3

Competency-Based Accreditation and Collaboration

FOSTERING INNOVATION THROUGH COLLABORATION: BREAKOUT GROUP DISCUSSIONS

Demonstrating the session theme of collaboration, members of the Global Forum on Innovation in Health Professional Education and workshop participants gathered in small group discussions to explore challenges and opportunities for greater harmonization among and between groups with vested interests in accreditation and quality improvement. Participants in each group included health professional educators, accreditors, and others. Each group had a leader, and in some cases a colleague from another profession assisted the leader by providing context and background on the topic from their perspective. The four breakout groups were

1. Bringing education and practice accreditors together for achieving quality throughout the education to practice continuum;
2. Building a competency-based accreditation system: balancing global standards with local relevance;
3. Collaborating for harmonization of competency-based standards across professions; and
4. Improving efficiencies of accreditation through greater collaboration among stakeholders.

The following are the reports from each of the breakout group leaders to the participants of the workshop. These comments are a summary of the group discussions presented by the group leaders, and they should not be viewed as consensus.

Bringing Education and Practice Accreditors Together for Achieving Quality Throughout the Education to Practice Continuum

Leader: Miguel Paniagua, M.D., National Board of Medical Examiners
Assisted by: Karen Sanders, M.D., Veterans Health Administration, and David Benton, R.G.N., Ph.D., FFNF, FRCN, FAAN, National Council of State Boards of Nursing

With the assistance of Karen Sanders and David Benton, Miguel Paniagua led his group through a series of questions related to bringing accreditation of education and practice closer together. The first question the breakout group addressed was, “What are the challenges in engaging the entire continuum of learners and organizations in the accreditation process?” Out of this discussion came the themes of compromise, incentive, simplification, importance of words, and capacity to influence (versus control) accreditation. Paniagua said that accreditation bodies as a whole first need to agree upon processes and collaborative efforts,

and then these ideas can be brought to the practice field. He raised the challenge of permitting accreditors to innovate while giving them the responsibility of regulating. He also stated that accreditation bodies could be incentivized to work more collaboratively with those outside of their professional siloes in an attempt to lighten the administrative burden on accredited institutions or programs who must answer to multiple accrediting agencies. The importance of word choice and the power of language was also raised as a challenge, as word choice should especially be considered when engaging other professions and trying to share competencies. Finally, said Paniagua, this type of engagement requires leadership, sharing of revenue, and understanding the differences in each of the systems.

The second question was “How do we align the requirements of accreditation standards with educational and practice programs, or vice versa?” The group talked about starting from an informed beginning before coming up with a consensus. Paniagua expressed hope that stakeholders could find common ground and agree upon certain core competencies across the various accreditations within professions. There is also a need for public availability of information to ensure that there is buy-in, said Paniagua. He emphasized that patients should be asked for their thoughts and opinions when it comes to aligning education and practice, and that stakeholders should listen to the communities of interest when making these changes. The gap between accreditation of practice and accreditation of educational programs was a theme throughout their discussion, he said.

The third question asked was “How does one prove the worth of accreditation in protecting the health of the public?” The group discussed potential outcomes that could demonstrate value, such as getting a good job or showing strong performances of colleagues within the practice environment. It would not be possible to do a randomized controlled trial, said Paniagua, because it would be impossible to remove accreditation and wait to see how many errors occur. Paniagua stated that it is important to remain mindful of the positive effect accreditation has not only by promoting safety within accredited programs, but also through access to health care for communities—especially communities in need.

The fourth question was “What is the future of education and accreditation balance across the world?” According to Paniagua, a thought that emerged from the group discussion was related to the shift in demographics caused by the heterogeneity of practice sites and practices in culture as well as by the retiring workforce. He added that with experienced personnel and providers leaving the workforce, and with a shifting nature of roles brought about by technology and costs, the health professions and the work of professionals may be very different in 20 years. The group also discussed the term international standard, and how it would likely be difficult to devise

a standard that fits every possible scenario although there will likely be commonalities that all can draw from.

The final question the breakout group discussed was “What is the best way to partner with patients, populations, communities, and governments in promoting the role of accreditation in ensuring quality education and training?” Paniagua reported on the need to refocus what accreditation is truly meant to do. He suggested that accreditors think about core principles of accreditation and why accreditation came into existence. Accreditation can begin with those willing to collaborate, he said, then work toward finding common ground with other stakeholders. In addition, motivation could be related to the populations served and not merely one’s self-serving interests. He raised possible innovations for partnerships including joint commitments with other professions and looking to fields outside of the health professions, such as the airline industry or information technology, for best practices and lessons learned that could be incorporated into the accreditation process.

