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Dalseg TR, Thoma B, Wycliffe-Jones K, Frank JR, Taber S. Enabling Implementation of Competency Based Medical Education through an Outcomes-Focused Accreditation System. PERSPECTIVES ON MEDICAL EDUCATION 2024; 13:75-84. [PMID: 38343559 PMCID: PMC10854411 DOI: 10.5334/pme.963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/08/2023] [Indexed: 02/15/2024]
Abstract
Competency based medical education is being adopted around the world. Accreditation plays a vital role as an enabler in the adoption and implementation of competency based medical education, but little has been published about how the design of an accreditation system facilitates this transformation. The Canadian postgraduate medical education environment has recently transitioned to an outcomes-based accreditation system in parallel with the adoption of competency based medical education. Using the Canadian example, we characterize four features of an accreditation system that can facilitate the implementation of competency based medical education: theoretical underpinning, quality focus, accreditation standards, and accreditation processes. Alignment of the underlying educational theories within the accreditation system and educational paradigm drives change in a consistent and desired direction. An accreditation system that prioritizes quality improvement over quality assurance promotes educational system development and progressive change. Accreditation standards that achieve the difficult balance of being sufficiently detailed yet flexible foster a high fidelity of implementation without stifling innovation. Finally, accreditation processes that recognize the change process, encourage program development, and are not overly punitive all enable the implementation of competency based medical education. We also discuss the ways in which accreditation can simultaneously hinder the implementation of this approach. As education bodies adopt competency based medical education, particular attention should be paid to the role that accreditation plays in successful implementation.
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Affiliation(s)
- Timothy R. Dalseg
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
- Royal College of Physicians and Surgeons of Canada, Ottawa, ON, Canada
- Toronto General Hospital, 200 Elizabeth Street, R. Fraser Elliott Building, Ground Floor, Room 480, Toronto, ON M5G 2C4, (416) 833-0121; Canada
| | - Brent Thoma
- Royal College of Physicians and Surgeons of Canada, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Keith Wycliffe-Jones
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason R. Frank
- Centre for Innovation in Medical Education, University of Ottawa, Ottawa, ON, Canada
| | - Sarah Taber
- Royal College of Physicians and Surgeons of Canada, Ottawa, ON, Canada
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O'Bryan G, Ensminger A, Billah I, Sithole E, Nghatanga M, Brandt L, Shepard M, Aupokolo M, Mengistu AT, Forster N, Zemburuka B, Mutandi G, Barnhart S, O'Malley G, Feldacker C. Implementing quality management strategies improves clinical quality as a voluntary medical male circumcision program in Namibia matures: a process analysis. BMC Health Serv Res 2023; 23:1044. [PMID: 37773121 PMCID: PMC10543846 DOI: 10.1186/s12913-023-10016-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/11/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Surgical voluntary medical male circumcision (VMMC) is a safe procedure; however, maintaining quality standards at scale, particularly during scale-up, is a challenge making ongoing quality management (QM) efforts essential. This study describes program quality measured by rates of adverse events (AEs) over four years of VMMC implementation in Namibia, compares AE rates over time, and discusses QM processes that contextualize AE trends and illustrate improvements in quality as the program matured. The International Training and Education Center for Health (I-TECH) assisted the Namibian Ministry of Health and Social Services (MoHSS) in expanding VMMC in three regions among boys and men over 10 years of age between January 2015 and September 2019. METHODS A comprehensive package of QM strategies was implemented by multi-disciplinary onsite teams with support from national and international technical advisors. Retrospective routine MoHSS data from the VMMC register, client forms, and monthly AE reports were collected during implementation in the three regions to assess the impact of QM interventions on AEs and to calculate the proportion of clients who experienced AEs over time. The proportion of clients who experienced an AE over time was compared using a Cochran-Armitage test for trend. RESULTS Between January 2015 and September 2019, 40,336 clients underwent VMMC and 593 (1.5%) clients experienced a post-operative AE in the three supported regions. The AE rate was highest in the first quarter of clinical service delivery in each region (January-March 2015 in Oshana and Zambezi, October-December 2017 in //Kharas) but declined over the implementation period as the program matured. This observed trend between program maturity and declining AE rates over time was significant (p < 0.001) when compared using a Cochran-Armitage test for trend. CONCLUSIONS As the I-TECH-supported VMMC program matured, QM measures were introduced and routinized, and clinical quality improved over time with the rate of AEs decreasing significantly over the implementation period. Applying systematic and continuous QM processes and approaches across the continuum of VMMC services and considering local context can contribute to increased clinical safety. QM measures that are established in more mature program sites can be quickly adopted to respond to quality issues in program expansion sites.
