Program accreditation

Introduction

Program accreditation requires standards of structure, process and achievement, self-assessment, and review by outside experts (1). It is usually a voluntary process based on published standards and performed by a governmental or non-governmental agency of peers. The accreditation process has several components:

• Completion of a self-assessment guide. A training program requesting accreditation completes a self-assessment guide. This guide is based on published accreditation standards. Completion of the guide allows the program to determine any gaps or weaknesses in their training. Gaps can then be addressed prior to the formal site visit.
• Review of self-assessment by accrediting agency. The accrediting agency reviews the program self-assessment, makes recommendations for improvement, and indicates whether the program has a realistic chance to meet the accreditation standards.
• Site visit. The accrediting agency must verify the contents of the self-assessment guide. This is traditionally done face-to-face. However, modern technology allows the possibility of virtual site visits via the internet. The site visit includes a tour of the facilities, review of training program materials (curriculum, assessment tool results, etc.), and separate interviews with the program’s Chairperson, Director for Education, faculty and residents. The site visitors prepare a report of their findings.
• Accreditation decision. The accrediting agency reviews self-assessment and site visitor report to determine if standards are met. A decision is made to accredit for a limited, defined time period or not to accredit. Recommendations for improvement are given.
• Re-accreditation. To maintain accreditation the program must complete the self-assessment towards the end of the limited, defined accreditation time period and go through the accreditation process again.

Why program accreditation?

The quality of eye care training programs varies throughout the world and within most countries. The reasons are multifactorial but two critical factors are the lack of national and international training

standards and lack of external review of training program quality. Adoption of program accreditation standards set a minimum bar and drive program improvement. This in turn protects the residents’ education, protects the public and will improve patient care. Alkhenizan and Shaw did a systematic review of the literature and identified 26 studies evaluating accreditation and health care outcomes (2). They found accreditation led to improved health care services and clinical outcomes in a variety of subspecialties including trauma, cardiology and sleep medicine.

Several groups have strong opinions on the value of program accreditation. The World Federation for Medical Education (WFME) views program accreditation as: “…a tool for protecting and improving the health of the population as well as for improving the quality of education (3).” The World Health Organization (WHO) and the WFME have formed a strategic partnership to improve medical education. One of their main initiatives is promotion of accreditation of basic medical education. This has led to accreditation standards for basic medical education (4) and a template to guide creation of postgraduate medical education accreditation (5). The Lancet Global Independent Commission concluded that “accreditation is central to the professional education institutions linking their instructional activities to their societal purpose (6).” The Carnegie Foundation also supports the development of program accreditation and says, “Accreditation systems should develop criteria for assessment, define metrics of output, and shape the competencies of graduates to meet societal needs (7).”

In 2014 the ICO Accreditation Position Paper endorsed accreditation of eye care training programs: “The ICO strongly believes that accreditation of eye care training programs, at all levels for the eye care team that includes residents, ophthalmic nurses, and ophthalmic allied health personnel, is essential to ensure the quality of training and ultimately delivery of the best eye care (8).” Furthermore, the position paper concludes: “The process of accreditation is essential to standardized quality eye care training.” Accreditation will drive programmatic improvement and ultimately a better eye care workforce.

Who is accrediting now?

Most existing ophthalmology training program accreditation bodies are either national or regional. Accreditation of residency programs is essentially mandatory in North America, the United Kingdom and Australia. Only a small number of other countries off accreditation. Regional program accreditation is offered through the European Board of Ophthalmology (EBO) and the West African College of Surgeons (WACS).