Building a Competency-Based Accreditation System: Balancing Global Standards with Local Relevance

Leader: Zohray Talib, M.D., George Washington University
Assisted by: Nelson Sewankambo, M.B.Ch.B., M.Sc., M.Med., FRCP Doctor of Laws (HC), Makerere University, Uganda, and Susan Day, M.D., Accreditation Council for Graduate Medical Education

The breakout group led by Zohray Talib focused its discussions around three main components: (1) key steps and resources in the process of establishing an accreditation system, (2) opportunities for encouraging interprofessional training through accreditation, and (3) lessons learned in balancing global and local standards in accreditation systems.

Potential Key Steps and Resources in the Process of Establishing an Accreditation System

The process of establishing an accreditation system, said Talib, begins with identifying the key stakeholders. The World Health Organization (WHO) pentagram lists the five key stakeholders for accreditation: academics, policy makers, health managers, health professionals, and communities. Once these stakeholders are identified, the process of how to engage them is critically important, said Talib. Stakeholders, including the community, can be brought together to define the vision for this initiative and the optimal functioning of health care professionals within the vision. Stakeholders can then identify competencies and begin to build the accreditation system that supports this vision.

In addition, building trust early with stakeholders facilitates the process, said Talib. When ministries of health, education, and finance—in some cases, competing stakeholders—are brought together, time upfront can build trust and co-ownership in the vision. Talib suggested that this process begin with defining the vision. Building and sustaining trust then requires feedback loops at multiple levels for individual programs and the accreditation systems—for example, at the level of practitioners in the field, their performance, in aggregate, could be shared with program leadership, and other stakeholders to gauge provider performance and to collectively address challenges. As the system grows and develops, there could be opportunities for feedback, to see if the system is working well and keeping up with the values and priorities of the society.

Opportunities for Encouraging Interprofessional Training

Talib said that when encouraging interprofessional training and practice, it is important to first start with the process of building a vision and engaging the community, then work backward into competencies, including interprofessional competencies. The accreditation system then reflects the vision and interprofessional goals. Nelson Sewankambo, Makerere University, shared the process that was used in Uganda where key stakeholders (including representatives from different health professions) in the country came together to develop their accreditation system based on the competencies that reflected local needs.

In the process of establishing an accreditation system, agreement in-country on common nomenclature for interprofessional education and training can advance the vision and can facilitate different professions to incorporate the same ideas into their programs.

New accreditation systems could also identify and include meta-competencies as an opportunity to strengthen interprofessional training; for example, certain leadership skills, cultural competencies, and communication skills might span different professions and could be part of the different accreditation systems. Identifying common areas of interest or common challenges could allow those working in limited resource settings to reflect on how to work together to make the best use of their limited resources. Interprofessional collaboration may be an opportunity for maximizing human, material, and financial resources.

To ensure ongoing relevance of an accreditation system, a platform for ongoing dialogue would be important to keep up with the evolving priorities in society, said Talib. As the societal value system or as the health system evolves, the accreditation system will need to reflect these changes. Similarly, to ensure the collective vision is realized, the service and practice

environment would need to reflect interprofessional practice so the positive effect of these changes can be applied.

Lessons Learned in Balancing Global Standards and Local Relevance

The breakout group then considered how to reconcile global standards and local relevance. First, it is important to understand context, said Talib. Local resources, local culture and practice, scope of practice for professions, and the realities of the health service environment are all part of this local context. The accreditation system should consider this local context, yet still address priority local health needs ensuring high-quality, locally relevant care. In low-resource settings, there is a tension between the desire to meet global standards while being locally relevant; to address this, one of the group members suggested that high quality, from a global perspective, should reflect the process of accreditation and the degree to which it maintains local standards. The specific competencies required of a profession within a system, would then reflect local needs. Accreditation systems would then be judged on the degree to which they require a consideration of local health indices, resources, and scope of practice.

Collaborating for Harmonization of Competency-Based Standards Across Professions

Leader: Peter H. Vlasses, Accreditation Council for Pharmacy Education
Assisted by: Patricia Hinton Walker, Uniformed Services University of the Health Sciences

The discussion reported by Peter Vlasses sought to have a better understanding of competency-based standards and interprofessional collaborative practice. To do this, the group addressed three main questions throughout its session:

1. What are competency-based professional standards? What is their purpose, and who develops them?
2. Where do competency-based professional standards occur in the lifespan of professionals? How are they evaluated?
3. How do competency-based standards relate to other types of standards or to entrusted professional activities?

Patricia Hinton Walker reported on several competency-based professional standards—including knowledge, skills, values, and ethics—that she and Vlasses identified from the group’s discussions. These standards can be both general and specific. One of the challenges, she noted, is that

much of the research is still being developed; therefore, standards are more evidence-driven than evidence-based. The group also discussed various purposes for competency-based professional standards that Hinton Walker reported as including ethics, leadership, and outcome-based competencies. Another purpose of these standards was to serve as a framework for curriculum development and an opportunity for improved assessment. The stakeholders who develop competency-based professional standards, she said, are educators, faculty, regulators, practitioners, and the public. She saw this as process driven, but ultimately competency-based.

