WMA Declaration of Chicago on Quality Assurance in Medical Education
Adopted by the 68th WMA General Assembly, Chicago, United States, October 2017
PREAMBLE
The goals of medical education are to prepare practitioners to apply the latest scientific knowledge to promote health, to prevent and cure human diseases, and to impart the ethical standards governing the thought and behavior of physicians. All physicians have a responsibility to themselves, the profession, and their patients to maintain high standards for basic medical education.
Well-planned and well-executed quality assurance programs are essential to ensuring that medical schools meet these goals and expectations. There are many threats to the quality of basic medical education. The ability to deliver a high standard of education can be affected by the availability of infrastructure, clinical resources, faculty, and finances. Also, the growth of basic medical education globally, with a rapid increase in the number of medical schools in some countries, raises concerns about the quality of graduates. A well-developed quality assurance program allows schools to identify and address conditions that threaten the quality of their basic medical education. Such programs need to be implemented as far as possible at medical schools around the world.
BACKGROUND
Standards developed by and for a medical school are designed to reflect what the school believes to be important quality measures. Institutional reviews using such internally-developed standards can ensure that the school’s missions are being met and that students are being prepared to achieve the desired outcomes. The presence of an institutional quality assurance program that uses its own defined criteria and is supported by knowledgeable personnel can be important to ensure educational program quality over time.
However, a better outcome will more likely be achieved by also including a second dimension of review that includes an external perspective. A national quality assurance system includes the use of standards of quality that are developed and approved at the national or regional level. Evaluating a medical school based on what a country or region expects of its basic medical educational programs leads to a higher and more consistent level of student preparation.
Unless compliance with standards set by a national evaluation system is required of medical schools, there is no guarantee that schools will undertake an internal evaluation or correct problems that interfere with educational quality. The World Medical Association (WMA) recognises the need for and importance of sound global standards for assuring the quality of basic medical education programs.
An accreditation/recognition system is a quality assurance mechanism that is increasingly common around the world. Accreditation/recognition systems are based on standards of educational quality that are developed to meet national needs and that use valid, reliable, and widely-accepted processes to assess the attainment of these standards by schools. After evaluating compliance with standards, cooperation and coordination among various stakeholder groups within and external to a medical school is needed to implement solutions to the problems identified.
PRINCIPLES FOR ACCREDITATION SYSTEMS
An accreditation system reviews educational programs or institutions using a pre-determined (typically national) set of process and outcome standards. The accreditation systems that exist around the world differ in several ways. In some countries, accreditation of medical schools has been occurring for decades; in other countries, accreditation is relatively new. Participation in accreditation is either mandatory or voluntary for medical schools and reviews take place over different intervals.
Accreditation is defined as the evaluation of educational programs or institutions based on a clear and specific set of standards. Accreditation guidelines should be articulated as standards that have been created with national needs in mind and with the input of relevant stakeholder groups within the country.
Certain general principles should form the basis for an accreditation system to ensure that the process is valid and decisions related to educational program quality are trustworthy. These principles include transparency, absence of conflict of interest, and reliability/consistency. Transparency means that the accreditation standards and processes are known to and understood by schools, evaluators, and decision-makers. To reduce the potential for conflict of interest, evaluators and decision-makers should have no ties to the institution being evaluated or to other institutions that may affect their ability to make a judgment free from positive or negative bias. Reliability and consistency require a common understanding of what constitutes compliance with standards and that, as far as possible, this understanding is applied consistently in reviews and decisions across schools.
Accreditation standards are measurable, but need not be quantitative. Standards are normally developed for both the process and the outcomes of a medical education program. Specific information should be identified to evaluate compliance. For example, the standards related to process could address the objectives for and structure of the curriculum; the qualifications of entering students and teaching faculty; and the availability of resources for program support, including adequate finances, sufficient faculty, and an appropriate educational infrastructure for the scientific and clinical phases of training. The outcomes of the medical education program are then evaluated to determine if graduates have been adequately prepared based on the school’s objectives.
In order to be most effective, standards used in accreditation need to be widely disseminated and thoroughly explicated so that medical schools, evaluators, and decision-makers share a common understanding of their meaning and the expectations for compliance. For the sake of process effectiveness and transparency, the medical school faculty, the evaluators who review the medical schools’ compliance with accreditation standards, and the decision-makers who determine accreditation status will require training.
Institutions will have achieved their objectives if they have continually complied with accreditation standards and when internal monitoring becomes a formal responsibility for one or more individuals within the medical school who have access to relevant quality-linked information (e.g., the results of student satisfaction surveys and student performance data). Ongoing review of some or all accreditation standards allows schools to correct problem areas before they are identified as part of the formal accreditation review and ensures that educational program quality remains high.
If an accreditation review identifies areas where improvement is needed, a medical school should promptly correct the deficiencies. The accreditation/recognition body normally sets a timeline for follow-up by the end of which the educational program should be able to demonstrate the actions that have been taken and the outcomes that have been achieved. This may require the medical school/university to provide financial resources and to provide faculty time, effort, and adequate infrastructure, to make the needed corrections.
To assist schools in addressing identified deficiencies, support and consultation could be provided by the staff of the accrediting body or other trained individuals. To avoid conflict of interest, those who provide consultation should not take part in accreditation reviews or in decisions about accreditation status.
RESPONSIBILITIES OF STAKEHOLDERS GROUPS WITHIN AND EXTERNAL TO MEDICAL SCHOOLS
The creation of an accreditation system that meets the principles for validity and trustworthiness requires actions by a variety of stakeholder groups, such as:
- Entities that sponsor accrediting bodies (e.g., governments, medical associations) need to ensure that the accrediting body is appropriately funded and staffed for its activities. Funding may come from the sponsors and/or from the accrediting body’s ability to generate its own funding from accreditation review fees. Accrediting bodies in certain countries may require additional funding and staffing to address the increase in the number of medical schools.
- It is advisable for school leadership to encourage an environment that values educational quality assurance activities. Faculty should be given time and recognition for their participation in program evaluation and accreditation activities, and medical students should be prepared and encouraged to provide feedback on all relevant aspects of the medical education program.
RECOMMENDATIONS
The WMA calls upon National Medical Associations (NMAs)to encourage medical schools to develop quality assurance programs regarding ongoing review of educational program quality.
The WMA urges NMAs to support and promote the ongoing development of national and regional accreditation/recognition systems for medical schools. These systems should be designed and led by physicians in collaboration with experienced medical educators and with input from other relevant experts.
The WMA calls upon NMAs to urge national governmental and private-sector policy-makers to ensure that the national accreditation system has adequate and appropriate resources for its activities. This includes sufficient and consistent funding to support the infrastructure and staffing of the accrediting body.
The WMA recommends that accreditation systems use nationally-relevant standards applied consistently by trained evaluators and decision-makers when reviewing medical schools.
The WMA encourages NMAs to advocate to policy-makers that participation in the national accreditation system should be required for all medical schools within a country.
The WMA calls upon NMA’s to urge national accreditation systems to participate in external reviews of their policies, practices, and standards. This may include seeking recognition by the World Federation for Medical Education (WFME). Recognised accrediting bodies and similar organisations are urged to establish a forum for discussion and collaboration among national accrediting bodies to share best practices and mechanisms to overcome challenges.
Physicians should be encouraged to lead and actively participate in national accreditation activities as evaluators and decision-makers and in quality assurance activities at their own medical schools.