Using Accreditation to Transform Diversity, Equity, and Inclusion Efforts Into Diversity, Equity, and Inclusion Systems

Impacts of the Accreditation Process for Undergraduate Medical Schools: A Scoping Review

OBJECTIVE

The objective of this study is to identify, synthesize and communicate research findings; identify research gaps; and formulate recommendations for future research regarding the impact of the accreditation process on undergraduate medical schools around the world.

METHOD

This scoping review followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping reviews (PRISMA-ScR). The electronic search was performed up to March 2024 to identify studies that investigated the impact of the accreditation process on undergraduate medical schools. Two independent reviewers performed the selection process and extracted data from the included studies to perform a qualitative analysis.

RESULTS

The search identified 5148 references. After the selection process, 31 studies from 14 countries were included for data extraction. Studies highlighted five main themes: curricular and governance changes, continuous quality improvement, students' performance, school recognition and student satisfaction, and accreditation data sharing proposal. Three studies presented negative points related to accreditation process.

CONCLUSION

The accreditation process induced both positive impacts and negative burdens for undergraduate medical schools. Continuous quality improvement is a common element identified by studies to help stakeholders ensure that accreditation improves the quality of medical education and, consequently, the health care provided. Experiences with accreditation should be shared and reported to improve the quality of medical education worldwide. Future studies must be carried out with a clear description of the domains and criteria considered during the accreditation process as well as the outcome measures used.

Supporting Patient Involvement in U.S. Medical Education Through Changes in Accreditation

For over half of a century, there have been calls for greater patient and community involvement in U.S. medical education. Accrediting agencies, as the regulatory authorities for medical education, develop policies that impact every program in the U.S.; they have the ability to support patient involvement across the medical education system. In this article, we first review the requirements of U.S. accrediting agencies for undergraduate and graduate medical education to involve patients in educational programs. While agencies have patient members on their committees, they do little to encourage patient involvement through their standards or procedures. We then describe opportunities for accreditation to support patient involvement across teaching and learning activities, curriculum design and evaluation, policymaking and governance, and scholarly endeavors. We link these opportunities to specific standards that could be revised or have their data reporting requirements adjusted. U.S. agencies could also follow the examples of their counterparts outside the U.S., which have created new standards to encourage patient involvement. Ensuring patient representation on educational programs' governing and policymaking bodies is one among many immediate actions that could be taken by accrediting authorities to encourage system-level reforms. As medical school and residency training represent the beginnings of decades of practice for physicians, properly involving patients would maximize benefits for learners, educators, and society.

Compliance With Accreditation Standards on Diversity: Is Institutional Support the Missing Link?

INTRODUCTION

The role of accreditation standards in fostering diversity and inclusion in academic programs remains poorly understood. Accreditation is one approach to increasing diversity through Standard A1.11. This study investigates the impact of the Accreditation Review Commission-Physician Assistant (ARC-PA) standards on diversity and inclusion in physician assistant (PA) programs and explores challenges faced by programs in achieving compliance.

METHODS

This qualitative exploratory study first reviewed diversity standards in accreditation documents among selected health professions; second, data on the frequency of citations from ARC-PA related to diversity were gathered and analyzed; finally, opinions from 23 PA faculty and leaders were solicited through semistructured interviews. Two research team members analyzed the data to identify themes.

RESULTS

Most institutions sponsoring PA programs had preexisting diversity policies before the inception of standard A1.11 of the ARC-PA. Between June 2020 and March 2023, seven programs received 16 citations related to Standard A1.11. Interviews with faculty revealed 4 major themes: (1) the importance of institutional support, (2) early pipeline development of applicants, (3) prioritizing faculty and/or student diversity as key program goals, and (4) local context, with institutional support and pipeline development being most prominent.

DISCUSSION

The inclusion of Standard A1.11 in the ARC-PA Standards signifies the growing recognition of diversity, equity, and inclusion (DEI) in PA education. Institutions can advance DEI in the PA profession by leveraging accreditation-related activities through leadership, partnerships, and accountability measures consistent with the institution's mission and applicable laws. Institutional support emerged as an important factor in compliance with diversity-related accreditation standards.

Accreditation of medical education in Brazil: an evaluation of seventy-six medical schools

BACKGROUND

We present the first results of the Accreditation System of Medical Schools (Sistema de Acreditação de Escolas Médicas - SAEME) in Brazil.