Vlasses then stated that competency-based professional standards could be incorporated across the continuum of education, from the degree level to residency programs, continuing education, and certification. He noted potential new avenues for competency-based professional standards that he drew from the group’s dialogue. These include health care systems and financing, technology issues, simulation, gaming, standardized patients, objective structured clinical examinations, and team-based objective structured clinical examinations.

Competency-based professional standards, said Hinton Walker, can be global, multifactorial, and/or needs based. Having both generic and specific standards is key, and standards can be related to both standards of practice and regulatory issues. Medical schools are using entrustable professional activities (EPAs), she said, which are demonstrable skills such as being able to do a patient history and a physical, to enter patient information into a chart, and to prescribe appropriately. She added that medical schools are now preparing students to enter residency with 13 expected skills.

According to Hinton Walker, the group then discussed where accreditors fit into the process of creating competency-based professional standards. She saw that the accreditors could develop competency-based standards using evaluations from both a quality assurance and a quality improvement perspective. Ongoing monitoring and evaluation of the program and institutional level is important, she said. Specialized, professional, institutional, regional, national, international, and residency accreditors could all be involved in this process. These types of standards would vary across professions and countries, owing to the different health systems, practice areas, and professional competency expectations that exist. Competencies can vary between states and between countries in both practice and regulation. Hinton Walker provided the example of compact licensure in nursing,¹ which could be a model for other professions that have wondered how to credential across settings and states rather than having many barriers.

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¹ According to the National Council of State Boards of Nursing, the Nurse Licensure Compact “allows nurses to have one multistate license, with the ability to practice in both their home state and other compact states” (NCSBN, 2016).

The breakout group brainstormed many opportunities, noteworthy practices, and barriers for harmonization of competency-based professional standards. Vlasses discussed the difference between harmonization and standardization, noting that standardization is very specific, and harmonization concentrates more on desired competencies and accepting multiple processes for achieving those competencies. Vlasses listed the following opportunities for competency-based professional standards:

• ethics
• professionalism
• moral agency at the level of the individual, the organization, and society
• adaptive and independent learning
• provider-to-person relationship and communication
• foundational learning
• cultural awareness, sensitivity, and humility
• leadership
• faculty development
• communication, collaboration, and respect
• profession roles and responsibilities

There are several noteworthy practices that exist, said Vlasses. He listed centers of excellence, professional collaboration for licensure, the Interprofessional Education Collaborative (IPEC), the Health Professions Accreditors Collaborative (HPAC), and the National Academies of Sciences, Engineering, and Medicine’s Global Forum on Innovation in Health Professional Education.

Some of the barriers to this work, identified by individual workshop participants, include payment structures, isolated small practices, medical hierarchy, varying scope of practices, varying criteria for licensure, curriculum space and openings for IPE, education scheduling, tuition and faculty credit for IPE initiatives, and cross-professional assessment of IPE initiatives by faculty. Opportunities include development of modalities on how to measure this work, sustainability of education and practice, improved quality and safety, joint continuing education, and interprofessional requirements.

Improving Efficiencies of Accreditation Through Greater Collaboration Among Stakeholders

Leader: Jennifer Butlin, Commission on Collegiate Nursing Education

The breakout group led by Jennifer Butlin, Commission on Collegiate Nursing Education, first identified various stakeholders of accreditation. This included the groups previously mentioned (the public, practitioners, faculty, educators, regulators, and communities), but also added the licensing and certification boards, federal agencies, the Council for Higher Education Accreditation, students, parents and families, employers and employees, patients and clients, consumers, accrediting agencies, institutional and program staff or officials, and professional or membership associations.

There are many benefits to achieving greater collaboration among stakeholders, said Butlin; including cost savings and efficiencies through economies of scale as well as developing a common understanding among entities and groups in order to add meaning to processes. For example, sometimes groups require different types of reports; knowing the reason and potential meaning behind these differences would be helpful. In this example, she suggested a conversation might be had that discusses streamlining reports and benefits to add meaning to why and how particular information is being collected, why certain data are being shared, and are the data meaningful.

One participant in her breakout group offered a perspective on her organization’s decision to spend millions of dollars in preparation for an accreditation visit. The participant suggested having every professional accrediting body’s efforts included in and accepted by one accrediting body in an attempt to reduce the amount of effort and work for all involved, which would lower administrative costs. A second breakout group participant provided another perspective based on reports that a number of accreditors are lengthening the terms of accreditation, which saves time and cost. However, the participant added, putting in place other mechanisms to ensure program accountability over the long accredited period is an important to point to consider.

