1. Accreditation of Medical Schools in North America

2. Premières accréditations début XXeme siècle
AMA
Council on medical education
Poor state of medical education
Carnegie foundation
Abraham Flexner

3. Abraham Flexner Educator Louisville college Influenced by:
Medical education in Europe (Germany)
John Hopkins medical school
Visited all 155 medical schools in US and Canada (with a delegate from AMA)

4. Johns Hopkins Baltimore Banker
1874: →7 millions to create a University and a hospital
« Each medical school must be in a University environment and be closely linked to an excellent hospital to treat, teach and do research»

5. Johns Hopkins medical school turning point in medical education in America
Student selection:
Pre requisite: basic sciences (2 years)
Admission tests
Curriculum
Scientific method
Basic sciences
Bedside clinical teaching
Interaction Faculty of medicine/hospital

6. Flexner report 155 medical schools (US & Canada)
Criteria: (inspired by Johns Hopkins)
Student selection
Program: 2+2
Full time faculty
Laboratories
Teaching hospitals linked to medical school

7. Rapport Flexner results
155 medical schools (US & Canada)
Only 5 considered « adequate »
Overproduction of inadequately educated doctors
Mediocre medical schools, many private « for profit »
Poor quality of medical education
Recommendations
Closure of several medical schools, mergers
Chicago: 15 écoles  3
Louisville: 7 écoles  1
155 → 80 medical schools

8. « Flexner report »

9. Flexner (1910) recommendations
Student selection
2 years of « science »
Admission tests
Scientific methodology
Bedside clinical teaching
Curriculum: 4 years
2 years: basic sciences
2 years: clinical sciences
Ressources:
Full time Faculty
Laboratories, library
Teaching hospitals

10. Flexner Report application
Rockefeller foundation: 50 millions de dollars for medical schools which « follow Johns Hopkins example » (apply Flexner’s recommendations)
Prediction: « Medical Education in North American will move from the lowest level in the civilized world, to the highest level » (Flexner)

11. Medical education in North America
Pre-Flexner
Schools of medicine
Private, «for profit», physician owned
No basic science – no labs
Learning by following a practicing physician with no university affiliation
Students not evaluated at the end

12. Medical education in North America
After Flexner
Student selection
Full time faculty
Structured curriculum(2+2 curriculum)
Basic sciences
Clinical sciences
Laboratories
Teaching hospitals

13. Flexner report Credibility Known standards Compulsory Consequences
Negative
Positive $$$

14. Accreditation of medical schools why?
compliance with international standards
Produce « adequate » physicians
Quality control and quality improvement
Governments:
Needs (population and health care system)
Students:
Fit to practice and respond to the needs
Mobility

15. ECFMG announcement (2010)
The Educational Commission for Foreign Medical Graduates (ECFMG®) has announced that, effective in 2023, physicians applying for ECFMG Certification will be required to graduate from a medical school that has been appropriately accredited.
To satisfy this requirement, the physician’s medical school must be accredited through a formal process that uses criteria comparable to those established for U.S. medical schools by the Liaison Committee on Medical Education (LCME) or that uses other globally accepted criteria, such as those put forth by the World Federation for Medical Education (WFME).

16. ACCREDITING THE ACCREDITORS
WFME
ACCREDITING THE ACCREDITORS

17. WFME recognition of accrediting agency criteria
Authority :
Recognized by gov or entity authorized to accredit
Standards
Available , Type, Periodical review
Process:
Self study, site visit, report
Role of the students
Policy
Conflicts of interest, independence
Procedure: appeals process,availability of information

18. Standards LCME (1942) www.lcme.org

19. Educating doctors for a future global role in Health Care
Medical education has a regrettable history of producing doctors fit for the past, and perhaps for the present, but not for the future
S Lindgren & D Gordon – Medical Teacher 33:551,2011

20. competency-based education competency-based curriculum
objectives
competencies
objectives ≠
outcomes
competency ≈
competency-based education
competency-based curriculum
competency-based assessment
outcome-based education
outcome-based assesment
learning outcome
learning objectives

21.  Teaching Evaluation Learning outcome Outcome-based education
Outcome-based assessment
Institutions
(Policies)
Programs
(Curriculum)
Process
(Interventions)
Teaching 
Evaluation
Learning outcome
Knowledge
(what he knows)
Competencies
(what he can do)
Performance
(what he does)
Consequences, results, impact

22. Professional Competencies Professional Practice? ? ?
Teaching Training
Professional Competencies
Professional Practice
HEALTH
Program evaluation
Quality control
Professional Certification
Licence to practice
Practice evaluation
Recertification

23. Mission General statement: « why was the medical school created? »
what does the society expect from us?
Includes a reference to:
Universal values (integrity, respect, non discrimination, ethics…)
Social accountability
Values of health care system (quality,equity, efficiency, pertinence)

24. Mission – institutional objectives
How does the medical respond to the mission
General objectives (desired outcomes)
Specific objectifs
Precise, operational, verifiable

25. Mission statement What do we do? How do we do it?
For whom do we do it?
What values are we bringing?

26. Mission – Institutional objectives
If you don’t know where you’re going, any road will do.
White Rabbit in ‘Alice in Wonderland’, Lewis Carroll and George Harrison

27. Evaluation/accreditation
Preparation
Self study
Site visit
Report
Follow up

28. not- Self study Description Analysis Recommend. Description Analysis

29. Evaluation/accreditation
have two objectives
Quality improvement
Quality control

30. LCME-Current Accreditation Standards
132 standards organized into 5 categories:
Institutional setting
Educational program
Medical students
Faculty
Resources for the educational program