METHODS

We evaluated the results of the accreditation of medical schools from 2015 to 2023. The self-evaluation form of the SAEME is specific for medical education programs and has eighty domains, which results in final decisions that are sufficient or insufficient for each domain. We evaluated the results of the first seventy-six medical schools evaluated by the SAEME.

RESULTS

Fifty-five medical schools (72.4%) were accredited, and 21 (27.6%) were not. Seventy-two (94.7%) medical schools were considered sufficient in social accountability, 93.4% in integration with the family health program, 75.0% in faculty development programs and 78.9% in environmental sustainability. There was an emphasis on SAEME in student well-being, with seventeen domains in this area, and 71.7% of these domains were sufficient. The areas with the lowest levels of sufficiency were interprofessional education, mentoring programs, student assessment and weekly distribution of educational activities.

CONCLUSION

Medical schools in Brazil are strongly committed to social accountability, integration with the national health system, environmental sustainability and student well-being programs. SAEME is moving from episodic evaluations of medical schools to continuous quality improvement policies.

The impact of accreditation on continuous quality improvement process in undergraduate medical education programs: A scoping review

Background

Accreditation in medical education has existed for more than 100 years, yet the impact of accreditation remains inconclusive. Some studies have shown the effects of accreditation on student outcomes and educational processes at medical schools. However, evidence showing the impact of accreditation on continuous quality improvement of undergraduate medical education programs is still in its infancy. This scoping review explores the impact of accreditation on continuous quality improvement (CQI).

Methods

This scoping review followed the methodology of the Preferred Reporting Items of Systematic Reviews and the Meta-Analysis extension for scoping reviews (PRISMA-ScR) checklist outlined by Arksey and O'Malley (2005). Databases, including PubMed, Medline, ERIC, CINHAL, and Google Scholar, were searched to find articles from 2000 to 2022 related to the accreditation of undergraduate medical education programs and continuous quality improvement.

Results

A total of 35 full-text articles were reviewed, and ten articles met our inclusion criteria. The review of the full-text articles yielded four themes: Accreditation and its standards in general, Accreditation and its impact on student outcomes, Accreditation and its impact on medical school's educational processes, Accreditation and CQI. However, the literature evidence suggesting the impact of accreditation on CQI is minimal. The quality assurance approach is based on meeting the standards of accreditation. The quality improvement approach is based on striving for excellence. Literature suggests a requirement to move from student outcomes to CQI measures. CQI requires everyone in the organization to take responsibility and accountability, considering quality as the result of every single step or process and leaders supporting improvements in data collection and data analysis for quality improvement.

Conclusions

The literature on accreditation and CQI are limited in number. More research studies are required to enhance undergraduate medical education accreditation practices' value to medical students, educators, academic leaders, programs, and the public. It was recommended that medical schools embrace the culture and vision perpetuated by the CQI process.

Strategies for recruiting underrepresented in medicine and sexual and gender minority students to emergency medicine

Background

Despite having well-described benefits, diversifying the physician workforce has been an ongoing challenge. Within emergency medicine (EM), multiple professional organizations have identified expanding diversity and inclusion as top priorities. The following is a description of an interactive session held at the SAEM annual meeting addressing recruitment strategies for underrepresented in medicine (URiM) and sexual and gender minority (SGM) students into EM.

Methods

During the session, the authors provided an overview of the current state of diversity in EM. In the small-group portion of the session, a facilitator helped characterize the challenges programs face in recruiting URiM and SGM students. These challenges were described during three distinct phases of the recruitment process: (1) preinterview, (2) interview day, and (3) postinterview.

Results

Our facilitated small-group session allowed for discussing the challenges faced by various programs in recruiting a diverse group of trainees. Common challenges in the preinterview and interview day included messaging and visibility as well as funding and support. Postinterview challenges included communication and the ranking process. Through this exercise, we were able to collaboratively share ideas on tangible solutions that programs may use to overcome their specific challenges.

Conclusions

Given the importance of intentionality in diversifying the physician workforce, the authors describe successful strategies implemented within one residency program and those shared by session participants to overcome recruitment challenges.

