Accreditation has been defined as a process whereby a professional association or nongovernmental agency grants recognition to a school or healthcare institution for demonstrated ability to meet predetermined criteria for established standards 1
Accreditation within the medical arena is longstanding throughout history. In 1910, the Joint Commission was established with the primary mission of continuously improving healthcare for the public by evaluating healthcare organisations and inspiring them to excel in providing safe and effective treatment of the highest quality and value. In the past 100 years, accreditation has extended to medical education and more specifically the implementation of standards in the training of medical specialists. This article focuses on the accreditation of training centres in adult respiratory medicine.
The foundation of the EU directive 75/362/ECC in 1975 produced guidelines for medical training institutions across Europe which was believed would open access to the job market for European specialists in respiratory medicine while also producing documentation for training institutions to follow in order to achieve high-quality education. The implementation of such standards has by no means mirrored the reality of medical training of respiratory specialists in Europe today. Stark differences exist in the training duration, the sitting of exit examinations and accreditation of training centres 2. Consequently, despite such regulations, mobility across Europe continues to be a challenge for some doctors. Considering the unsystematic process of respiratory medicine training across Europe, there is most certainly scope to improve quality in patient care and to fortify adult respiratory medicine.
THE HERMES INITIATIVE
HERMES (Harmonising education in respiratory medicine for European specialists), is an initiative which responded to Europe's need to regulate education in respiratory medicine and ensure raising quality in adult respiratory care. A specialist Task Force representing 13 countries in Europe has worked prolifically since 2005 to support this educational mission for reform. Within the HERMES model, a structure for reaching these goals follows the development of a syllabus, a curriculum, an examination and finally the development of accreditation documentation for training centres in adult respiratory medicine in Europe.
The HERMES syllabus, published in 2006 3, is essentially a list of all the knowledge items which must be covered through the training period. The syllabus document forms the foundation of the curriculum, published in 2008 4, whereby further requirements referencing the knowledge, skills, attitudes, behaviours and guidelines that trainees need to attain are listed. The HERMES syllabus forms the backbone of the HERMES examination in adult respiratory medicine. Today, the HERMES examination is officially adopted as the knowledge examination part 1 of the national exit exam in Switzerland for trainees of adult respiratory medicine. Within the Netherlands, Dutch trainees took part in an in-training assessment pilot on October 8, 2010 with the possibility of adopting the examination as a yearly in-training exam or exit exam. Further campaigning has ensured that the HERMES examination was declared legally equivalent to the National examination in June 2010 as prescribed by the Austrian Society of Pneumology, Other countries including Greece, Ireland and Spain formally support and recommend the HERMES examination to trainees, a raising status which is affording the HERMES examination merit, esteem and legal recognition within Europe.
HERMES ACCREDITATION DOCUMENT
With raising international standards in healthcare, increasing public expectations and an increase in the prevalence of respiratory diseases, the familiar focus of accreditation of the hospital structure is now challenged. No longer can medical institutions accept that standards only apply to the traditionally accredited hospital structure, as a new shift moves towards the inclusion of processes and outcome in accreditation practices 5. Through the assessment of medical educational programmes with internationally accepted quality standards, the accreditation process and indeed the accrediting bodies move one step closer towards the common goal of the overall improvement of patient care and health 6.
Accreditation is the application of standards as a basis for sustained quality assurance. The purpose of the accreditation phase within the HERMES initiative is to ensure that all training centre networks in adult respiratory medicine across Europe, and beyond, have the opportunity to obtain accredited certification for their educational programmes in respiratory medicine training. With the intention of providing criteria for training institutions to follow, the HERMES accreditation document 7 was composed and structured in eight sections: 1) training centre network (participating sites and network structure); 2) minimum components for a full training programme in adult respiratory medicine; 3) content of clinical experience; 4) content of educational experience; 5) content of research and scientific experience; 6) infrastructure and support for the trainee; 7) organisation of the training programme; and 8) requirements for specific facilities.
Each of these sections within the accreditation document acts as the reference point to ensure that a training centre network meets the prerequisites of training in respiratory medicine, and are thus worthy of accreditation according to European standards.
METHODOLOGY
Discussions on the development of the accreditation document began in June 2009. The HERMES accreditation document was moulded using a number of key references to develop criteria and sections within the manuscript. The Task Force met on three occasions to review and modify until the final document was approved by all in March 2010.