Butlin added that collaboration would promote a common understanding among stakeholders and create buy-in from stakeholders (such as practitioners and educators). This common understanding could be helpful in holding each other accountable. Sharing evidence of improved effectiveness and identifying and learning from best practices could benefit all stakeholders. In addition, collaboration could help streamline processes (such as having real-time data exchange), increase transparency of the processes, and add meaning to the processes so accreditation is better understood and appreciated. Students would be able to practice across borders, and stake-

holders could learn from their peers in the international community. Ideally, these benefits would lead to improved performance of educational programs and accreditors.

While the benefits are clear, there are also many challenges to enhancing collaboration among stakeholders, said Butlin. A major issue within and across professions involves turf battles leading to a reluctance to negotiate, give up authority, or share funding. Competition for clinical sites, for attracting students, and among accrediting agencies may also exist. There can be unwillingness or a lack of understanding on how to collaborate. Logistics, incompatible systems, and scheduling create further barriers to working together. Stakeholders may also have a lack of flexibility to be able to collaborate, or collaboration may create more work for them, since it is an investment in time and energy. Organizations and stakeholders may have different purposes, missions, and visions. Another challenge is that accreditors’ roles and responsibilities are expanding, and there are increased pressures on accreditors to do more. Clear communication about roles, missions, and values is important, as there is often a lack of understanding about this. Lastly, Butlin raised the challenge of identifying key players to be part of the discussion. This involves getting all the key players involved, and more importantly, making sure to engage the people who have the authority to make decisions within their organizations.

She then reported on opportunities for collaboration identified by individual workshop participants during the breakout session. This includes dissemination of effective models that could save professions time and money, and could promote learning from each other about best practices. Other opportunities could involve leadership changes and evolving organizational missions that can allow for new opportunities in collaboration and improved efficiencies through collaboration. There are also research opportunities, Butlin said, that can identify not only best practices but evidence-based practice to improve collaboration. Joint site visits and collaborations with international partners are ways that stakeholders can learn from international colleagues and from other professions.

According to Butlin, preparing stakeholders for successful accreditation collaboration requires an existent common understanding among partners and buy-in from stakeholders. Stakeholders, such as patients, families, and communities, would need to understand their roles and how they may differ, as well as understand why each one should care about accreditation. Additionally, the breakout group discussed how an orientation process may be helpful before collaboration is undertaken. Butlin closed by saying that key players would need to be identified before collaboration could begin, and students and employers should be informed ahead of time about the role of accreditation and their ability to participate in and influence accreditation.

MARKETPLACE OF IDEAS

The Marketplace of Ideas is an open space where participants of the workshop met informally during the lunch recess to discuss an accreditation innovation put forth by a Forum member or his or her affiliate. Anyone attending the workshop could join any of the discussion topics. Each topic was presented briefly to the entire audience just prior to breaking for lunch. The eight discussion topics were organized into four main themes: interprofessional education, enhancing quality and innovation, high-stakes examinations, and innovation. Similar discussion topics were grouped together but discussed separately as participants wandered from one discussion to the next, similar to an oral poster session. Below are the abstracts for each discussion topic. These abstracts were prepared by the individual workshop speakers listed, and have not been endorsed or verified by the National Academies. They should not be construed as reflecting any group consensus.

Interprofessional Education: Discussion 1
Assessment of Interprofessional Teamwork Competencies: A Role in Accreditation Systems?

Abstract submitted by Miguel Paniagua, M.D.,
Medical Advisor Test Materials Development,
National Board of Medical Examiners
Assisted by: William Werner, M.P.A.,
National Board of Medical Examiners

In the Fall of 2014, the National Board of Medical Examiners hosted a 2-day meeting with thought leaders in the area of interprofessional collaboration within the health care setting. The aim of the meeting was to identify opportunities to assess and improve the clinical performance of teams of health care professionals and improve patient outcomes. This meeting produced a number of promising possibilities and ideas. Most notably, a collaborative process produced what was termed the eight pillars of effective teamwork—a list of concepts and competencies that the group believed to be the foundation of team assessment:

1. leadership
2. trust and respect
3. communication/listening
4. foundational knowledge
5. performance
6. flexibility/adaptability

7. backup (supportive) behavior
8. team/collective orientation

As most health care is delivered by a team of professionals from a variety of disciplines at a number of experience levels, identifying ways to assess their clinical performance is an integral part of the future of both health care provision and education across professions. The accreditation workshop presents a rare opportunity to take a deeper dive into the “eight pillars of effective teamwork” and understand where other members of the education and assessment community prioritize interprofessional team training and performance as part of the accreditation process.