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Affiliation(s)
- Gillian O'Bryan
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Alison Ensminger
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Idel Billah
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Edwin Sithole
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Magdaleena Nghatanga
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Laura Brandt
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Mark Shepard
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Mekondjo Aupokolo
- Directorate of Special Programmes-Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Norbert Forster
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Brigitte Zemburuka
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Gram Mutandi
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Gabrielle O'Malley
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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Pinnell J, Tranter A, Cooper S, Whallett A. Postgraduate medical education quality metrics panels can be enhanced by including learner outcomes. Postgrad Med J 2020; 97:690-694. [PMID: 33184130 DOI: 10.1136/postgradmedj-2020-138669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 07/16/2020] [Accepted: 09/30/2020] [Indexed: 11/04/2022]
Abstract
Postgraduate medical education (PME) quality assurance at Health Education England (HEE) currently relies upon survey data. As no one metric can reflect all aspects of training, and each has its limitations, additional metrics should be explored. At HEE (West Midlands), we explored the use of learner outcomes, speciality examination pass rates and Annual Review of Competence Progression (ARCP) outcomes, as quality metrics. Feedback received from our local Quality Forum of 40 senior educators frames the discussion through this paper. Overall, learner outcomes are useful quality metrics that add to survey data to provide a more comprehensive picture of PME quality. However, the utility of ARCP outcomes as quality metrics is currently limited by concerns regarding variations in ARCP practice between regions. To address these concerns, ARCPs need the same processes, rigour, scrutiny and investment as other high-stakes assessments. This will improve the reliability and validity of the ARCP as an assessment and improve the usefulness of ARCP outcomes as quality metrics. Research is required to determine the optimal combination of metrics to use in PME quality assurance and to appraise the validity and reliability of the ARCP as an assessment.
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Affiliation(s)
- Jonathan Pinnell
- Quality and Commissioning Team, Health Education England West Midlands, Edgbaston, UK .,Rheumatology, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Andrew Tranter
- Quality and Commissioning Team, Health Education England West Midlands, Edgbaston, UK
| | - Sarah Cooper
- Quality and Commissioning Team, Health Education England West Midlands, Edgbaston, UK
| | - Andrew Whallett
- Deputy Postgraduate Dean, Health Education England West Midlands, Edgbaston, UK
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Taber S, Akdemir N, Gorman L, van Zanten M, Frank JR. A "fit for purpose" framework for medical education accreditation system design. BMC MEDICAL EDUCATION 2020; 20:306. [PMID: 32981517 PMCID: PMC7520946 DOI: 10.1186/s12909-020-02122-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Accreditation is a key feature of many medical education systems, helping to ensure that programs teach and assess learners according to applicable standards, provide optimal learning environments, and produce professionals who are competent to practise in challenging and evolving health care systems. Although most medical education accreditation systems apply similar standards domains and process elements, there can be substantial variation among accreditation systems at the level of design and implementation. A discussion group at the 2013 World Summit on Outcomes-Based Accreditation examined best practices in health professional education accreditation systems and identified that the literature examining the effectiveness of different approaches to accreditation is scant. Although some frameworks for accreditation design do exist, they are often specific to one phase of the medical education continuum. MAIN TEXT This paper attempts to define a framework for the operational design of medical education accreditation that articulates design options as well as their contextual and practical implications. It assumes there is no single set of best practices in accreditation system development but, rather, an underlying set of design decisions. A "fit for purpose" approach aims to ensure that a system, policy, or program is designed and operationalized in a manner best suited to local needs and contexts. This approach is aligned with emerging models for education and international development that espouse decentralization. CONCLUSION The framework highlights that, rather than a single best practice, variation among accreditation systems is appropriate provided that is it tailored to the needs of local contexts. Our framework is intended to provide guidance to administrators, policy-makers, and educators regarding different approaches to medical education accreditation and their applicability and appropriateness in local contexts.