31. Summary Survey Team Findings
During the visit, the survey team will identify:
Areas of strength Particularly noteworthy areas that contribute in a major way to the achievement of the school’s mission or that could serve as models
Areas in compliance with monitoring 1) A medical education program has the policy, process, resource, or system required by a standard but there is insufficient evidence to indicate that it is effective; or 2) A medical education program currently is in compliance with a standard, but known circumstances exist that could lead to future noncompliance
Areas of noncompliance

32. USA Canada AMA CMA AFMC AAMC 1942
LCME: Liaison Committee on Medical Education
1979
CACMS: Committee on Accreditation of Canadian Medical Schools
CACMS
CMA
AFMC
LCME
AMA
AAMC

33. Phase of Education Accreditation Body
-Committee on Accreditation of Continuing Medical Education
-Royal College of Physicians and Surgeons of Canada
-College of Family Physicians of Canada
Practice (CME)
PGME: 2 – 7 years
UGME: 4 years
-Royal College of Physicians and Surgeons of Canada
-College of Family Physicians of Canada
MD Degree
-Committee on Accreditation of Canadian Medical Schools

34. Common citations (Educational program)
The directors of all courses and clerkships must design and implement a system of formative and summative evaluation of student achievement in each course and clerkship.
ED-33 (6)
There must be integrated institutional responsibility for the overall design, management, and evaluation of a coherent and coordinated curriculum.
ED-31 (5)
Each student should be evaluated early enough during a unit of study to allow time for remediation.
Quality Improvement – Addressing the Standards

35. Example from a recent CACMS survey
NON COMPLIANCE
ED-3. The objectives of a medical education program must be made known to all medical students and to the faculty, residents, and others with direct responsibilities for medical student education and assessment.
Finding: At the site visit, the majority of medical students interviewed were not aware of the overall education program objectives.
Quality Improvement – Addressing the Standards

36. There exists a basic standard for accreditation of a medical school

37. WFME global standards Basic medical education
AREAS : broad components in the process, structure, content, outcomes/competencies, assessment and learning environment of basic medical education and cover:
1. Mission and outcomes
2. Educational program
3. Assessment of students
4. Students
5. Academic staff/faculty
6. Educational resources
7. Program evaluation
8. Governance and administration
9. Continuous renewal
SUB-AREAS :specific aspects of an area, corresponding to performance indicators.
STANDARDS :specified for each sub-area using two levels of attainment:

38. WFME global standards Basic medical education
AREAS : broad components in the process, structure, content, outcomes/competencies, assessment and learning environment of basic medical education and cover:
SUB-AREAS :specific aspects of an area, corresponding to performance indicators.
STANDARDS :specified for each sub-area using two levels of attainment:
Basic standards “must”
Standards for quality improvement “should”

39. Social accountability of medical schools

40. Definition of social responsibility
social responsibility & accountability
Definition of social responsibility
...the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have the mandate to serve.
World Health Organization, 1995 “

41. Global consensus for social accountability

42. 1. Consultation (Delphi) – 2008 2. Meeting East London, SA – 2010 3
1. Consultation (Delphi) – Meeting East London, SA – Implementation

43. GCSA AREA 1: ANTICIPATING SOCIETY’S HEALTH NEEDS
AREA 2: PARTNERING with the HEALTH SYSTEM and other STAKEHOLDERS
AREA 3: ADAPTING to the EVOLVING ROLES OF DOCTORS and other HEALTH PROFESSIONALS
AREA 4: FOSTERING OUTCOME-BASED EDUCATION
AREA 5: CREATING RESPONSIVE and RESPONSIBLE GOVERNANCE of the MEDICAL SCHOOL
AREA 6: REFINING the SCOPE of STANDARDS for EDUCATION, RESEARCH and SERVICE DELIVERY
AREA 7: SUPPORTING CONTINUOUS QUALITY IMPROVEMENT in EDUCATION, RESEARCH and SERVICE DELIVERY
AREA 8: ESTABLISHING MANDATED MECHANISMS for ACCREDITATION
AREA 9: BALANCING GLOBAL PRINCIPLES with CONTEXT SPECIFICITY
AREA 10: DEFINING the ROLE of SOCIETY

44. Global consensus

45. Social obligation scale
Boelen C, Woollard R. The extra leap to excellence for educational institutions Medical Teacher, Vol 33, N°8, 2011

46. Social Accountability of Canadian Medical Education
Obligation for medical schools to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. WHO, 1995

47. 1. Vision for Health Care Providers
Health Canada and AFMC, 2010
10 recommendations
5 enabling recommendations
Several addressed social accountability mandate of medical schools

48. 1. Address Individual and Community Needs
Social responsibility and accountability are core values underpinning the roles of Canadian physicians and Faculties of Medicine. This commitment means that, both individually and collectively, physicians and faculties must respond to the diverse needs of individuals and communities throughout Canada, as well as meet international responsibilities to the global community.

49. What is excellence in a university?
What is excellence in a medical school?

50. Ignoring teaching in the rankings has serious implications“
The myopia of
rankings – focusing on competitive research and less on teaching and learning – is well known.
Dirk Van Damme, Head of the Centre for Educational Research and Innovation at the Organisation for Economic Cooperation and Development. Times Higher Education, 16 September 2010

51. Ignoring teaching in the rankings has serious implications“
The bias in the information base of existing rankings towards research outcomes could detract from efforts to improve educational performance.
The Organisation for Economic Cooperation and Development (OECD)

52. The ASPIRE programme Accreditation of a medical school
We need both accreditation of basic standards and recognition of excellence
Accreditation of
a medical school
and basic standards
Recognition of excellence in education in a medical school
The ASPIRE programme
International Recognition of Excellence in Medical Education

53. Tewfik Nawar Emeritus professor Faculty of medicine, Sherbrooke university Sherbrooke, Quebec, Canada