Development of graduate medical education curriculum
The International Federation for Emergency Medicine (IFEM), through the Core Curriculum and Education Committee, has developed model curricula for Undergraduate (basic) Medical Education in Emergency Medicine (EM) [1], Graduate (postgraduate or specialist) Medical Education (GME) in Emergency Medicine [2] and Continuing Professional Development post training [3]. For GME, this provides the structure to assist in the development of a comprehensive training program for specialists in EM. In most countries, this is developed by a society or organization of specialists in EM. In line with these model curricula, the accreditation framework here provides a model for National EM societies to develop their own system of accreditation of training sites used as part of their GME program.
Purpose of accreditation
In the context of this document, accreditation refers to an official body giving authority or sanction to an individual, a training site or an organization when recognized standards have been met with respect to training for emergency medicine specialists.
In medical care, there are many areas where standards may be set by an official body. This can include standards of practice of an individual, standards with regards to the design and equipping of a health facility, standards of care provided or standards relating to the performance of a facility in whole or in part. Accreditation provides a process whereby the performance of an entity can be assessed against these standards and then appropriately recognized.
For a specialty such as EM, recognized by the appropriate official body in that jurisdiction, a GME curriculum in EM provides the pathway and standards with which to train and certify specialist practitioners. Training is provided through a combination of formalized teaching across a range of modalities and supervised clinical experience in an appropriate environment, such as a hospital emergency department. The supervision and teaching may be provided by members of the specialist organization or by other practitioners with suitable training and experience. Accreditation provides a quality assurance mechanism by which a specialist organization or other authority can assess and ensure optimal delivery of the teaching and training of the curriculum.
Standards and the accreditation based on these can be applied on a number of levels. The General Medical Council of the United Kingdom (GMC) described this through their Education Strategy and Quality Improvement Framework [4]. It is based on the principles of proportionality, accountability, consistency, transparency and targeting. In the GMC Quality Improvement Framework, the governance of the quality of training is described at three levels:
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Quality Assurance – this refers to “the policies, standards, systems and processes in place to maintain and enhance the quality of medical education and training.” This would normally be carried out by a national authority (such as a Department of Health or a national medical council) tasked with recognising specialties, medical schools, their curricula and training programs.
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Quality Management – this refers to the process used to accredit and monitor the performance of training sites (named “Local Education Providers” in the GMC Quality Improvement Framework). It should be based on appropriate standards set by the relevant body. Namely, that would be the organization responsible for defining the standards of the specialty in a jurisdiction (for example, a specialist EM organization).
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Quality Control – this refers to the role training sites have in ensuring they are delivering training that meets the standards set through the quality management process. This would be a responsibility of the senior education leaders, supervisors and trainers working at these training sites.
Aim of framework
The aim of this model framework is to describe an approach to accreditation at the “Quality Management” level described above. It specifically covers the accreditation of training sites, and should be able to be integrated with the other levels of quality improvement as required.
The World Federation for Medical Education (WFME) has produced a series of documents, “Global Standards for Quality Improvement” in medical education, referring to Basic Medical Education [5], Postgraduate Medical Education [6] and Continuing Professional Development (CPD) of Medical Doctors [7]. For those organizations seeking to undertake a “Quality Assurance” level process in the absence of established national standards and processes, these standards provide a useful starting point to assess such a training program.
The framework described here is primarily aimed at the “Quality Management” level as described above. It is derived from work done for the Accreditation of Specialist Medical Training Sites Project, commissioned by the Australian Health Ministers’ Advisory Committee (AHMAC) through its Health Workforce Principal Committee [8]. It consists of a hierarchy of Domains, Standards and Criteria that are applicable to training sites associated with any specialist training program. In describing the framework, examples that may apply to a specific EM specialist training program are included.
As well as describing the standards that need to be met for effective training, the framework also needs to include the authority under which the standards are applied, and the system that governs, assesses and monitors the accreditation process and its outcomes (for example, see Table 1 in Taber, et al.) [9].
Model framework
The model framework consists of a series of related elements:
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Domains, standards and criteria for accreditation.
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Governance and delivery of accreditation process.
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Accreditation teams – membership and training.
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Outcomes of accreditation.
Accreditation domains, standards, criteria
Table 1 lists model generic standards for training sites. Examples of how they might apply specifically to an EM training program are included. They also broadly align with the WFME Quality Improvement Standards for Postgraduate Medical Education [6], which are designed to apply to a national training program.
Areas such as selection and admission into training, formal teaching, or allocation of rotations may be the responsibility of the training site and/or the national training program. There should be relevant standards that apply to these areas for the national training program, or additional standards may need to be developed where these responsibilities rest with the training site.
As shown in the “EM Examples” column in Table 1, further guidance can be provided through examples or detail around the evidence required to demonstrate that the standards are being met.
Governance and delivery of accreditation
The governance and delivery of the training site accreditation includes the elements of accreditation standard development, development and supervision of accreditation processes, decisions on process outcomes and delivery of the accreditation process itself.
Development of accreditation standards
Whilst the model framework here provides suggested domains, standards and criteria for the accreditation of training sites, a national training program in a jurisdiction is expected to modify and potentially add to these such that they correctly align with the training structures at the national and local level, local EM models of care and any external clinical or regulatory requirements. Whilst there may be external frameworks and processes that can be used for local purposes, they should still be adapted to suit local needs and requirements. As these directly relate to the delivery of the curriculum, this would normally be done through the body responsible for overseeing the curriculum, such as a national EM specialty organization.