Interprofessional Education: Discussion 2
Buy-in for Interprofessional Education (IPE) Standards in Accreditation

Abstract submitted by Lemmietta G. McNeilly, Ph.D., CCCSLP, CAE Chief Staff Officer, SpeechLanguage Pathology, ASHA Fellow, American SpeechLanguageHearing Association (ASHA)

The challenges and opportunities for consideration by each of the health professions, including IPE standards in accreditation are multifactorial. Implementation of IPE and interprofessional practice is variable and occurs in different capacities across the globe. Collaborative professional practice drives accreditation standards and is a significant component of the changes in some professional standards. Accreditors conduct practice analyses periodically, typically every 5–10 years. These include literature reviews and multiple data points as elements for considerations as standards are updated. With changing practice patterns and varying degrees of data available that support the efficacy of IPE, it is important that accreditors and those that support inclusion of IPE standards clearly describe the rationale for inclusion of IPE in accreditation standards. It is also important for accreditors to use mechanisms that facilitate buy-in from academic programs regarding the standards that address interprofessional education and collaborative practice. Academic programs will employ the standards in ways that yield success for the university. Identification of key strategies and sharing of clear messages to convey the elements of IPE to all significant parties are necessary components that will result in successful outcomes.

Enhancing Quality and Innovation: Discussion 1
Is Accreditation Necessary for a Quality Training Program?

Abstract submitted by Debbie Hettler, O.D., M.P.H., FAAO Clinical Director, Associated Health Education, Office of Academic Affiliations, U.S. Department of Veterans Affairs

The U.S. Department of Veterans Affairs (VA) Office of Academic Affiliation (OAA) established an innovative pilot program to provide residency training for physician assistant (PA) residents during the 2012–2013 academic year. The goal of the program was to increase the available pool of residency-trained and credentialed physician assistants able to assist in the advanced care of veterans in patient-aligned care teams (PACTs). It was also the hope of this pilot program to demonstrate that the training of physician assistants within the VA would promote their recruitment and retention within a PACT. Approximately half of those completing the program were hired by VA at the conclusion of their training. OAA is looking to expand this pilot to include a mental health physician assistant residency for the 2016–2017 academic year.

All affiliate-sponsored training programs that rotate trainees through VA usually must be accredited by the appropriate agency, which must be recognized by the U.S. Department of Education or the Council for Higher Education Accreditation. All VA-sponsored training programs must be accredited. In general, it is the program itself that must be accredited by the appropriate accrediting body for that discipline. Accreditation of the school by a regional accrediting body does not suffice. In some disciplines, accreditation cannot be granted before the program has graduated trainees. For these programs, as well as pilot programs, there must be a credible plan for achieving full accreditation within the first 3 years of its existence.

The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) is the accrediting agency that protects the interests of the public and the PA profession by defining the standards for PA education and evaluating PA educational programs within the territorial United States to ensure their compliance with those standards. The ARC-PA is an independent accrediting body authorized to accredit qualified PA educational programs leading to the professional credential of PA. Accreditation is a process of quality assurance that determines whether the program meets established standards for function, structure, and performance. In July 2014 the programs were informed that ARC-PA had decided that the current accreditation process for clinical postgraduate PA programs will be held in abeyance. They went on to state,

• Is accreditation necessary to guarantee quality training programs, or just an additional cost burden to the health care system?
• What alternative systems can assure quality if accreditation is not available?
• Can accreditation be properly done for one discipline by another discipline?
• Are there opportunities for multiple disciplines to share an accreditation process?

Enhancing Quality and Innovation: Discussion 2
The Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education

Abstract submitted by Joseph A. Zorek, Pharm.D.¹; and Cynthia L. Raehl, Pharm.D.^2
1University of Wisconsin–Madison;
²Texas Tech University Health Sciences Center

A comparative analysis of IPE accreditation standards throughout 10 U.S. health professions was published in 2013 in the Journal of Interprofessional Care. The IPE accreditation statements from nursing and pharmacy were most robust. Collectively, results indicated that graduates were not required to complete IPE and, therefore, may not have been prepared for collaborative practice. A common IPE accreditation standard was proposed as one mechanism to improve team readiness across professions. Since this publication, several U.S. accrediting bodies formed the Health Professions Accreditors Collaborative (HPAC).² This group has endorsed the Interprofessional Education Collaborative’s (IPEC’s) core competencies and pledged to pursue the common goal to better prepare students

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² Members of HPAC include the Accreditation Council for Pharmacy Education, the Commission on Collegiate Nursing Education, the Commission on Dental Accreditation, the Commission on Osteopathic College Accreditation, the Council on Education for Public Health, and the Liaison Committee for Medical Education.

for collaborative practice. Several accrediting bodies also released updated standards at this time. Given these developments, the decision to pursue an update to the comparative analysis was made to explore the effect of these changes on quality and innovation in health professions education. Results showed a clear uptake of language and competencies from IPEC’s expert panel report. The most notable changes were observed in the accreditation documents from medicine (both allopathic and osteopathic), pharmacy, and psychology. Trends observed indicate that innovation in IPE accreditation is occurring via adoption of a common competency framework alongside active coordination among several accrediting bodies. This raises important questions about the role of accreditation in enhancing quality and innovation in health professions education.

