Paper Contribution C
The Role of Accreditation in Increasing Racial and Ethnic Diversity in the Health Professions
Norma E. Wagoner, Ph.D., Leon Johnson, D.Ed., M.B.A., and Harry S. Jonas, M.D.
The authors will review accreditation from a historical and process-oriented vantage point and examine various health professions standards relating to diversity. Because our expertise lies in the field of medical student education, we will closely analyze those standards promulgated by the Liaison Committee on Medical Education (LCME), including a discernment of the impact the LCME standards have had on U.S. medical school programs. As background for the role of accreditation, the authors review the social contract that the health professions have with the public. Background information also includes looking at ways in which accrediting bodies can assist through standards to achieve diversity in student bodies and faculties. Within this context, we examine the recent Supreme Court decision to determine the latitude now allowed to develop new standards for admissions. Throughout this commissioned paper the authors will make recommendations as to the development of new accreditation standards, strengthening of existing ones, and ways in which accreditation, with effort and collaboration among health care leaders, will ultimately result in a diverse U.S. health-care workforce commensurate with a diverse population.
THE ROLES AND REPSONSIBILITIES OF ACCREDITING BODIES
The Goal of Accreditation
The U.S. Department of Education (ED) defines accreditation as “a status granted to an institution that indicates it is meeting its mission and
the standards of the [accreditation] organization and seems likely to continue to meet that mission for the foreseeable future” (U.S. Department of State, 2003, p. 2). Accreditation is the primary means by which the federal government ensures that U.S. institutions and programs of higher education maintain and improve their quality standards of education. It has been in place for nearly a century. Those institutions/programs that meet and maintain specified educational standards are deemed “accredited,” or as holding “accreditation.”
Although accrediting bodies have their own specific standards, they may require that institutions and programs that seek accreditation have an overall stated purpose (or mission) that defines the students it serves and delineates the objectives of the institution’s or program’s activities. In addition, accrediting organizations direct each educational institution/program to show evidence that it accomplishes the following:
Provides adequate resources necessary to achieve its purposes; that is, financial resources, sufficiently prepared faculty and instructional staff, clearly defined admissions policies, and a coordinated and coherent curriculum;
Defines educational objectives; and
Demonstrates evidence that those objectives are being achieved.
A private form of self-regulation, accreditation offers a strong incentive to institutions/programs to improve academic quality as they go through the required periodic reviews. Accreditation’s most critical responsibility is to sustain and enhance the quality of higher education. In so doing, it protects the public by identifying institutions/programs that have yet to establish “sound academic and fiscal practices leading to quality operations” (Eaton, 2003, p. 1). In addition to serving the public’s interest and needs, accreditation acts as a protective barrier against the undue pressures of politics. Accrediting organizations have adopted this role in part because of the willingness of the federal government to rely on accreditation to guarantee academic quality rather than directly assuming responsibility. Each of the 50 states has a system of licensing institutions of higher education that allows them to conduct business and issue degrees legally in that state. The determination of how institutions/programs meet minimum education standards primarily falls on the accreditation body.
Through their domains and standards, accrediting bodies encourage institutional freedom in developing programs that secure sound educational experimentation and constructive innovation (APA, 2002).
Inherent in their overall goal, accrediting organizations assume the responsibility of making certain that institutions/programs pursue and
achieve diversity both in accordance with their individual mission statements and educational objectives, as well as with the standards of the accrediting body (CCNE, 1998). Their purpose further includes the improvement of institutions or programs relevant to resources invested, processes followed, and results achieved. The monitoring of certificate, diploma, and degree offerings ties closely to state and national examinations, licensing rules, and the oversight of preparation for work in the profession (NLNAC, 1999).
What Constitutes an Accrediting Body
In accordance with their mission, accrediting organizations determine and oversee compliance of standards. Furthermore, they provide mechanisms to perform an evaluation of an institution’s/program’s mission, educational philosophy, and goals/objectives, as well as to assess the performance of the program in achieving these goals. Currently 19 nongovernmental organizations accredit approximately 6,300 institutions, and an additional 60 (e.g., law, medicine, business) accredit approximately 17,500 programs (Eaton, 2003). Institutional accreditation deals with the quality and integrity of the total institution, while program accreditation evaluates programs in the various specialized professional or occupational fields.
Who Governs Accrediting Bodies
The ED oversees all accrediting bodies, including specifying and approving the role and scope of their activities (Commissioned Paper C). ED performs a periodic review of each organization to determine the merit of its continuation as the accreditation body. ED activities in this regard are determined by federal legislation known as the Higher Education Act. The reauthorization of that legislation, currently under consideration, should focus on the importance of increasing racial and ethnic diversity in the health professions. Although not directly involved in the process of accreditation, ED does publish a list of accrediting organizations that it recognizes as reliable authorities on the quality of education or training provided by institutions of higher education and their educational programs. Should an accrediting association fail to achieve ED recognition, students under the jurisdiction of that association no longer would be eligible for certain federal loan programs.
Accrediting bodies oversee (1) general, liberal education; (2) technical and vocational education and training; and (3) education and training for the professions. Accrediting bodies generally belong to one of two organizations:
The Council for Higher Education Accreditation (CHEA), which ensures the quality and integrity of the total institution in its efforts to meet stated mission, goals, and objectives; or
The Association of Specialized and Professional Accreditors (ASPA), which oversees programs of study in professional or occupational fields (e.g., law, medicine, dentistry).
Nongovernmental organizations such as CHEA and ASPA align closely with public interest. While maintaining a “suitable distance from the political realm” (Eaton, 2003, p. 6), they serve in a critical capacity in their commitment to regulating academic values.
How the Accreditation Process Works
The accreditation process consists of a review and assessment of an institution or program relevant both to the accrediting body’s standards as well as to the institution’s/program’s mission, educational philosophy, and goals/objectives. Accrediting organizations also evaluate evidence regarding the application of available resources, programs, and administration in assisting the students in attaining their educational goals. Medical institutions usually acknowledge that, without being proscriptive, the accreditation process has served as a powerful influence in shaping the medical education experience. Accrediting organizations initiate the accreditation process every 5 to 10 years or sooner, depending on the success of the institution/program in demonstrating continuing compliance and improvements in the quality of its educational program.
