an accreditation review. In the USA, the accreditation of basic medical education programmes is technically voluntary, but a school must be accredited in order for graduates to enter GME and obtain licensure to practise, a policy that effectively ensures that all schools must be accredited in order to function. In some cases of voluntary accreditation within a specific country that lacks these types of incentives linked to practice, accredited schools can still offer certain advantages to students. For example, in Mexico, students at accredited schools are provided with enhanced clinical clerkship opportunities compared with their peers at non-accredited institutions. For US citizens studying medicine outside the country, in order to be eligible to receive federally funded student loans, any foreign school attended must meet certain requirements, including accreditation by an agency that has met a comparability determination of the accreditation process. The purpose of the US Department of Education National Committee on Foreign Medical Education and Accreditation (NCFMEA) is to review the standards used by foreign countries to accredit medical schools and determine whether those standards are comparable with standards used to accredit medical schools in the USA. Thus, medical schools located outside the USA that seek to attract US citizen students are given incentives to seek accreditation by an agency that has been deemed comparable by the NCFMEA.
In other countries, such as India, obtaining accreditation by a voluntary agency (e.g. the National Assessment and Accreditation Council [NAAC]) in addition to the mandatory accreditation by the Medical Council of India (MCI) carries some prestige in a crowded field of medical education programmes. A school considering voluntary accreditation needs to weigh the direct cost of seeking the accreditation review and the costs associated with making the necessary changes dictated by the standards against the indirect value of obtaining a secondary accreditation status. Unfortunately, because of the programme evaluation difficulties noted earlier, namely the lack of meaningful outcome measures, it is difficult to provide an economic argument to support or discount accreditation activities. In addition, medical schools must consider the resources needed to meet and document standards. Faculty may be required to spend considerable time away from educational activities to fulfil accreditation obligations. Nevertheless, regardless of the specific motivations of institutions to seek accreditation, and the direct and indirect costs involved, there is an expectation that the net effect of meeting defined standards of education is positive, for both the students (in terms of education quality) and the institution.