High-Stakes Examinations: Discussion 1
High-Stakes Testing: Implications for Accreditation Standards for Health Professions Education

Abstract submitted by Mary E. Mancini, R.N., Ph.D., NEBC, FAHA, ANEF, FAAN
Associate Dean and Chair, Undergraduate Nursing Programs,
Baylor Professor for Healthcare Research,
College of Nursing and Health Innovation,
The University of Texas at Arlington

Accreditation standards associated with simulation centers, such as the Society for Simulation in Healthcare’s accreditation program for simulation programs, and specialty accreditation programs for discipline-specific education should be used to define and monitor organizational proficiency in the use of high-stakes testing. While there is an increasing tendency toward the use of competency-based assessment models, there is little discussion about the requirements an organization should meet to have consistency among its assessors such that there is proficiency in doing these assessments in a manner that assures reliable and valid results.

Potential questions include

1. What standards should accreditation agencies consider applying to organizations that use high-stakes testing?
2. Are their minimum criteria for individuals involved in making high-stakes assessments?
3. What are the best practices for creating the environment for reliable and consistent high-stakes testing?

Schools for health professionals can demonstrate they are using evidence-based best practices when evaluating students’ performance in the simulation setting through demonstrating adherence to accreditation standards for performance in the area of assessment.

Resources

American College of Surgeons. 2016. Accredited education institutes. https://www.facs.org/education/accreditation/aei (accessed September 21, 2016).

McLeod, G. A., J. Barr, and A. Welch. 2015. Best practice for teaching and learning strategies to facilitate student reflection in pre-registration health professional education: An integrative review. Creative Education 6(4):440-454.

NLN (National League for Nursing). NLN fair testing guidelines for nursing education. Washington, DC: NLN.

Sando, C. R., R. M. Coggins, C. Meakim, A. E. Franklin, D. Gloe, T. Boese, S. Decker, L. Lioce, and J. C. Borum. 2013. Standards of best practice: Simulation Standard VII: Participant assessment and evaluation. Clinical Simulation in Nursing 9(6):S30-S32.

SSH (Society for Simulation in Healthcare). SSH accreditation of healthcare simulation programs. http://www.ssih.org/Accreditation (accessed September 21, 2016).

High Stakes Examinations: Discussion 2
Setting, Implementing, and Acting on a Bright-Line Outcome Standard³ for Program Pass Rates on a National Board Exam

Abstract submitted by Mark Merrick, Ph.D., ATC, FNATA President, Commission on Accreditation of Athletic Training Education

The call for transparency and accountability in accreditation has never been greater, and the focus for the public and governmental agencies centers on educational outcomes. Accreditation standards that set clear and understandable expectations for student outcomes and that establish accountability for educational programs are in demand. As a specialty accreditor, the Commission on Accreditation of Athletic Training Education (CAATE) noted a sharp disparity in performance of graduates of some programs on the profession’s credentialing examination. In response, CAATE examined metrics related to program performance and, in 2012, CAATE implemented a bright-line standard that delineated a minimum 3-year aggregate first-attempt pass rate on the credentialing exam. In 2016, once programs had graduated three cohorts under the standard, CAATE placed 26 percent of the accredited professional programs on probation for violation of this standard. CAATE also created and shared a decision algorithm for accreditation actions relative to this standard that clarifies how decisions for

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³ Set by the accrediting body, a bright-line outcome standard is a clearly defined, objective measure of competence.

probation, show cause, and withdrawal of accreditation for noncompliant programs are reached. CAATE’s experience in creating, implementing, and now enforcing the standard includes some difficulties and successes that may be informative to both accreditors and education associations when considering potential bright-line standards.

Innovation: Discussion 1
Accreditation Versus Innovation

Abstract submitted by Rick Talbott, Ph.D., FASAHP, FASHA, FAAA
Dean, Pat Capps Covey College of Allied Health Professions,
University of South Alabama; Past President,
Association of Schools of Allied Health Professions;
President, Allied Health Professions Political Action Committee

The one issue that is of most concern to nonmedical programs and nursing programs is coping with the limitations that many of the professional accreditations agencies put on innovative ways to achieve clinical experience and competence. A major bottleneck in meeting the increasing demand for allied health professionals is the inherent restrictions that many professional accreditation standards put on alternative pathways to clinical competency—such as an unnecessary degrees or other discipline requirements of preceptors, limitations on the use of simulations and virtual-standardized patients, and sometimes inadvertent but controlling language that restricts innovative solutions to educationally efficacious and opportunity-expanding solutions.