In line with prescribed recommendations, the Task Force recognised a need to include indicative numbers of minimum procedures to be performed during training. In order to accomplish such a task attaining valid and reliable results, a survey was designed and forwarded to a larger audience of national delegates, training-programme directors and trainees in adult respiratory medicine across Europe. The purpose of the survey was to collate responses on the indicative number of procedures (within the HERMES syllabus and curriculum) to be performed by the training centre annually to ensure trainees' adequate exposure. This was a contentious issue for the Task Force as it would be the second time that the survey was to be conducted, the first attempt yielding limited success. With a slight variation in the wording of the survey to request the “minimum number of procedures to be performed during training to ensure the trainees' adequate exposure”, a clear trend emerged in responses. Although the survey offered ranges from <10 to >100, the Task Force successfully employed the results to establish indicative numbers of procedures which the training centre should perform yearly to ensure ample exposure during training. There was clear consensus among the Task Force that the number of procedures performed by a trainee is not a sufficient measure of a trainee's competence and should be in line with other observation and assessment techniques.
DISCUSSION
Great challenges are embedded within the implementation of the HERMES accreditation project phase. To employ high quality educational standards in respiratory medicine, a robust structure for accreditation must be set. The high costs required for implementation, the challenge of changing training processes, and the diversity of current training trends across countries present impending difficulties that lie ahead.
In a survey conducted by the European Respiratory Society (ERS) in 2005, it was established that not all countries have an official list of accredited training centres. Furthermore, while some countries within Europe have established independent bodies to regulate medical training at postgraduate levels, other countries rely on their national ministries to govern medical training programmes and have no official list of accredited training centres 8.
Trends in accreditation of medical training across countries emphasise disparities in educational standards and training criteria. To address these discrepancies requires the crossing of national and cultural boundaries, and to seek out means to provide all countries with the opportunity to meet at least minimum acceptable standards and to encourage competitiveness across respiratory specialist training centres in Europe. So, how can the HERMES Task Force overcome such challenges?
Development of robust accreditation documents and processes
Accreditation is highly dependent on a vigorous structure for assessment and its success demands a simple, easy to observe regime which is applicable to the hospital training centre. The HERMES Task Force will focus on three specific areas for development: 1) documented minimum criteria for accreditation; 2) supporting documents to determine if the criteria set within the accreditation document are met; and 3) requirements for the visiting programme and application for accreditation. The results yield clear documentation of standards and processes to be followed in order to be awarded European accreditation of ERS training centres in adult respiratory medicine. To date, the HERMES Task Force has successfully completed the first step.
The next stages refer to the process itself and are modelled on the deep-rooted accreditation practice within the medical arena: site visitation. Specifications for the accreditation body, self-reporting, the visitation programme 9 and costs are considered sections to be included in the final section of the criteria for accreditation document. However, the difficulties rooted in putting theory into practice 10 will require further investigation to ensure that the HERMES project offers the most applicable model for implementation.
Crossing international boundaries
In order to address further challenges of crossing legal and economic boundaries, a number of supporting initiatives are considered: collaboration with national and European societies; raising awareness at European level; and ensuring inclusive participation (possible provision of financial support). Although HERMES accreditation will bear no legal standing in individual countries, collaboration with European and national societies will assist in the campaign for recognition, merit and acclaim.
All initiatives and support structures required to create a rigorous accreditation programme continue to be deliberated by the Task Force. The future path of European accreditation of training centres in respiratory medicine is en route and now supported by the ERS Criteria for Accreditation document. The next and final stage intends to investigate the most effective methods and how to execute this project step.
CONCLUSION
The accreditation document offers a foundation with established criteria for certification. To implement an inclusive accreditation process whereby all training centre networks in respiratory medicine, have an opportunity for recognition, and the implementation of training standards in adult respiratory medicine is the final and most challenging hurdle the Task Force will confront.
Considering the lack of uniformity of respiratory medicine training in Europe and inconsistencies in standards across countries, the existence of the HERMES project is justified. In recent years, improving quality healthcare through the standardisation of criteria in education and training is a theme visited by a number of EU medical specialist organisations. Within the HERMES initiative, respiratory medicine has followed this path. The success of the project is already, to some degree, rooted in the evidence that many countries consider the HERMES documents and activities worthy of national and legal acknowledgement and a mark of European excellence. In the closing chapter of the adult HERMES project, there is little doubt of the positive contribution to its intended mission; delivery of exceptional practices in medical training in adult respiratory medicine and continuous enhancement of high-quality patient care.
Footnotes
Statement of Interest
None declared.
- ©ERS 2010