THE HISTORICAL AND CURRENT ROLE OF THE LIAISON COMMITTEE ON MEDICAL EDUCATION
Assessment of the quality of medical education programs began in the United States more than 150 years ago, when a group of physicians who were frustrated and discouraged about the lack of educational excellence of these programs decided to address the issue. Prior to this time, the quality of medical education in the United States was so poor that those U.S. residents who desired a first rate medical education attended European institutions. The hundreds of so-called medical schools in this country, mostly proprietary, provided little in the way of a formal education and for the most part consisted of storefront operations that awarded the degree of doctor of medicine primarily to those willing to pay for it.
With the improvement of American medical education as their focus,
this group of early-day physicians founded the American Medical Association (AMA) in 1847. This effort prompted the Carnegie Foundation to fund a study of U.S. medical education, conducted by Abraham Flexner. Flexner’s landmark report, published in 1910 (Flexner, 1910), resulted in the closure of the vast majority of the poor-quality medical schools. Among those closed were five of the seven medical schools that admitted black applicants. The report also led to the development of a process to set standards to guarantee higher quality education, including periodic review of medical schools to ensure compliance with established standards. The process of accreditation now extends to all levels and types of educational programs.
In the early part of the twentieth century, two organizations, the AMA and the Association of American Medical Colleges (AAMC), conducted the accreditation of U.S. medical schools. In 1942, because of both war-time constrictions in resources and the objections of medical school deans to the efforts required to undergo two accreditation reviews, the AMA and the AAMC formed an accreditation partnership. This became known as the Liaison Committee on Medical Education, or LCME, with the AMA representing rank-and-file practicing physicians and the AAMC representing academic physicians.
The LCME assumed full responsibility for accreditation of medical education programs leading to the M.D. degree in the United States. Subsequently the organization, in cooperation with the Committee on Accreditation of Canadian Medical Schools (CACMS), expanded its scope to include accreditation of Canadian programs leading to the M.D. degree. CACMS is structured similarly to the LCME, with equal representation from the Association of Canadian Medical Colleges and the Council on Medical Education of the Canadian Medical Association, making it a joint venture between the organization representing academic medicine and the organization representing organized medicine. Although the committees function independently and meet separately, cross-representation occurs at both the membership and the secretariat levels. The LCME consists of 17 members: 6 appointed by the AMA, 6 appointed by the AAMC, 2 students selected from the student organizations of the two sponsors, 2 public representatives, and 1 CACMS representative.
In the introduction to the LCME standards document, Functions and Structure of a Medical School, updated in June 2002, the organization defines accreditation as a “voluntary, peer-review process designed to attest to the educational quality of new and established educational programs” (LCME, 2002, p. ii). The introduction continues (and this is key to the subject being addressed in this paper): “By judging the compliance of medical education programs with nationally accepted standards of educational quality, these accrediting agencies serve the interest of the general public and of the students enrolled in those programs” (LCME, 2000, p. ii).
Development of Accreditation Standards
The four sponsoring organizations that constitute North American accreditation for the M.D. degree develop the actual accreditation standards by consensus. Standards typically are broadly drawn up and not overly proscriptive to allow more innovative approaches throughout 152 very different U.S. and Canadian medical schools. Accreditation standards are written in narrative fashion and divided into two categories, “musts” and “shoulds.” The “musts” standards require compliance regardless of circumstances. Although accrediting bodies expect institutions/programs to comply with “should” standards, they allow them to be modified by extenuating circumstances. The sponsoring organizations do not incorporate numerical standards and, in fact, only one number appears in the entire LCME standards document, and that is the minimal number of time in weeks required to obtain the M.D. degree.
Changing accreditation standards involves a rather complicated, lengthy process that requires a public hearing and approval by the accrediting organizations, CACMS and the LCME, and their sponsors. Once the accreditation standard has been changed, ED reviews it and may make recommendations regarding the wording or the use of such standards.
The Present Role of the LCME
Today LCME’s accreditation of educational programs leading to the M.D. degree involves visits to the 126 U.S. medical schools on an 8-year cycle. Approximately 18 months prior to the visits, the LCME asks the institution/program to select an internal task force, various committees that broadly represent faculty, students, administration, teaching hospital representatives, and support staff to conduct an Institutional Self-Study. The purpose of the self-study is “to promote institutional self-evaluation and improvement” (LCME, Guide to Institutional Self-Study, 2002, p. 1). In addition, this experience affords medical schools/programs the opportunity to establish objectives, as well as the proposed means of achieving those objectives relative to its mission.
The LCME chooses a team of medical educators consisting of administrators, faculty members of U.S. medical schools, and/or practicing physicians, usually five in number, to visit the school. On occasion, the team might also include one of the two LCME public members or one of the two student members. The team meets with administrators, faculty, and students to examine all aspects of the educational program, including governance and administration, the academic environment, medical student issues, faculty issues, and educational resources, including finances, general facilities, clinical teaching facilities, information resources, and library ser-
vices. The LCME requires each school, prior to the team visit, to prepare a comprehensive database that includes detailed information about each of the above listed areas. The school is required to mail this to the LCME team members well in advance of the site visit.
At the end of the two-and-one-half-day site visit, the team chairperson presents an oral report at an exit interview with the dean of the medical school and the university president or chancellor. This report covers three areas: Areas of Strength, Areas of Partial Compliance or Non-Compliance With LCME Standards, and Areas in Transition. Following this oral exit interview, the team departs and each member prepares a segment of the report that the team’s secretary later compiles into a full-text written document submitted to the dean for editing of any factual errors. This is then sent to the full membership of the LCME. At the next regular meeting of the LCME, the report is presented, discussion ensues, and after discussion, members decide what action to take regarding accreditation of the educational program. Such action may consist of extending full accreditation for an 8-year term, extending full accreditation pending a return limited visit to determine whether the program has come into compliance with specified standards, or placing the program on probation. If the LCME grants accreditation for an 8-year term, it usually asks the school to submit periodic written reports indicating its progress in addressing any issues identified in the report.