Innovation: Discussion 2
Using Accreditation to Foster Well-Being and Address Burnout in Health Professionals, Students, and Educators

Abstract submitted by Elizabeth (Liza) Goldblatt,
Academic Collaborative for Integrative Health

This discussion group will explore the role of accreditation in ensuring that schools or programs address the health, well-being, and resilience of health professional students and their educators. Such accreditation requirements could prepare the future health workforce to better deal with the known stresses of work in health care environments that lead to unhealthy or destructive behaviors and/or burnout of health professionals. Health professionals who are aware of the importance of health and well-being and have their own personal methods for cultivating resilience could, in turn,

support skill building that will help the future health workforce assist their patients toward disease prevention, health, and greater well-being.

It is well known that many of today’s health professionals experience high levels of job-related burnout caused by the stressful nature of their work. Parallel challenges are often evident in cohorts of students preparing for these professions. Such ongoing stress not only negatively affects their personal health, but also affects the health of the patients with whom they work. How well can health professionals be expected to focus on the health and well-being of their patients if they are not engaged in such practices in their own lives? In addition, highly educated health professionals in whom a significant societal investment has been made may choose, through dissatisfaction, to leave their primary profession in search of more work/life balanced careers at this time when there are multiple pressures on the health care workforce.

Based on a recent informal review of accrediting standards and competencies for a limited set of health professional education (M.D., R.N., N.D., D.C., L.Ac., massage therapy) it appears that programs may include content on self-care that is not reflected in accreditation documents (or criteria). Exceptions are the Commission on Massage Therapy Accreditation (COMTA, 2016) that requires a self-care component within the curriculum competencies and the Council on Naturopathic Medical Education that requires students have “a well-developed sense of personal wellness” (CNME, 2016).

In addition, the Academic Council for Graduate Medical Education has recently engaged a process that is developing “a pathway for moving forward to positively impact resident/faculty/practicing physician well-being” (ACGME, 2016). These and other examples from participants’ institutions and professions will be used to inform the discussion on education accreditation standards for addressing well-being, stress, and burnout of health professionals, students, and their educators.

WEBCAST SESSION

While participants attended the Marketplace of Ideas, a side event provided opportunities for the webcast viewers to also consider innovations geared toward virtual participants from around the globe. The session was moderated by Maria Tassone, University of Toronto, Canada, and featured three presentations related to accreditation.⁴ Below are the abstracts for each webcast session presentation. These abstracts were prepared by the individual workshop speakers listed, and have not been endorsed or verified

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⁴ Videos of the webcast session can be found on the Global Forum on Innovation in Health Professional Education workshop website, www.nationalacademies.org/hmd/Activities/Global/InnovationHealthProfEducation/2016-APR-21 (accessed September 21, 2016).

by the National Academies. They should not be construed as reflecting any group consensus.

Social Accountability and Accreditation

Abstract submitted by Roger Strasser, A.M., Dean, Northern Ontario School of Medicine, Canada

This brief presentation will explore examples of mechanisms that connect socially accountable education to accreditation. The World Health Organization (WHO) defines the “social accountability of medical schools” as “the obligation to direct their education, research, and service activities toward addressing the priority health concerns of the community, region, and the nation that they have a mandate to serve” (Boelen and Heck, 1995). Accreditation of medical and other health profession schools has the potential to encourage their programs to be socially accountable and guided by the values of quality, equity, relevance, partnership, and cost-effectiveness. In Canada, the Committee on Accreditation of Canadian Medical Schools now includes social accountability as an element in the standard on mission, planning, organization, and integrity of the medical education program. The Training for Health Equity Network (THEnet) is a group of health profession schools worldwide that are guided by a social accountability mandate. THEnet developed, piloted, and published an Evaluation Framework for Socially Accountable Health Professional Education that assists schools in implementing and assessing their social accountability. The Northern Ontario School of Medicine (NOSM) has a social accountability mandate and engages the community as a key mechanism for development, delivery, and evaluation of NOSM’s education programs. There is great potential for socially accountable education programs to produce a “fit-for-purpose” health workforce that is responsive to community health needs.

Accreditation and the Search for “New Professionalism”

Abstract submitted by Jan De Maeseneer, M.D., Ph.D. (Hon) FRCGP¹; and Barbara Krekels, M.A.^2
1Ghent University, Belgium;
²Flemish Strategic Advisory Council Welfare, Health and Family, Belgium

Context

A comprehensive accreditation procedure should be able to assess whether professional education is responsive to the future needs of the

population. Institutions for health professional education have the opportunity to engage in a reflection at policy level concerning the changes related to sociodemographic, cultural, and epidemiological developments in society. We report how such a process actually takes place in the Flemish region in Belgium.

Objective

The objective is to define the “professional profile” that will be needed in health care and welfare in the future to respond to societal change.

Methods

Meetings and plenary discussion of the Strategic Advisory Council for Welfare, Health, and Family in Flemish region, composed of 28 stakeholders from the large civil society: supply; demand; personnel in the sector of well-being, health, and family; professionals; socioeconomic organizations (e.g., trade unions, employers, representatives of people living in poverty). Moreover, there are eight independent scientific experts in the council.