To my knowledge, international ophthalmology program accreditation is only offered by one group at present, the Accreditation Committee for Graduate Medical Education International (ACGME-I). They are an offshoot of the accreditation agency for graduate medical education in North America. They have worked with seven institutions in Lebanon, Qatar, Oman, Singapore and the UAE (9). However, their requirements will mostly be relevant to highly developed countries. For instance, they require the ACGME-I Review Committee determine the number of residents a program may train (10). Many countries are told how many residents they will train by governmental agencies. In addition, surgical education is required and residents must have 36 hours of ocular pathology (11). Surgery is not a global requirement for ophthalmology training programs and many do not have access to ocular pathology training. Finally, for residents to be accepted into a ACGME-I program they must have successfully completed a broad-based clinical year (PGY-1) in a program accredited by the ACGME-I, the Accreditation Council for Graduate Medical Education (ACGME), or the Royal College of Physicians and Surgeons of Canada (IV.A.2.a). Most residents entering ophthalmology training programs around the world will not graduate from a program as stipulated by the ACGME-I. Although admirable and aspirational, these requirements will discourage the vast majority of existing international ophthalmology training programs.

The ICO’s strong position on program accreditation led to the development of ICO International Guidelines for Accreditation of Ophthalmology Residency Programs in 2015 (12). The ICO Accreditation Committee (comprised of 10 international experts) utilized the aforementioned WFME guidelines template (5) and adapted it for ophthalmology training programs. Other existing accreditation guidelines (ACGME, EBO, Pan American Association of Ophthalmology (PAAO), WACS) were reviewed by the committee to aid in guideline development. The guidelines are organized into nine parts as recommended by the WFME:

• Mission and outcomes;
• Training process;
• Assessment of trainees;
• Trainees;
• Staffing;
• Training settings & educational resources;
• Evaluation of training process;
• Governance and administration;
• Continuous renewal.

In keeping with WFME recommendations there are both “Basic” (must have) and “Quality Development” (aspirational) levels of attainment. Thus, the guidelines comprehensively cover items such as expectations of residents, training setting, structure and resources, teaching methods, and assessment methods of the resident, faculty and program. The ICO guidelines are now being converted to a Self-Assessment guide that can be completed by a program to identify gaps and facilitate improvement. In addition, the ICO is starting a pilot project offering time-limited ICO Accreditation to ophthalmic training programs around the world. There will be both “Basic” and “Aspirational” levels of accreditation. There will also be two types of accreditation, “Full” that includes surgery and “Non-Surgical” because not all countries require surgery competence in basic residency training. The process of ICO accreditation will include self-assessment guide completion, site visit (face-to-face and/or virtual) and ICO review of the program’s data to determine accreditation status. The hope is that accreditation of programs will become a ubiquitous process, thus assuring some level of quality to students and ultimately better patient care. ICO Accreditation wilt also let the prospective resident know the program has met international guidelines and is of a certain quality. This should drive the best students to the accredited programs. This in turn will create the desire in other programs for similar recognition thus driving their program’s improvement, better resident education, and ultimately better patient care.

Conclusions

The process of accreditation is essential to standardized quality eye care training and should lead to continued program improvement, better resident education and improved patient care. The ICO has developed international accreditation guidelines and is developing a self-assessment guide based on these standards. The ICO International Accreditation pilot plan is being finalized and should bring the benefits of accreditation to programs where no accreditation system currently exists.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Eye Science for the series “Medical Education for Ophthalmology Training”. The article has undergone external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/aes.2017.06.03). The series “Medical Education for Ophthalmology Training” was commissioned by the editorial office without any funding or sponsorship. KCG served as the unpaid Guest Editor of the series. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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8. ICO Endorses Accreditation for Eye Care Training Programs. Available online: http://www.icoph.org/downloads/ICOAccreditationPositionPaper.pdf. Accessed April 9, 2017.
9. ACGME-I History. Available online: http://www.acgme-i.org/About-Us/History. Accessed April 9, 2017.
10. ACGME International Foundational Program Requirements for Graduate Medical Education. Available online: http://www.acgme-i.org/Portals/0/FoundInternational03312016.pdf. Accessed April 9, 2017.
11. Advanced Specialty Program Requirements for Graduate Medical Education in Ophthalmology. Available online: http://www.acgme-i.org/Portals/0/Specialties/Ophthalmology/ophthalmology07012016.pdf. Accessed June 15, 2017.
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