HEALTH PROFESSIONS’/MEDICAL EDUCATION’S RESPONSIBILITY WITHIN THE SOCIAL CONTRACT
The concept of the social contract dates back to the seventeenth-century writing of Hobbes and Locke and the later works of Rousseau. In more recent times, various authors writing about medicine’s contract with society have advanced two general themes: First, the responsibility of medical schools to society arises from the nature of the profession itself. That is, by virtue of being a helping profession, all those involved in medicine have an obligation to produce maximum benefit not only to individual patients, but also to society as a whole. Second, because medical schools receive public funds and benefit from public exemptions, they are morally obligated to act in the public interest, which entails taking societal needs into account.
John Colloton, in his 1988 chairman’s address to the AAMC, reiterated the first of these contentions: “The traditional covenant between academic medicine and society had its origin in trust. It was based on the premise that academic medicine’s unique programs and commitments constituted substantial societal contributions, and thus justified generous support and the privilege of self regulation” (Colloton, 1989, p. 55). In a 2003 article from
the Association of Canadian Medical Colleges’ Working Group on Social Accountability. Parboosing (2003, p. 852) contends:
Society provides medical schools and the medical profession with certain privileges and resources; these are justified only insofar as they are placed unambiguously in the service of those in need and their community. The public and patients expect that governments and the health care professions will work collaboratively to ensure that the Canadian health care system continues to provide the necessary access and quality to meet the needs of the population…. Canadian medical schools along with their partners, such as academic health centers, governments, communities and other relevant professional organizations, have a major role to play in influencing the changes in the health care system that are necessary to ensure an effective, efficient, accessible, equitable and sustainable system.
The World Health Organization has defined the social accountability of medical schools as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation that they have a mandate to serve” (Borsellino, 2003, p. 1). In a speech in 1989, the then-president of the Robert Wood Johnson Foundation, Dr. Steven Schroeder, reinforced the second premise of accountability: “Because academic medical centers are supported primarily by public funds, and their educational, patient care, and research missions are delegated by society, the health needs of the general population must be considered in decisions about program development” (Schroeder et al., 1989, p. 803).
Although few would argue with the concept of medicine’s responsibility to society, various opinions have been voiced as to how institutions/ programs should meet this responsibility. Thus no conclusive standard of action has been created that the health professions can adopt. The AAMC and its President, Dr. Jordan Cohen, have clearly articulated the importance of medical schools’ responsibility to society and their requirement to fulfill a social contract, particularly in regard to meeting society’s need for a diverse health care workforce (Cohen et al., 2002). Indeed, serving public interest and need have been “fundamental to establishing and maintaining a system of higher education that proves responsive to the society it serves” (Eaton, 2003, p. 6). To fulfill this obligation, accrediting organizations must ensure that institutions/programs abide by their social contract.
Beginning with this segment of the document, the authors delineate a series of recommendations.
1. Recommendation. That accrediting bodies undertake a strategic planning process that gives strong consideration to reaffirming the social contract as an obligation of the educational institution.
DIVERSITY AS PART OF THE SOCIAL CONTRACT
Immigration continues to add to the growing diversity of the U.S. population. Generalist physicians can now expect a high percentage of their patients to be from minority cultures (Cross et al., 1989). The differences among minority cultures significantly impact health care delivery, thus creating a critical need for diversity in the health professions. Higher education in part fulfills its societal contract by developing a diverse health professions’ workforce that truly reflects our society. It best accomplishes this by having diverse faculties and admitting and maintaining diverse student bodies.
Demographic changes will become increasingly apparent among future U.S. workers. “By the year 2050, one of every two workers will be African American, Latino, Asian American, Pacific Islander, or Native American,” noted the Institute of Medicine in a 2001 report (IOM, 2001, p. 1). The increasing number of minorities will continue to create social and political changes throughout society, particularly in health care, where pressures on the financing and delivery systems increase to close the gap in health status between minorities and majority populations.
Using data from the Commonwealth Fund 1994 National Comparative Survey of Minority Health Care (survey sample of 3,789 adults with minorities oversampled,) authors Saha and colleagues (2002) reported their findings in an article in Health Affairs entitled “Do Patients Choose Physicians of their Own Race?” The authors found that a significant correlation existed between African-American and Latino patients’ ability to choose their physicians and to see physicians of their own race. Approximately a quarter of those African Americans and Latinos surveyed were patients of racially concordant physicians (explicitly considered physician race or ethnicity when selecting their physicians). Among Latinos, 42 percent factored language into their choice of a physician.
In a May 2003 article in Academic Medicine, Bollinger states, “Because we know that minority physicians are more likely to practice in areas that contain high concentrations of minorities, diversity among practicing physicians and medical administrators increases the availability of health care within underrepresented minority communities” (Bollinger, 2003, p. 435). The late Dr. Herbert Nickens postulated that minority physicians are more “culturally sensitive to their populations and organize the delivery system in ways more congruent with the needs of a minority population.” (Nickens, 1992, p. 2395).
Several medical schools in the United States have achieved diversity in their student bodies through a focused mission or by means of special programs. For example, the University of New Mexico Health Sciences Center has as an institutional mission to provide a diverse workforce and
has in place methods by which to assess longitudinal outcome data to determine whether the school is meeting this goal. A 10-year retrospective study demonstrates that the school has been highly successful from its initial identification of a cohort of minority students that ultimately engages in practice in the rural and underserved areas of the state. This mission is supported throughout all levels of the institution (University of New Mexico, unpublished data, 2003). Another school, the University of Illinois at Chicago College of Medicine, graduates one of the largest cohorts of minority students in the country. The college has developed programs to encourage applications from qualified individuals from medically underserved areas of Illinois. The college maintains a professional staff to provide guidance and counseling to motivated students from minority ethnic groups and those resident candidates whose backgrounds indicate potential for practice in underserved areas of the state (AAMC, 2001–2002). The Drew/University of California at Los Angeles (UCLA) medical program offers 24 of the 145 UCLA entering places to students interested in addressing the concerns of an underserved population. Students spend the first 2 years at UCLA and their second 2 years at the Martin Luther King, Jr./Charles R. Drew Medical Center in south central Los Angeles.