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Affiliation(s)
- Sarah Taber
- Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
| | - Nesibe Akdemir
- OLVG Teaching Hospital, Amsterdam, Netherlands
- VU Medical Center, School of Medical Sciences, Amsterdam, Netherlands
| | - Lisa Gorman
- Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
| | - Marta van Zanten
- Foundation for Advancement of International Medical Education and Research, Philadelphia, PA USA
| | - Jason R. Frank
- Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
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Frank JR, Taber S, van Zanten M, Scheele F, Blouin D. The role of accreditation in 21st century health professions education: report of an International Consensus Group. BMC MEDICAL EDUCATION 2020; 20:305. [PMID: 32981519 PMCID: PMC7520947 DOI: 10.1186/s12909-020-02121-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Accreditation is considered an essential ingredient for an effective system of health professions education (HPE) globally. While accreditation systems exist in various forms worldwide, there has been little written about the contemporary enterprise of accreditation and even less about its role in improving health care outcomes. We set out to 1) identify a global, contemporary definition of accreditation in the health professions, 2) describe the relationship of educational accreditation to health care outcomes, 3) identify important questions and recurring issues in twenty-first century HPE accreditation, and 4) propose a framework of essential ingredients in present-day HPE accreditation. METHODS We identified health professions accreditation leaders via a literature search and a Google search of HPE institutions, as well as by accessing the networks of other leaders. These leaders were invited to join an international consensus consortium to advance the scholarship and thinking about HPE accreditation. We describe the consensus findings from the International Health Professions Accreditation Outcomes Consortium (IHPAOC). RESULTS We define accreditation as the process of formal evaluation of an educational program, institution, or system against defined standards by an external body for the purposes of quality assurance and enhancement. In the context of HPE, accreditation is distinct from other forms of program evaluation or research. Accreditation can enhance health care outcomes because of its ability to influence and standardize the quality of training programs, continuously enhance curriculum to align with population needs, and improve learning environments. We describe ten fundamental and recurring elements of accreditation systems commonly found in HPE and provide an overview of five emerging developments in accreditation in the health professions based on the consensus findings. CONCLUSIONS Accreditation has taken on greater importance in contemporary HPE. These consensus findings provide frameworks of core elements of accreditation systems and both recurring and emerging design issues. HPE scholars, educators, and leaders can build on these frameworks to advance research, development, and operation of high-quality accreditation systems worldwide.
