The Sun Never Sets on Graduate Medical Education-International Peer Review of ACGME-I-Accredited Programs and Institutions.

Abstract

Since 2009, the Accreditation Council for Graduate Medical Education-International (ACGME-I) has accredited Sponsoring Institutions, residency programs, and fellowship programs outside the United States with the mission of improving health care in those countries by improving the education of physicians.1 When it began in 2009, ACGME-I accredited programs in one country, Singapore, and the review process was conducted by ACGME senior staff members. Today, the sun never sets on ACGME-I-accredited programs. ACGME-I accredits 165 residency and fellowship programs and 19 Sponsoring Institutions in Asia, Africa, the Middle East, and the Americas. Accrediting Sponsoring Institutions and educational programs with differing patient populations, disease demographics, and medical practice patterns takes an approach that is flexible yet maintains standards of quality education and patient care. The purpose of this article is to describe how ACGME-I realizes its mission by conducting peer review on an international scale.ACGME-I recognizes that global accreditation comes with an obligation for peer review using a collaborative and inclusive process conducted by peers representing the jurisdictions under review. To meet this goal, the makeup and structure of meetings for the Review Committees-International (RC-I) is different than Review Committees in the United States. While a US Review Committee includes geographic representation from all areas of the country, the RC-I strives to include members from each of the countries where ACGME-I accredits programs. While US Review Committees focus on one specialty, ACGME-I has 2 RC-Is, one that reviews medicine-based programs and one that reviews surgical/hospital-based programs. Each committee includes a broad representation of specialists across regions and specialties, and Sponsoring Institutions are reviewed by either RC-I as both committees include members who are designated institutional officials. Membership on the current committee and the specialties reviewed are outlined in the Table.Currently, the RC-I meets twice a year over a 3-day period. Each meeting includes a 1-day program review meeting for the medicine-based and the surgical/hospital-based committees. Between these 2 days, a committee of the whole group convenes in a business meeting where the RC-I discusses revisions to program requirements, revisions to policy, new member nominations, and makes recommendations to the ACGME-I Board of Directors for final approval.The goal of ACGME-I is to have an accreditation process that is transparent, impartial, and without bias. RC-I members have a fiduciary duty toward the ACGME-I to declare any perceived, potential, or actual conflict of interest (COI) in all their activities and to follow the policies and procedures as outlined in the ACGME-I Manual of Policies and Procedures.2A module is held at the induction of all new members to the committee with the goal of providing insight into ACGME-I COI policy. Definitions and details of the policy are explained to help members identify areas of potential or actual COI. ACGME-I considers that a COI exists for any program or institution in the same country as the member. Additionally, an annual declaration is completed, giving members the opportunity to identify other COI by answering specific questions related to their professional or financial interests, and thus identifying areas in which a potential conflict or duality of interest would occur. The policy is available on the ACGME-I website on an annual basis, and members are encouraged to review and agree to follow the policy.The medical and surgical/hospital-based review committees are made up of members from countries with ACGME-I-accredited institutions and programs, as well as members from the United States. Because of the size and structure of these committees, it is inevitable that one or more of the programs reviewed or policies discussed at the business meeting will represent a conflict or duality of interest to one or more members. For program and Sponsoring Institution accreditation decisions, COI is addressed at different stages of the process. First, ACGME-I staff assign reviews based on declared COI and to those outside the country or jurisdiction of the program or institution under consideration. Second, ACGME-I staff remove all documents related to a member's COI from their reviewer book. Finally, at the review meeting, the concerned member is recused during the discussion and decision-making process for all programs to which they have a COI. For program requirement revisions or policy discussions, actual, apparent, or potential conflict or duality of interest does not automatically preclude members from being part of the discussion or decision-making process. In fact, the perspectives offered by members most familiar with the relevant cultural or local context are often invaluable. If there is a question or concern about COI, the committee chair will address the matter according to the policy.The Figure illustrates the continuous improvement cycle of institutional and program review. The first step in ACGME-I accreditation is for the Sponsoring Institution to achieve accreditation. ACGME-I's Sponsoring Institution requirements outline personnel and a committee structure to provide institutional oversight of accredited programs. The Sponsoring Institution requirements also include policies that must be in place to protect residents and fellows along with requirements to help ensure a healthy and safe work environment.Once a Sponsoring Institution achieves initial accreditation, programs must meet 2 sets of ACGME-I requirements. Foundational Requirements outline the educational infrastructure and minimum resources needed for all specialty programs.3 These include robust systems for program, faculty, and resident evaluations; resident and faculty appointment; faculty ratios; and minimum time for program director and core faculty members. While Foundational Requirements are uniform across specialties, each program must also meet a second set of specialty-specific Advanced Specialty Requirements. These specify what programs must implement in terms of the educational infrastructure and what they must demonstrate regarding their competency-based curriculum, resources, and other learning experiences that are essential in the discipline. The RC-I reviews programs to determine whether there is substantial compliance to each set of requirements before awarding initial or continued accreditation. A program can be awarded Advanced Specialty accreditation only if both sets of requirements are met. Reviews consider and triangulate multiple sources of information, such as submitted program information forms, site visitor reports, resident surveys, and faculty surveys. Accreditation decisions are communicated to programs via a letter of notification outlining any applicable citations, areas for improvement, or progress reports.Leading up to RC-I meetings, programs are assigned by ACGME-I staff to a primary and secondary reviewer. As there is broad specialty representation within the medical