Nearly 50 years ago, in Brown v. Board of Education, the Supreme Court observed that education is “the very foundation of good citizenship” (Brown v. Board of Education, 1954). The court’s affirmative decision on the constitutionality that diversity is convincing reinforcement that “Effective participation by members of all racial and ethnic groups in the civic life of our nation is essential if the dream of one Nation, indivisible, is to be realized.” (Supreme Court of the United States, 2003, Grutter et al. v. Bollinger et al., 539 U.S. p. 19).
Diversity in Admissions
The Impact of the Supreme Court Decision
The major impact of the Supreme Court decision rendered on June 23, 2003, as it pertains to accreditation, centers squarely on the admissions process and an institution’s ability to produce a diverse health care workforce. The University of Michigan cases, Grutter et al. v. Bollinger et al. and Gratz et al. v. Bollinger et al., were the most significant tests of affirmative action to reach the courts in generations in that they challenged the university’s “ability to compose a student body that enables it to achieve its educational mission and fulfill its obligations to the larger society” (The Compelling Need, 1999, p. 7). Two different admissions policies were at issue.
The Grutter et al. v. Bollinger et al. case challenged the university’s law
school admissions policy giving African American, Latino, and Native American applicants a loosely defined special consideration that helped ensure a “critical mass” of such applicants in each new class. A statement released by the Associated Press on June 23, 2003, questioned “whether this policy unconstitutionally discriminated against white students” (AP, 2003). The Supreme Court ruling in this case preserves the concept of affirmative action for minorities who otherwise might be underrepresented on top campuses, while clearly denoting that racial preferences must be used sparingly. The Court majority appeared to advise that if universities were willing to invest the resources to follow the Michigan Law School model and to “painstakingly evaluate each applicant as an ‘individual’ and not as a mere jumble of statistics, then they too would most likely find themselves on the right side of the law in trying to assemble a diverse class” (Steinberg, 2003, p. A25).
With this decision, the justices effectively overruled major portions of the 1996 U.S. Court of Appeals ruling for the Fifth Circuit in Hopwood v. Texas and will allow colleges and universities in the states of Texas, Louisiana, and Mississippi to use race-conscious admissions policies designed to advance diversity. State laws in California, Washington, and Florida still prohibit universities from employing such admissions policies. However, private universities can use properly designed race-conscious policies consistent with their obligations under Title VI of the Civil Rights Act of 1964 and other federal laws (Joint Statement, 2003). AAMC President Dr. Cohen commented that the recent Supreme Court decision gave medical schools (and presumably all health professions’ schools) the power to fulfill one of our most solemn obligations: the development of a health professions workforce that truly mirrors our society (Cohen, 2003).
The second case, Gratz et al. v. Bollinger et al., challenged the University of Michigan’s undergraduate admissions policy attempting to create a critical mass of African American, Latino, and Native American enrollments by giving these applicants an automatic 20-point bonus on the school’s 150-point “selection index.” The justices ruled against this policy, holding that it was not tailored narrowly enough to advance an interest in diversity because it lacked flexibility and provided insufficient individualized consideration to applicants (The Compelling Need, 1999). The Supreme Court’s decision momentarily calms the affirmative action/diversity waters for private and other selective undergraduate and graduate institutions with the resources to comply within the parameters of the decision. Although race cannot be the exclusive or predominant factor in an admissions decision, institutions have some deference in defining the qualifications and composition of their student bodies. A race-conscious admissions policy must consider at least some nonracial factors to ensure that “all
factors that may contribute to the student body diversity are meaningfully considered” (Joint Statement, 2003).
In light of this decision, and given the economic realities of higher education, some large-enrollment and less prosperous colleges and universities may decide to abandon race as an admissions characteristic altogether. Should large institutions choose this route, challenges will accrue to health professions schools hoping to find a cadre of diverse students seeking admission, let alone expecting to graduate a group of students who leave their college years enriched by diversity experiences.
2. Recommendation. Given the Supreme Court ruling on June 23, 2003, medical schools should team up with other health professions to discern how to effectively work within the law to find ways in which to increase diversity in the admissions process.
3. Recommendation. Accrediting bodies should carefully review existing standards and develop more specific references to racial and ethnic diversity both in the student admissions processes and in faculty recruitment.
Achieving Diverse Enrollments
Alan B. Krueger, Benheim Professor of Economics and Public Affairs at Princeton University and a co-editor of The Journal of the European Economic Association, recently observed, “A quarter century from now, the Supreme Court will have a tougher call as to whether diversity is still a compelling state” (Krueger, 2003, p. C2). The legacy of discrimination is a powerful retardant to progress in attaining a diverse health-care workforce. However, the Supreme Court has masterfully crafted a constitutional rationale and set an optimistic agenda that is realistic in terms of diversity in higher education, particularly in leadership producing graduate professional programs. Because it addresses and resolves discrimination at its core, diversity, if established as an accreditation requirement, will hasten the elimination of race consciousness in college and university admissions.
Core Competencies as Part of the Social Contract
In fulfilling the social contract, institutions/programs have an obligation to ensure that health profession and medical school graduates demonstrate achievement through outcome measures as specified in the accreditation standards. In addition, they must meet graduation requirements, pass appropriate licensure exams, pass appropriate certification exams, and satisfy other criteria that measure competency as deemed appropriate by the institution/program. The question arises as to whether these requirements
have succeeded in producing graduates with the full range of qualifications. As tools of the “social contract,” diversity and the core competencies presage a better likelihood that health care professionals have the capability and sensitivity necessary to treat all patients with the respect and understanding they deserve.