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Affiliation(s)
- Jason R. Frank
- Office of Specialty Education, Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Sarah Taber
- Office of Specialty Education, Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
| | - Marta van Zanten
- Foundation for Advancement of International Medical Education and Research, Philadelphia, PA USA
| | - Fedde Scheele
- OLVG Teaching Hospital, Amsterdam, The Netherlands
- VU Medical Center, School of Medical Sciences, Amsterdam, The Netherlands
- Athena Institute for Transdisciplinary Research, Amsterdam, The Netherlands
| | - Danielle Blouin
- Department of Emergency Medicine, Queen’s University, Kingston, Canada
| | - on behalf of the International Health Professions Accreditation Outcomes Consortium
- Office of Specialty Education, Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
- Foundation for Advancement of International Medical Education and Research, Philadelphia, PA USA
- OLVG Teaching Hospital, Amsterdam, The Netherlands
- VU Medical Center, School of Medical Sciences, Amsterdam, The Netherlands
- Athena Institute for Transdisciplinary Research, Amsterdam, The Netherlands
- Department of Emergency Medicine, Queen’s University, Kingston, Canada
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Akdemir N, Peterson LN, Campbell CM, Scheele F. Evaluation of continuous quality improvement in accreditation for medical education. BMC MEDICAL EDUCATION 2020; 20:308. [PMID: 32981518 PMCID: PMC7520980 DOI: 10.1186/s12909-020-02124-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Accreditation systems are based on a number of principles and purposes that vary across jurisdictions. Decision making about accreditation governance suffers from a paucity of evidence. This paper evaluates the pros and cons of continuous quality improvement (CQI) within educational institutions that have traditionally been accredited based on episodic evaluation by external reviewers. METHODS A naturalistic utility-focused evaluation was performed. Seven criteria, each relevant to government oversight, were used to evaluate the pros and cons of the use of CQI in three medical school accreditation systems across the continuum of medical education. The authors, all involved in the governance of accreditation, iteratively discussed CQI in their medical education contexts in light of the seven criteria until consensus was reached about general patterns. RESULTS Because institutional CQI makes use of early warning systems, it may enhance the reflective function of accreditation. In the three medical accreditation systems examined, external accreditors lacked the ability to respond quickly to local events or societal developments. There is a potential role for CQI in safeguarding the public interest. Moreover, the central governance structure of accreditation may benefit from decentralized CQI. However, CQI has weaknesses with respect to impartiality, independence, and public accountability, as well as with the ability to balance expectations with capacity. CONCLUSION CQI, as evaluated with the seven criteria of oversight, has pros and cons. Its use still depends on the balance between the expected positive effects-especially increased reflection and faster response to important issues-versus the potential impediments. A toxic culture that affects impartiality and independence, as well as the need to invest in bureaucratic systems may make in impractical for some institutions to undertake CQI.
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Affiliation(s)
- Nesibe Akdemir
- OLVG Teaching Hospital, Amsterdam, the Netherlands
- Amsterdam UMC, Amsterdam, the Netherlands
| | - Linda N. Peterson
- Committee on Accreditation of Canadian Medical Schools, Ottawa, Canada
| | | | - Fedde Scheele
- OLVG Teaching Hospital, Amsterdam, the Netherlands
- Amsterdam UMC, Amsterdam, the Netherlands
- Athena Institute for Transdisciplinary Research, Amsterdam, the Netherlands
- Dutch Royal Medical Council, Chair Legislative College for Accreditation of Residency Training 2016–2019, Utrecht, the Netherlands
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van der Aa JE, Aabakke AJM, Ristorp Andersen B, Settnes A, Hornnes P, Teunissen PW, Goverde AJ, Scheele F. From prescription to guidance: a European framework for generic competencies. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2020; 25:173-187. [PMID: 31451981 PMCID: PMC7018687 DOI: 10.1007/s10459-019-09910-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/09/2019] [Indexed: 06/01/2023]
Abstract
In postgraduate medical education, required competencies are described in detail in existing competency frameworks. This study proposes an alternative strategy for competency-based medical education design, which is supported by change management theories. We demonstrate the value of allowing room for re-invention and creative adaptation of innovations. This new strategy was explored for the development of a new generic competency framework for a harmonised European curriculum in Obstetrics and Gynaecology. The generic competency framework was developed through action research. Data were collected by four European stakeholder groups (patients, nurses, midwives and hospital boards), using a variety of methods. Subsequently, the data were analysed further in consensus discussions with European specialists and trainees in Obstetrics and Gynaecology. These discussions ensured that the framework provides guidance, is specialty-specific, and that implementation in all European countries could be feasible. The presented generic competency framework identifies four domains: 'Patient-centred care', 'Teamwork', 'System-based practice' and 'Personal and professional development'. For each of these four domains, guiding competencies were defined. The new generic competency framework is supported by European specialists and trainees in Obstetrics and Gynaecology, as well as by their European stakeholders. According to change management theories, it seems vital to allow room for re-invention and creative adaptation of the competency framework by medical professionals. Therefore, the generic competency framework offers guidance rather than prescription. The presented strategy for competency framework development offers leads for implementation of competency-based medical education as well as for development of innovations in postgraduate medical education in general.