Other expected features include a clear statement of the intended scope and purpose of the accreditation process, general information for the facilities being accredited, definitions for any specific terminology that relates to the specialist program’s processes. Terminology that is understood and agreed in the wider context should be used wherever possible.
Development and supervision of accreditation process and decisions on outcomes
A committee or similar structure responsible for supervising the delivery of accreditation should be established. This committee may be within the body responsible for the national training program, or part of an external body specifically tasked with accreditation of training for one or more specialties. It should ideally include expertise on the curriculum, the delivery of accreditation, training sites, supervisors, trainees, consumers/laypeople, other members of the healthcare team (such as other medical specialties, nurses or allied health) and regulators (where relevant). Where accreditation has a direct impact on trainee employment, employer representation may be relevant as well. Members need to be aware of and able to appropriately manage perceived or actual conflicts of interest, such as decisions involving a training site a member has a direct interest in. There should be clear terms of reference for the committee that address the above issues.
Other issues such a committee may need to manage are:
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Sources of information – the relative role and nature of site visits, questionnaires, formal and informal reporting.
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Accreditation cycle – in most instances, accreditation determinations will occur on a regular cycle (e.g., once every five years). Within that cycle, there should some form of progress reporting (e.g., annually) to keep the committee up to date on changes and developments at the site. The cycle may need to be varied where issues are identified at a site that need closer monitoring or changes matched to a specific timeframe. Site visits may be part of the start or end of a cycle, or part of closer monitoring where necessary.
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Decisions on outcomes, with communication of this to the site and other relevant parties, such as a government health authority.
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Membership and training of accreditation teams (where site visits are part of the program).
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Quality improvement of the accreditation process.
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Matching the standards and processes to community expectations and national needs, such as required workforce skills and geographical distribution of trainees.
Accreditation processes
Potential models for accreditation processes include:
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Through and by the committee managing accreditation for the national EM body (e.g. Australasian College for Emergency Medicine).
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Through an external body with expertise in accreditation of training, potentially combined with accreditation in other health areas through a streamlined process (examples include the UK General Medical Council and the USA Accreditation Council for Graduate Medical Education).
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Self-assessment by sites, with review by an oversight committee.
These models are not exclusive to each other, and how they are used will be determined by a combination of available resources (including human resources), complexity and size of existing training structures and external regulatory requirements.
Where the process uses a formal visit to the training site, it should involve an assessment of the site against the accreditation standards, include observation of the clinical training environment and any training facilities, provide opportunities to interview key people in the local training process (such as the Director of Training, supervisors, support staff) and receive confidential feedback from trainees at the site.
The goals of the visit and the standards that will be applied should be transparent and publicly available. This should also include a description of the metrics used to determine that a standard is met.
Accreditation teams – skills and training
Regardless of how the accreditation process is undertaken, where the process involves a visit by a team of assessors external to the training site, the following skills should be represented in the team (more than one skill may be held by any individual team member):
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Experience in the accreditation process and assessing the standards.
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Understanding and experience in the training curriculum and its local delivery (e.g., Directors of Training from other sites, Supervisors).
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Specialist knowledge in EM practice.
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Understanding of the trainee experience (e.g., other trainees or recent graduates from a program).
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An ability to have an objective and independent view of the conduct of the process (e.g., a jurisdictional or other external member).
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An opportunity for team development (e.g., junior team members as observers).
All team members should be briefed on the accreditation standards and their appropriate application, understand the decision-making process, its implications and their responsibilities and obligations with regard to the process. They should also understand and be able to deal with conflicts of interest if and when they arise.
Outcomes of accreditation
Under most existing accreditation systems, a successful outcome would result in some form of certification allowing the site to conduct the training program for a specified period of time (if all standards are satisfied, at least the length of the cycle between visits, where visits are used). There may also be consideration of the training capacity of the site (how many trainees can be supported at a particular site). Where standards are only partially satisfied, there should be a process that allows for delivery of training to continue with remediation of any issues, such as reducing the length of the cycle with a further review through a site visit or by a local education supervisor, or by having specific conditions that must be satisfied to allow ongoing certification.
In the event the program fails to meet the accreditation standards and remediation has been unsuccessful or not possible, a pre-defined method should exist to close the program and transfer any faculty and trainees.
There should also be an ability to deal with disputes over the determined outcome, such as documented appeals or review processes.
Thematic analysis of GME accreditation standards in emergency medicine
To support member organizations in creating their own accreditation standards and structures based on the model, we conducted a thematic analysis of the accreditation standards used for GME in Emergency Medicine across Australia, New Zealand, Canada, the United Kingdom, and the United States of America. This is detailed in Appendix 1.
This demonstrates where the standards in the IFEM Model Framework have similarities to existing national accreditation frameworks for EM training sites, as well as demonstrating where these standards fit within an international accreditation framework from the World Federation for Medical Education. As well as multiple similarities across domains, the analysis also demonstrates where there are differences in scope and delegated responsibilities. As a model framework, the IFEM Model Framework is deliberately set at a higher level than the comparison frameworks and this is evident in the analysis. This is detailed in the Commentary section of Appendix 1.
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