Leaders in health education, accrediting bodies, and federal agencies have debated the subject of competencies for many years, focusing on defining those they consider essential, attempting to determine indicators of achievement, and devising measurable outcomes. In recent years the Accreditation Council for Graduate Medical Education (ACGME) has worked with the American Board of Medical Specialties (ABMS) to delineate core competencies that must be attained by those in residency training and practice (ACGME, 2001). We believe that full implementation of such requirements will eventually alter the culture across all areas of medicine. It certainly appears likely that accreditation, particularly with inclusion and emphasis on diversity and cultural competence, also will be able to effect significant change. Modeling aspects of the approaches taken by ACGME and ABMS would provide a major step toward attaining the goal of producing a diverse workforce capable of proffering quality care to a diverse society.
In June 2002, the IOM held a Health Professions Education Summit that brought together 150 expert participants to generate a report on whether “doctors, nurses and other health-care professionals are being adequately prepared to provide the highest quality and safest medical care possible” (IOM, 2003a, p. 7). Their report stressed the importance of integrating a core set of competencies across professions, recommending that all programs that educate and train health professionals adopt these five core competencies: “the abilities to deliver patient-centered care, work as a member of an interdisciplinary team, engage in evidence-based practice, apply quality improvement approaches, and use information technology. The report calls on accreditation, licensing, and certification organizations to make certain that students and working professionals develop and maintain proficiency in these core areas.” (IOM, 2003b).
Cultural Competency as Part of the Social Contract
Cultural competency has been described as “a set of academic and personal skills that allow us to increase … understanding and appreciation of cultural differences among groups” (Archbold, 1996, pp. A1, A5). In light of this, cultural competency realistically falls under the objective of the IOM recommended core competency, the “ability to deliver patient-centered care.”
In her recent article, “Insurgent Multiculturalism: Rethinking How and
Why We Teach Culture in Medical Education,” Wear states, “Very few academic medical educators would deny the need for students to understand and respect differences among people based on gender, race, ethnicity, social class, physical or intellectual abilities, sexual identity or religious beliefs. Yet racial disparities in health have been documented throughout history …Wear, 2003, p. 550). Cultural competency requires that health practitioners not only recognize and treat patients’ illnesses, but that they understand the illnesses within the context of each patient’s social and cultural backgrounds.
4. Recommendation. That high-profile organizations such as the IOM, Department of Health and Human Services, CHEA, ASPA, LCME, and ACGME, along with key foundations and health professions’ organizations, convene for the purpose of (1) agreeing upon a core set of competencies that includes diversity and cultural competency, and (2) developing a clear and uniform definition of the core competencies.
5. Recommendation. That accrediting organizations translate the core competencies into standards. Individual accrediting bodies (nursing, medicine, etc.) would need to work out the details of standards that focus on best practices for their disciplines.
Although many institutions currently grapple with finding methods of teaching and assessing cultural competency in students, few have considered doing the same for their faculty. Obviously having a culturally competent faculty and admitting students with the potential for fully developing cultural competency skills would greatly aid schools/programs in their effort to graduate caring, compassionate students with respect for people of all types.
6. Recommendation. Accrediting organizations should require universities and their health-care programs to revise their mission statements to include more specific references to racial and ethnic diversity, cultural competency, and culturally appropriate care for diverse populations. Such standards could further suggest including faculty developmental processes to enhance the teaching of cultural competency.
Student treatment has become an important and well-understood part of the educational environment in all health professions schools. Many institutions/programs have standards relating to student treatment, with outcome measures provided through student questionnaires. One of these, the 2002 AAMC Graduation Questionnaire, asked students in the 126 U.S. medical schools to rate two important issues: (1) cultural differences and health-related behaviors/customs (71.5 percent indicated their education in this area was “appropriate,” while 23.5 percent rated it “inadequate”); and
(2) culturally appropriate care for diverse populations (71.2 percent rated their education in this area “appropriate,” and 24.2 percent denoted it as “inadequate”) (AAMC, 2002). With one-quarter of approximately 17,000 medical students considering their educational experiences in these cultural issues inadequate, it becomes apparent that greater emphasis needs to be placed on teaching and assessing cultural competency.
If our nation were homogeneous, we would have universal cultural values, belief systems, and language, with health-care providers who share the same set of values, beliefs, and rituals as their patients. Obviously this is not the case, and because educational diversity requires that caregivers provide quality care to a diverse population, they must be taught cultural competency through a developmental process. As Wear notes, “cultural competency, agreed upon as a core value and ostensibly modeled in clinical settings, has taken hold in curriculum decision making at all levels, from medical school to residency to continuing medical education.” In considering new curriculum models for cultural competency, Wear admonishes schools to broaden their approach: “Medical education rarely looks outside its own literature to examine how culture is conceived and taught in other domains” (Wear, 2003, p. 550).
A recent article by Halpern, Lee, Boulter, and Phillips synthesized nine major reports on physician competencies and concluded that “medical education and training programs have been slow to introduce curriculum content that reflects the important changes in practice organizations and health care delivery” (Halpern et al., 2001, p. 606). The authors recognized challenges in implementing curriculum reform and stated that competencies need to be “organized and sequenced for stage of training and specialty, and barriers to change require strategic and operational planning.” We believe that accreditation could serve as a major force in meeting these challenges.
7. Recommendation. Leaders from different health disciplines should meet biennially to promote ways to integrate the core competencies into health professions education.
8. Recommendation. Accrediting bodies should develop standards mandating that institutions/programs incorporate cultural competency into the curriculum. Because some of the other health professions’ standards already emphasize the importance of teaching cultural competency (reviewed later in this paper), collaboration on best practices could be especially helpful in devising effective standards. Such standards should require that schools/programs incorporate curricular elements that involve continuous, first-hand experiences with diverse patients. The school/program would need to include how it intends to
assess whether the teaching and experiences offered did in fact increase cultural competency.
9. Recommendation. That accrediting bodies devise new standards that address ways in which institutions/programs can better judge student readiness in areas of professionalism, communication, and interpersonal skills. Accrediting bodies should work closely with licensing agencies that test for core competencies in graduates of health professions programs in the process of change, such that as new core competencies are developed, these might be included in assessments for licensure. Testing that has consequences always serves as a powerful incentive, particularly when the reward centers on achieving licensure, certification, or recertification.