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Affiliation(s)
- Jessica E van der Aa
- Department of Research and Education, OLVG Hospital, Amsterdam, The Netherlands.
- Athena Institute, Faculty of Science, VU, Amsterdam, The Netherlands.
| | - Anna J M Aabakke
- Department of Obstetrics and Gynaecology, Herlev University Hospital, Herlev, Denmark
- European Network of Trainees in Obstetrics and Gynaecology (ENTOG), Brussels, Belgium
| | - Betina Ristorp Andersen
- Department of Gynaecology and Obstetrics, North Zealand Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Annette Settnes
- Department of Gynaecology and Obstetrics, North Zealand Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Hornnes
- Department of Gynaecology and Obstetrics, North Zealand Hospital, University of Copenhagen, Copenhagen, Denmark
- European Board and College of Obstetrics and Gynaecology (EBCOG), Brussels, Belgium
| | - Pim W Teunissen
- Department of Obstetrics and Gynaecology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
- School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Angelique J Goverde
- European Board and College of Obstetrics and Gynaecology (EBCOG), Brussels, Belgium
- Department of Reproductive Medicine and Gynaecology, University Medical Centre, Utrecht, The Netherlands
| | - Fedde Scheele
- Department of Research and Education, OLVG Hospital, Amsterdam, The Netherlands
- Athena Institute, Faculty of Science, VU, Amsterdam, The Netherlands
- European Board and College of Obstetrics and Gynaecology (EBCOG), Brussels, Belgium
- Department of Obstetrics and Gynaecology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
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Affiliation(s)
- Nesibe Akdemir
- PhD Researcher, Department of Medical Education, OLVG Hospital, School of Medical Sciences, VU Medical Center, Amsterdam, the Netherlands
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Fishbain D, Danon YL, Nissanholz-Gannot R. Accreditation systems for Postgraduate Medical Education: a comparison of five countries. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2019; 24:503-524. [PMID: 30915642 DOI: 10.1007/s10459-019-09880-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 02/23/2019] [Indexed: 06/09/2023]
Abstract
There is a widespread consensus about the need for accreditation systems for evaluating post-graduate medical education programs, but accreditation systems differ substantially across countries. A cross-country comparison of accreditation systems could provide valuable input into policy development processes. We reviewed the accreditation systems of five countries: The United States, Canada, The United Kingdom, Germany and Israel. We used three information sources: a literature review, an online search for published information and applications to some accreditation authorities. We used template analysis for coding and identification of major themes. All five systems accredit according to standards, and basically apply the same accreditation tools: site-visits, annual data collection and self-evaluations. Differences were found in format of standards and specifications, the application of tools and accreditation consequences. Over a 20-year period, the review identified a three-phased process of evolution-from a process-based accreditation system, through an adaptation phase, until the employment of an outcome-based accreditation system. Based on the five-system comparison, we recommend that accrediting authorities: broaden the consequences scale; reconsider the site-visit policy; use multiple data sources; learn from other countries' experiences with the move to an outcome-based system and take the division of roles into account.
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Affiliation(s)
- Dana Fishbain
- Department of Health Management, School of Health Sciences, Ariel University, Ariel, Israel.
- The Scientific Council, Israeli Medical Association, POB 3566, 5213604, Ramat Gan, Israel.
| | - Yehuda L Danon
- Department of Health Management, School of Health Sciences, Ariel University, Ariel, Israel
| | - Rachel Nissanholz-Gannot
- Department of Health Management, School of Health Sciences, Ariel University, Ariel, Israel
- Myers-JDC-Brookdale Institute, Jerusalem, Israel
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Akdemir N, Ellwood DA, Walters T, Scheele F. Accreditation as a quality improvement tool: is it still relevant? Med J Aust 2018; 209:249-252. [DOI: 10.5694/mja17.00934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/12/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Nesibe Akdemir
- OLVG Hospital, Amsterdam, The Netherlands
- VU University Medical Center, Amsterdam, The Netherlands
| | - David A Ellwood
- Griffith University, Gold Coast, QLD
- Gold Coast University Hospital, Gold Coast, QLD
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