Perceptions of racism in a children's psychiatric inpatient unit: A qualitative study of entrenching and uprooting factors

WHAT IS KNOWN ON THE SUBJECT?: The impacts of racism on health are well documented and are greater for mental than for general health. Mental health professionals are well positioned to help dismantle racism and structural barriers compromising optimal patient care.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

We describe a systematic and orderly way to identify factors that contribute to entrenching racism as the status quo or that help to uproot it. By incorporating a racial equity lens, we can better understand daily racism and inform the optimal antiracist actions most relevant to an inpatient psychiatric setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our two-domain/six-theme model may serve as a rubric for individuals to engage in structured self-reflection, for organizations in auditing or programmatic evaluation, or as scaffolding for difficult but frequently elided conversations. The unique strengths of a mental health environment can be harnessed toward the elimination of racism and racist practices in clinical care and in the workplace ABSTRACT: INTRODUCTION: It is well documented that racism plays a role in health care access and outcomes. However, discussions about racism in the inpatient psychiatric workplace are generally avoided. To address this gap, we incorporated a racial equity perspective into a qualitative study to better understand daily racism, its impact on patients and staff, and to inform optimal antiracist actions most relevant to inpatient psychiatric settings.

AIM/QUESTION

We sought to identify factors that may contribute to or deter from racism to inform interventions to sustain a psychologically supportive environment for patients and staff.

METHODS

We conducted semistructured interviews using a purposive sample of 22 individuals in an acute child psychiatric inpatient service. We analysed transcripts using thematic analysis guided by a constructivist grounded theory conceptual framework.

RESULTS

We identified two countervailing processes: (1) Entrenching-factors that sustain or increase racism: Predisposing, Precipitating, and Perpetuating and (2) Uprooting-factors that rectify or reduce racism: Preventing, Punctuating, and Prohibiting. We organized each of the elements into a '6P' model along a temporal sequence around sentinel racist events. For each of the six components we describe: Contributing Factors, Emotional Reactions, and Behavioural Responses as reported by participants.

IMPLICATIONS FOR PRACTICE

Identifying factors that entrench or uproot racism can inform specific steps to improve the care of all children and families on an inpatient child psychiatry unit. The two-domain/six-theme model we developed can serve as a rubric for individuals or milieu-based inpatient settings serving patients of any age to engage in structured self-reflection, auditing, program evaluation, or as scaffolding for difficult but frequently elided conversations.

Meeting the Accreditation Standard for Diversity

ABSTRACT

While increasing diversity has been an ongoing concern in physician assistant (PA) education, there is now a concentrated focus on diversity, equity, inclusion, and social justice, elevating these to top priorities. To achieve the goal of diversifying the PA workforce, PA programs, with their institution's support, must systematically inculcate strategies for overcoming and dismantling barriers against students of color and students underrepresented in medicine (URiM). These strategies should disrupt the status quo and expand structural processes that ensure successful diversification of students, especially URiM students, LGBTQ students, students from medically underserved areas, and first-generation college students.

Trauma-Informed Care Curricula for the Health Professions: A Scoping Review of Best Practices for Design, Implementation, and Evaluation

PURPOSE

Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but best practices for TIC education remain unclear. To remedy this, the authors conducted a multidisciplinary scoping literature review to discern best practices for the design, implementation, and evaluation of TIC curricula for health care professionals.

METHOD

The research team searched Ovid MEDLINE, Cochrane Library, Elsevier's Scopus, Elsevier's Embase, Web of Science, and the PTSDpubs database from the database inception date until May 14, 2021. Worldwide English language studies on previously implemented TIC curricula for trainees or professionals in health care were included in this review.

RESULTS

Fifty-five studies met the inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma and responding to subsequent disclosures (41 studies [74.5%]), defining trauma (34 studies [61.8%]), and understanding trauma's impact on health (33 studies [60.0%]). Fifty-one of the studies included curricular evaluations, with the most common survey items being confidence in TIC skills (38 studies [74.5%]), training content knowledge assessment (25 studies [49.0%]), participant demographic characteristics (21 studies [41.2%]), and attitudes regarding the importance of TIC (19 studies [37.3%]).

CONCLUSIONS

Future curricula should be rooted in cultural humility and an understanding of the impacts of marginalization and oppression on individual and collective experiences of trauma. Moreover, curricula are needed for clinicians in more diverse specialties and across different cadres of care teams. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care professionals.