10. Recommendation. Once new standards have been established, accrediting bodies could offer national workshops or seminars to schools/ programs that would review the intent and meaning of the new standards. In addition, the accrediting bodies could create a website that lists key resources and best practices and offers opportunities to site visit programs that showcase best practices. To keep the public aware of efforts being made, the website could contain results of yearly research in education that offers the latest in assessment or development of new information on health and illness in various ethnic and minority groups.
Accreditation requires that institutions demonstrate through outcome measures that what schools teach is being successfully incorporated and practiced by their graduates. As accrediting bodies include cultural competency and other areas of competencies (e.g., professionalism, communication, interpersonal skills) in their established standards, institutions/programs will need to develop new tools to assess these more abstract qualities. The development of these new tools could best be accomplished through a collective effort across the health professions. A coalition of organizations such as the National Board of Medical Examiners, the Federation of State Medical Boards, and specialty certifying boards would aid significantly in achieving this goal.
THREE HEALTH PROFESSIONS’ ACCREDITING BODIES’ STANDARDS RELATING TO DIVERSITY
The standards of health professions’ accrediting organizations differ in regard to core competencies. However, most have developed a limited number of standards requiring that students achieve a degree of competence in matters of diversity and that programs establish diversity in admissions. A
few have created standards in an attempt to establish diversity among faculty. (Analysis of LCME standards for medicine is in a later section of this paper, along with recommendations for change.) When reading the standards (where they exist) of the three major health professions to be reviewed, it becomes clear that they do place a high value on diversity while varying in strength of statement.
The American Dental Association’s Commission on Dental Accreditation Programs is the specialized accrediting agency recognized by ED to accredit programs that provide basic preparation for licensure or certification in dentistry and related disciplines (ADA, 2002). The Accreditation Standards for Dental Education Programs document states: “Institutional definitions and operations … ensure patients’ preferences and that their social, economic and emotional circumstances are sensitively considered.” (DEP standards, 1998, p. 6). In keeping with this commitment, DEP has established standards for dental education programs that directly pertain to achieving diversity in admissions: “Admissions policies and procedures must be designed to include recruitment and admission of a diverse student population.” Another standard states, “Graduates must be competent in managing a diverse patient population and have the interpersonal and communication skills to function successfully in a multicultural environment.” It should be noted that all of the dental accreditation standards contain the word “must,” thus disallowing circumstantial means of noncompliance. These authors have no evidence as to how effective the dental profession has been in providing programmatic support to meet the standards, nor what assessment tools enable the profession to effectively measure the outcomes sought through the standards. It would be helpful to learn from the dental profession whether the word “must” has been effective in its recruitment and retention of a diverse student body.
Accrediting bodies for this field govern education for advanced-level psychology students attaining training primarily in the understanding and intricacies of health and human development. The Committee on Accreditation for Professional Programs in Psychology includes in its scope of accreditation (APA, 2002): (1) the doctoral graduate training program; (2) the internship carried out during the doctoral training; and (3) postdoctoral residencies in professional psychology. The following selections from psychology accreditation standards give evidence to the commitment of establishing diversity and retaining culturally competent faculty and students.
Standard five under this domain reads: “The program engages in actions that indicate respect for and understanding of cultural and individual diversity … with regard to personal and demographic characteristics, not limited to: age, color, disabilities, ethnicity, gender, language, national origin, race, religion, sexual orientation and socioeconomic status.” Standard five continues: “Respect for and understanding of culture and individual diversity is reflected in the program’s policies for the recruitment, retention, and development of faculty and students, and in its curriculum and field placements” (p. 8).
Standard three under Domain B, Program Philosophy, Objectives and Curriculum Plan, states, “In achieving its objectives, the program has and implements a clear and coherent curriculum plan that provides the means whereby all students can acquire and demonstrate substantial understanding of and competence in the following areas … Issues of cultural and individual diversity that are relevant to all of the above” (p. 9).
Standard one under Domain D, Cultural and Individual Differences and Diversity, references the need for “programs to make systematic, coherent, and long-term efforts to attract and retain faculty from differing ethnic, racial and personal backgrounds into the program” (p. 12).
Standard two under Domain D states that a program “has and implements a thoughtful and coherent plan to provide students with relevant knowledge and experience about the role of cultural and individual diversity in psychological phenomena as they relate to the science and practice of professional psychology” (p. 12).
ED recognizes two accreditation bodies for the nursing profession. The older of the two, the National League for Nursing Accrediting Commission (NLNAC), has responsibility for the specialized accreditation of all types of nursing education programs, both postsecondary and higher degree, that offer a certificate, diploma, or a recognized professional degree. NLNAC has as one of its goals that of promulgating a common core of standards and criteria for the accreditation of nursing programs (NLNAC, 2002). Although NLNAC currently has no standards directed toward achieving diversity, in 2002 the organization voiced support of the Pew Health Commission Competencies for 2005 (1991 report) and the 21 Competencies for the Twenty-First Century (1998 report). The 1991 Pew Report—Healthy America: Practitioners for 2005, Agenda for Action, calls for “a change in strategies wherein both the state and federal government assume a responsible role in health care and education. The Report recommends that the federal government encourage accreditation bodies to work closely with schools as they develop their responses to a changing environment” (Shugars
et al., 1991, p. 24). In the report 21 Competencies for the Twenty-First Century, only one of the core competencies relates to diversity: Competency 12 advocates the need to provide culturally sensitive care to a diverse society by: “creating a diverse learning environment by recruiting a culturally and racially diverse faculty and student body” (O’Neil and the Pew Health Commission, 1998, pp. 36–37). NLNAC’s support of these 21 competencies acknowledges their value by asking nursing programs to interpret skills and competencies in the content, context, function, and structure of their programs.
ED also recognizes the Commission on Collegiate Nursing Education (CCNE). This specialized/professional accrediting organization is designed to evaluate and make judgments about the quality of baccalaureate and U.S. graduate programs in nursing (CCNE, 1998). Conceived by the American Association of Colleges of Nursing in 1996, CCNE began accrediting operations in 1998. A board of commissioners governs the body and serves as the final authority on all policy and accreditation matters. CCNE currently has no standards regarding diversity in admissions.