Results

The council reported that the changing society will be characterized by more complexity with an increasing ethnic and cultural diversity, an economic trend toward more competition, an aging society, a change in family structures, increasing chronic conditions, and scientific and technological developments. The changes in society entail more individualization, a focus on autonomy and self-determination, but also more uncertainty and dysfunctioning of human beings.

Actually, the answers to the challenges have been sought in more specialization (as a strategy to reduce complexity), instrumentalization of professional work, and medicalization and therapeutization.

The priority of comprehensive care and support should be to contribute to the quality of life. This requires an eco-bio-psycho-social model where people value their possibility to function and their ability to participate in society.

The council decided that we need new answers: a more generalist approach is needed and emphasis should be on connecting people—connectedness as a precondition for autonomy. To achieve those goals, professionals require generalist competencies—enabling a professional to provide care and support, based on the general strategy, with the aim to address a broad range of unspecified health and/or well-being (related) problems. The care should focus on the quality of life, on supporting self-

care and the care of informal caregivers, on strengthening social cohesion, on embracing diversity, and on the appropriate use of technology and information and communication technologies. The care provider should focus on functioning, pay attention to what really matters for people, support autonomy through information, and strengthen participation and inclusion. Finally, the council did not see the solution to the challenges in the creation of a “superprofessional,” but in stimulating interprofessional cooperation.

Conclusion

A comprehensive accreditation process should take into account important policy documents, describing how the society is going to respond to new challenges. Based on the experience in the Flemish region in Belgium, institutions for health professional education should focus on more generalism and an approach integrating personal autonomy with connectedness and social cohesion. Curriculum design, didactic approaches, clerkships, and skills training of health professionals should be assessed in the light of those developments.

Educational Program Recognition for Meeting the International Confederation of Midwives Midwifery Educational Standards

Abstract submitted by Mary Barger, Ph.D., M.P.H., CNM, American College of NurseMidwives

Well-educated midwives are capable of delivering nearly 90 percent of the essential care of women and their newborns before and after birth (UNFPA et al., 2014). Adequate numbers of midwives are the most cost-effective solution to reducing infant mortality and improving maternal health globally. However, only four of the countries with high rates of maternal and newborn mortality have enough educated midwives to meet the needs of the population (UNFPA et al., 2014). Thus, the urgent need to produce more midwives is met by some policy makers urging the development of truncated midwifery education programs to produce the quantity, but not the quality, of needed midwives.

In 2009, with an update in 2011, the International Confederation of Midwives (ICM) adopted and promulgated the ICM Global Standards for Midwifery Education (Thompson et al., 2011). Detailed companion documents were developed to assist educational programs to develop both their curriculum and their faculty to meet these standards. However, the literature is sparse, especially in less developed countries, about established processes to assure the public that midwifery educational programs meet these or any other standard of education.

In a first attempt to identify if midwife educators perceived a need for a program that would recognize if their programs met the ICM Education Standards, an Internet survey was untaken in 2014. The survey was developed by members of ICM’s educational standing committee with feedback from persons on the committee’s email list of educators. The survey asked four basic questions:

1. What is the perceived need for a recognition process?
2. What is the feasibility of the educational program to produce a self-evaluation report, and what resources would be required?
3. What are some ideas about how to verify the report, and what resources would be required?
4. What is the willingness of local midwives to be trained as program verifiers?

Invitations to complete the survey in English, Spanish, or French were disseminated through the committee’s email list, the Global Alliance for Nursing and Midwifery email list, and through reaching out to individual educators in low-resource countries.

A total of 227 surveys from different countries with all regions of the globe represented were completed. English was the language used by the majority of respondents (69 percent), followed by Spanish (23 percent) and French (8 percent). Nearly 80 percent of respondents identified a need for a recognition program, and a similar percent agreed they were capable to prepare both a self-evaluation report and a verification process. However, less than 20 percent did not identify needing extra resources for either of these tasks. About half endorsed needing additional financial resources and additional staff time, with 46 percent identifying needing some expert consultation to prepare a self-evaluation report. Presumably any global recognition program would rely on electronic transmission of reports and documents, and 40 percent of respondents identified needing improved electronic capacity. Lastly, 82 percent felt midwives would volunteer to be trained and act as verifiers for the process but should be compensated.

The results showed a large majority of educators would like a mechanism to demonstrate the quality of their midwifery education programs. This result was somewhat surprising given the large number of responses from countries that already have fairly strong midwifery education program accreditation processes, namely Australia and New Zealand, the European Union, North America, and the United Kingdom. Some respondents saw a recognition process as important for improving global practice and assisting with the movement of midwives among countries as well as identifying programs for student exchange experiences.

REFERENCES

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