A Path Toward Equity and Inclusion: Establishing a DEI Committee in a Department of Pediatrics

The Diversity, Equity, and Inclusion (DEI) committee was established in 2017 within the Department of Pediatrics at Rush University Medical Center (RUMC), an academic medical health center located on the near west side of Chicago, IL. Results from climate surveys highlighted the need for increased DEI initiatives within the department, and a renewed national reckoning on racial tensions sparked an additional sense of urgency for system-level change. This paper outlines the initial creation and ongoing efforts of the DEI committee. Information related to the structure of our committee, aims of our work, progress toward identified goals, as well as ongoing barriers is provided. Academic medical health centers are tasked not only with working and training together, but also to care for a diverse group of patients within a larger community. As such, academic medical health centers represent a unique backdrop and opportunity for individual and system-level change.

Racial and Ethnic Differences in Internal Medicine Residency Assessments

Importance

Previous studies have demonstrated racial and ethnic inequities in medical student assessments, awards, and faculty promotions at academic medical centers. Few data exist about similar racial and ethnic disparities at the level of graduate medical education.

Objective

To examine the association between race and ethnicity and performance assessments among a national cohort of internal medicine residents.

Design, Setting, and Participants

This retrospective cohort study evaluated assessments of performance for 9026 internal medicine residents from the graduating classes of 2016 and 2017 at Accreditation Council of Graduate Medical Education (ACGME)-accredited internal medicine residency programs in the US. Analyses were conducted between July 1, 2020, and June 31, 2022.

Main Outcomes and Measures

The primary outcome was midyear and year-end total ACGME Milestone scores for underrepresented in medicine (URiM [Hispanic only; non-Hispanic American Indian, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Hispanic Black/African American]) and Asian residents compared with White residents as determined by their Clinical Competency Committees and residency program directors. Differences in scores between Asian and URiM residents compared with White residents were also compared for each of the 6 competency domains as supportive outcomes.

Results

The study cohort included 9026 residents from 305 internal medicine residency programs. Of these residents, 3994 (44.2%) were female, 3258 (36.1%) were Asian, 1216 (13.5%) were URiM, and 4552 (50.4%) were White. In the fully adjusted model, no difference was found in the initial midyear total Milestone scores between URiM and White residents, but there was a difference between Asian and White residents, which favored White residents (mean [SD] difference in scores for Asian residents: -1.27 [0.38]; P < .001). In the second year of training, White residents received increasingly higher scores relative to URiM and Asian residents. These racial disparities peaked in postgraduate year (PGY) 2 (mean [SD] difference in scores for URiM residents, -2.54 [0.38]; P < .001; mean [SD] difference in scores for Asian residents, -1.9 [0.27]; P < .001). By the final year 3 assessment, the gap between White and Asian and URiM residents' scores narrowed, and no racial or ethnic differences were found. Trends in racial and ethnic differences among the 6 competency domains mirrored total Milestone scores, with differences peaking in PGY2 and then decreasing in PGY3 such that parity in assessment was reached in all competency domains by the end of training.

Conclusions and Relevance

In this cohort study, URiM and Asian internal medicine residents received lower ratings on performance assessments than their White peers during the first and second years of training, which may reflect racial bias in assessment. This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder physician workforce diversity.

Performing in diverse settings: A diversity, equity, and inclusion approach to culture

Diversity, equity, and inclusion (DEI) are being built into the fabric of today’s organizations, and utilizing such a lens is vital to understanding cross-cultural performance. Yet, most of the culture and diversity literature has grown in silos and is therefore not leveraging the many benefits that their integration could provide. To counter this gap, we advance a theoretical framework featuring a new definition of cross-cultural performance (CCP) from a DEI perspective, as a new angle for doing work across cultures. Specifically, CCP is defined as the integration of multiple cultural perspectives of individuals who work together with the goal of enabling a diverse, inclusive, and equitable work environment. By applying the DEI lens to CCP, we elevate the meaning of performance due to added consideration of compositional differences, the possible barriers to employees’ success, and the extent to which others’ perspectives are indeed valued. Accordingly, our framework identifies three main components of CCP: catalyzing cultural differences, taking part in engaging communication, and promoting allyship activities. Furthermore, we specify emotional management as the glue of these three components, and key outcomes at different levels of analysis. Last, we discuss the implications of our framework to both theory and practice as well as directions for future research.