Another agency that has been working toward creating diversity in the nursing profession is the National Advisory Council on Nurse Education and Practice (NACNEP). Authorized under Title VIII of the Public Health Service Act, NACNEP provides advice and recommendations to the Secretary and Congress concerning the range of issues relating to the nurse workforce, education, and practice improvement. In its 1996 report to the Secretary of Health and Human Services and Congress on the Nursing Workforce, NACNEP identified as a critical goal that of increasing the racial/ethnic diversity of the registered nurse workforce to meet the nursing needs of the population. In 2000, the National Agenda for the Nursing Workforce met and subsequently issued a report to the Secretary of Health and Human Services (NACNEP, 2000, p. xi) that contains this statement, “The health of the nation depends on an adequate supply of nurses and a nursing workforce that reflects the racial and ethnic diversity of the population.” The report continues with the admonition that “Without significant interventions the nursing workforce will continue to be out of balance with the health care demands imposed by the changing population demographics.” The report recommends specific goals and actions that can serve as a national action agenda to be undertaken to address these issues.
As seen from this brief review, these three health professions have two common goals: to graduate students who possess cultural competencies and to achieve diversity through admissions. Accrediting bodies for dentistry, medicine (described in the next section), and psychology have relatively consonant standards relating to the acquisition of core competencies pertaining to diversity. As for nursing, NLNAC has adopted the Pew 21 Core Competencies with an admonition to nursing programs to incorporate these
competencies into their educational programs. Existing standards, however, lack uniformity of language and greater explication on ways by which to assess outcomes.
THE LCME’S COMMITMENT TO ACHIEVING DIVERSITY IN ADMISSIONS
The LCME regularly holds retreats to examine the accreditation process and to review the role and range of its activities. At a retreat held several years ago, the question was raised as to what role the LCME should take in effecting social change. At that time the group concluded that because issues such as racial and ethnic diversity were societal, and that the role of an accrediting body was to set educational standards, the LCME’s scope of effort did not include attempting to address societal issues. Since that time, AAMC President Dr. Cohen has voiced his opinion: “A diverse healthcare workforce will help expand health care access for the underserved, foster research in neglected areas of societal need, and enrich the pool of managers and policymakers to meet the needs of a diversity society.” (Cohen et al., 2002, p. 91).
Within the scope of this commitment, the LCME has established standards geared toward increasing racial and ethnic diversity in the student body and on medical school faculty. Currently 5 of the 126 standards listed in the LCME standards document, Functions and Structure of a Medical School, pertain directly to diversity. Over the past several years, the LCME has sought to tighten the language and provide annotation of the standards in order to effectively communicate its full intent (LCME, 2002).
Analysis and Recommendations Regarding the Five LCME Accreditation Standards on Diversity
Five LCME standards pertain specifically to diversity. A brief discussion of each follows, along with recommendations. The authors have taken into consideration whether site team visitors can easily analyze those standards requiring specific outcomes and means of assessment.
1. ED–21: “The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases and treatments.”
Although this standard has as its goal a very well intentioned outcome, its double-pronged approach, directed toward both faculty and students, renders it virtually ineffective. Most schools have few, if any, provisions on how to effectively abide by the standard relevant for both. The ability to
measure outcomes for this standard remains marginal; even the best informed LCME site visitors have no way to assess whether both faculty and students have met the cultural competency (understanding) as set forth. In all likelihood, the visiting team’s focus would center on assessing the types of cultural competency curricular programs available for students and the content of faculty development programs being offered to address this issue.
11. Recommendation. Considering the intent and scope of this standard, we recommend crafting standards directed toward achieving the two separate outcomes currently stated in ED–21 and developing measurable outcomes to assess cultural competency (understanding) in the separate standards.
Having been a site team visitor to several institutions, this author (Wagoner) suggests that once the LCME has strengthened existing standards and instituted new ones, the organization provide a more comprehensive training program for site visitors on how to properly interpret standards.
2. ED–22: “Medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery.”
This critically important standard essentially speaks to the matter of trust, a subject much discussed in health professions’ literature. Trust in the doctor-patient relationship can only be established when physicians overcome preconceived biases and acquire insight and understanding into another person’s values, beliefs, and needs. In the article, “Trust, Patient Well-Being and Affirmative Action in Medical School,” DeVille highlights the importance of trust, calling it “central to the individual physician’s ability to practice good medicine.” He notes that minorities’ historical and current experience with the medical profession and health delivery system frequently breeds suspicion rather than faith. He concludes: “Society and the medical profession have a compelling interest and duty to produce physicians who inspire trust” (DeVille, 1999, p. 247). Although schools can be cited for noncompliance of this standard, this author (Wagoner) knows of no institution that has been cited for failure to achieve the outcome specified by ED–22 or for lacking a mechanism by which to assist individual students in overcoming biases.
12. Recommendation. Standard ED–22 hinges on the development of measurable core competencies. Once accrediting bodies have developed the core competencies, they should place a high priority on determining how the competencies are being achieved. An array of assessment instruments could furnish this information.
3. MS–8: “Each medical school should have policies and practices ensuring the gender, racial, cultural and economic diversity of its students.”
This broad-based standard acknowledges the LCME’s commitment to the stated goal of diversity in students entering medicine, although the standard is weakened by use of the word “should” rather than “must.” The intention of this standard mirrors that of dentistry in its focus on the recruitment and retention of diverse students. At present, site visit teams can assess the school’s admissions selection process and the extent to which diversity exists by evaluating medical school data. Therefore, unlike the previous two standards, this one has outcomes that can be measured by specific instruments. However, as written, the standard fails to acknowledge the importance of diversity in the context of a quality education or in the quality of health-care access or delivery for an ever-increasing diverse population.
13. Recommendation: Reframe the standard to emphasize the importance of having a diverse, culturally competent workforce in order to provide the highest quality health care. Ensure that the standard’s wording is changed from “should” to “must” in all current and newly created standards.