and surgical/hospital-based review committees, at least one of the reviewers is generally assigned from the same specialty or a related field (ie, a pediatrician assigned to review another pediatric subspecialty program). Although familiarity with the assigned specialty may be helpful to reviewers, it is far from essential and even less so in assessing Foundational Requirements. The focus of the peer review process is to determine compliance to set standards which all reviewers are able to apply as educators regardless of their specialty-specific knowledge. To further address potentially difficult reviews or borderline programs, the primary and secondary reviewers will touch base before the program is discussed with the full RC-I.The RC-I has other responsibilities in addition to conducting institutional and program reviews. These responsibilities center around providing input to decisions that will ultimately be made by the ACGME-I Board of Directors. For example, the RC-I reviews existing program requirements and develops new program requirements. As in the case with US programs, requirements are reviewed every 10 years. The process includes soliciting public comments from the international community on the ACGME-I website, followed by an extensive review of these comments and final revision by the RC-I before they are sent to the ACGME-I Board for final approval. The RC-I also has responsibility to nominate potential members and provide potential policy revisions to the ACGME-I Board.The guiding principle for program review is ensuring quality patient care. Program requirements are established to enhance flexibility to meet local culture and health care needs of the population while maintaining educational quality. The following examples illustrate how the RC-I has put these principles into practice.An example of how ACGME-I accreditation helped drive improvement in patient care is in pediatrics and the subspecialty of adolescent medicine. Advanced specialty requirements in pediatrics include the need for subspecialty faculty members and clinical experiences in adolescent medicine.4 Several programs in Middle Eastern countries were initially unable to meet these requirements, as pediatric practice ended at age 12, and no other specialty included education or clinical care focused on the unique health care needs of adolescent patients. To encourage improvement in patient care and education, the RC-I cited programs for their lack of a curriculum in adolescent medicine. To resolve these citations, pediatrics programs lobbied to increase the age that pediatricians treat patients to 16, and again to 18 years old. Subspecialists in adolescent medicine were hired, and new rotations and didactic sessions were added.One example of how flexibility is enhanced while quality is maintained is the way the RC-I judges faculty qualifications. In the United States, faculty members must have current certification in their specialties through either an American Board of Medical Specialties board or an American Osteopathic Association board. Initially, ACGME-I mirrored the US requirements by stipulating that all faculty members must have US board certification or its equivalent; however, faculty members from all over the world teach in ACGME-I-accredited programs, making it impossible for the RC-I to reliably determine equivalency. The committee reviewed policies and procedures at ACGME-I-accredited Sponsoring Institutions for making faculty appointments and found that robust systems for evaluating faculty credentials were in place. The committee decided to revise the requirement to allow faculty to have either US board certification or possess qualifications that meet all criteria for faculty appointment at the program's Sponsoring Institution. The Sponsoring Institution requirements were also revised to ensure robust processes were in place by specifying criteria the institution must include when making faculty appointments. This change put the responsibility for judging faculty qualifications on the institution, not the RC-I, and thus allowed flexibility to meet local standards while ensuring that quality processes were in place.Finally, an example from pathology illustrates how flexibility was permitted to meet local culture norms while educational quality was maintained. Religious and cultural practices and patterns of medical care in the Middle East result in few autopsies being performed, and qualified pathology programs at ACGME-I-accredited Sponsoring Institutions were unable to apply for accreditation. To resolve this problem, the RC-I formed a task force of Review Committee members, pathology program directors from the Middle East, and a US pathology expert. The task force studied autopsy practice in the Middle East and determined that revision of the autopsy requirement could provide appropriate educational experiences for pathology residents and still meet cultural practices. The revision reduced the total number of autopsies required and expanded the ways the requirement could be met. The result is that new pathology programs have been accredited throughout the Middle East, and the first reviews indicate that they are providing quality education in pathology.As the number of institutions and countries with ACGME-I-accredited programs grows, the makeup of the RC-I continues to evolve to become a truly international committee. Chairs of both committees are from ACGME-I-accredited programs, and in 2022, two-thirds of the members will represent countries with ACGME-I-accredited programs. Also beginning in 2022, the RC-I will include resident members from ACGME-I-accredited programs. The committee is now developing criteria for public members to be added in 2023. The public members will represent the population of countries where graduates of ACGME-I-accredited programs practice. These new additions to the RC-I will participate as full members in rendering accreditation decisions and will provide valuable input to the committees' deliberations.As familiarity and expertise in implementing ACGME-I accreditation standards improves, the process of accrediting programs has also evolved. In the beginning, review of programs was conducted periodically with cycle lengths and scheduled site visits. Starting with the 2017–2018 academic year, all programs in Singapore are reviewed annually in a process similar to the Next Accreditation System in the United States. With the 2020–2021 academic year, annual review of programs will be expanded to include all countries and jurisdictions where ACGME-I accredits programs.ACGME-I uses the US model of peer review that has been adapted to accredit Sponsoring Institutions, residency programs, and fellowship programs outside the United States. In the short term, the success of this adaptation is based on accreditation requirements that are flexible while maintaining quality and a process guided by a set of policies and procedures to ensure a fair and unbiased review conducted by international peers. In the long term, success will be measured within the countries and jurisdictions where ACGME-I accredits programs so that hopefully the sun never sets on improvements in physician education and ultimately on improved patient and population health.