The subtext of this standard states: “The extent of diversity needed will depend on the school’s missions, goals, and educational objectives, expectations of the community in which it operates, and its implied or explicit social contract at the local, state and national levels.” This subtext gives institutions tremendous latitude to gear their policies and practices toward their current missions, goals, educational objectives, and social contract, which may be woefully inadequate to create a diverse student body or to train medical students to be racially, culturally, and gender sensitive. Unless an institution’s leadership has a strong commitment to the goal of diversity, achieving this standard in its full measure will be a matter of circumstance rather than advocacy.
4. MS–31: “In the admissions process and throughout medical school, there should be no discrimination on the basis of gender, sexual orientation, age, race, creed or national origin.”
14. Recommendation. That the word “should” be replaced by the word “must.”
This standard encompasses verbiage found in most medical school admissions handbooks that puts them in compliance with the Equal Employment Opportunity Commission laws disallowing discrimination in the ad-
missions process on the listed bases. Although well intentioned, the standard provides no means of determining whether schools/programs are conforming in the admissions process, particularly in how they handle/consider/recruit individual candidates. Assessment by LCME site visitors at this microlevel would be well beyond the purview of their responsibility. In essence, they have to trust the school’s word that it is in compliance.
15. Recommendation. In order to provide measurable outcomes, this standard needs to require (1) that each school/program publish yearly statistics regarding its class diversity, and (2) that each institution/ program have its mission statement readily available for inspection by students so that those seeking an institution that values diversity could more effectively target their applications. This sort of public accountability also would enable patients to recognize programs that have a commitment to creating a diverse workforce.
5. FA–1: “The recruitment and development of a medical school’s faculty should take into account its mission, the diversity of its student body and the population it serves.”
For the past three decades, the number of women on medical school faculties has increased. The 2001 AAMC Faculty Roster source shows that women constitute 32.6 percent of U.S. faculty (AAMC, 2001). However, the same has not been true for minorities, whose number does not come close to reflecting the patient population or, in many instances, the student population at any particular medical school. In the IOM Symposium on Diversity in the Health Professions entitled The Right Thing to Do, The Smart Thing To Do, in his chapter on “How Do We Retain Minority Health Professions Students?” Dr. Michael Rainey stated, “There is a severe shortage of underrepresented minority (URM) faculty teaching core courses. Although African Americans, Native Americans, Mexican Americans, and Mainland Puerto Ricans make up almost 25% of the U.S. population, they account for less than 8% of all practicing physicians. Only 3% of medical school faculty members belong to one of these minority groups.” In 1989, URM faculty represented only 2.9 percent of clinical faculty in U.S. medical schools (Rainey, 2001).
THE ROLE OF OTHER ORGANIZATIONS IN AIDING ACCREDITATION
We believe that select governmental organizations, private foundations, accrediting organizations, and national health professions share a common interest in supporting diversity and developing a set of core competencies
applicable to all health professions. We offer the following suggestions for cooperative undertakings:
Offer grant incentives to support change:
to health professions’ schools to build bridges between their institutions/programs and public undergraduate institutions and select private schools. This liaison would help ensure a future pipeline of diverse students prepared to meet the health care challenges of the 21st century;
and to health professions’ schools to increase faculty/student diversity.
Facilitate multidisciplinary partnering of health professions’ schools committed to promoting diversity and cultural competency through the development of educational modules (clinical case studies) for institutions/ programs for online testing and self-learning. Other modules could be devised to establish programs that aid in the development of cultural competency skills. This might include references to articles and other literature that offer insight into how effective programs at other institutions (across disciplines) accomplish their educational objectives.
Take explicit actions to identify diversity-related issues within the education and work settings and develop strategies to address them. “A laissez-faire approach will not confront the unconscious practice biases that exist” (Schmieding, 1991, p. 70). Reporting the results of such efforts will prove critical to the success of diversity.
Honor institutions by giving yearly monetary awards to encourage and acknowledge those that have demonstrated excellence in developing outstanding educational modules. In order to foster collaboration across the health professions, emphasis should be on interdisciplinary educational modules that promote team approaches to care, quality improvement, and the use of educational technology. Other modules could include those that address challenges of health care access, health-care delivery, cultural competency, patient education, and any other modules that better the quality of health care and increase patient safety. It will be imperative to continuously monitor any efforts undertaken by any or all of these organizations to identify, support, and pursue diversity within the health professions student body, workforce, faculty, and staff. To demonstrate public accountability, the agencies and organizations should publish their benchmark progress toward policy goals and articulated action items.
The importance of accreditation in fulfilling the health professions’ social contract cannot be understated. As stewards of the public’s trust and guardians of the social contract, accrediting organizations have an obliga-
tion to use their authority to help increase competency and racial and ethnic diversity in the health professions. They can accomplish this by ensuring that all institutions and programs identify these as necessary objectives. At present, accreditation standards vary widely in their mandates and may not achieve the objectives to the extent required to promote diversity or to educate competent health-care professionals. Accomplishing this lofty goal will require the creation of a comprehensive, symbiotic, and open relationship among health-care leadership organizations, accrediting organizations, and the health professions. Together these groups can collaborate on all relevant issues regarding the attainment of diversity; the design, measurement, and assessment of core competencies; and the methods by which to encourage the development of educational materials. Accrediting bodies are exceptionally positioned to spearhead this cooperative effort.
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APPENDIX TO PAPER CONTRIBUTION C
The U.S. Department of Education oversees the LCME. Public Law 96–88 of October 1979 authorizing the organization of the ED defined its mission. The following areas are considered ED’s purview:
Strengthen the federal commitment to ensuring access to equal educational opportunity for every individual.
Supplement and complement the efforts of states, the local school systems, other instrumentalities of the states, the private sector, public and private nonprofit educational research institutions, community-based organizations, parents, and students to improve the quality of education.
Encourage the increased involvement of the public, parents, and students in federal education programs.
Promote improvements in the quality and usefulness of education through federally supported research, evaluation, and sharing of information.
Improve the coordination of federal education programs.
Improve the management of federal education activities.
Increase the accountability of federal education programs to the president, Congress, and the public.