Archives of Medicine and Health Sciences

MEDICAL EDUCATION
Year
: 2021  |  Volume : 9  |  Issue : 2  |  Page : 320--327

Quality assurance of medical education in India: The concerns, available guiding frameworks, and the way forward to improve quality and patient safety


Thomas V Chacko 
 Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India

Correspondence Address:
Prof. Thomas V Chacko
Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala
India

Abstract

With India having the largest number of medical schools (619) globally and these numbers are increasing every year, quality assurance (QA) in medical education is a matter of shared concern and responsibility for all stakeholders in India and the interconnected world. Hence, an attempt is made through key literature review on good practices by accreditation agencies that have put in place comprehensive QA systems in their respective countries. Looking through the lens of the “Systems Approach” (inputs–process–outcomes) to investigate and intervene in educational systems and the quality improvement framework followed by the UK, the focus of the system followed in India has been identified as predominantly “Inputs-based Minimum Requirements Standards” and essential elements of processes influencing the educational outcomes and quality control (QC) through monitoring of progression toward graduate outcome competencies among students and the workplace where they get employed as part of the scrutiny by accreditation system are found missing. The way forward to address the concerns of all stakeholders and ensure patient safety through well-known systems and processes of QA at the national level and QC through quality management within institutions is suggested. Further, the working models for quality improvement in medical education such as the World Federation for Medical Education Standards and the National Assessment and Accreditation Council Standards for Higher Educational Institutions are taken as exemplars for preparing a way forward that can be useful to the National Accreditation Agency and medical schools in India including its expeditious implementation by applying for international recognition as an accreditation agency is presented.



How to cite this article:
Chacko TV. Quality assurance of medical education in India: The concerns, available guiding frameworks, and the way forward to improve quality and patient safety.Arch Med Health Sci 2021;9:320-327


How to cite this URL:
Chacko TV. Quality assurance of medical education in India: The concerns, available guiding frameworks, and the way forward to improve quality and patient safety. Arch Med Health Sci [serial online] 2021 [cited 2022 May 29 ];9:320-327
Available from: https://www.amhsjournal.org/text.asp?2021/9/2/320/334020


Full Text



 Introduction



India has the largest number of medical schools in the world with 619 listed on the National Medical Commission (NMC) Website, of which 340 are administered by the government and 279 in the private sector, and together, they admit 126,000 students every year who will become the Indian medical graduates (IMGs). As per its recognition program, out of these 619 listed, 483 are recognized and the remaining are in the process of getting full recognition.[1]

 The Concerns



There are areas of concern about the quality of the graduates and therefore about patient safety, and the process of recognition of these colleges is based on fulfillment of input standards regarding infrastructure facilities and faculty which the institution must fulfill. The assumption here is that if input standards (minimum requirements) are met, the products of the educational system would be of acceptable standards and this is an area of concern as this need not always be true in every medical college in every state of India. However, in recent times, reform efforts have been made (by Medical Council of India [MCI] and NMC which replaced it) to move from traditional discipline-based knowledge-focused teaching to outcome-based competency-driven approach within the existing disciple-based delivery of the curriculum with documentation of competencies needed for professional tasks, roles, and attributes that the IMG must demonstrate. However, the concern remains whether the student assessment system actually measures the stated expected graduate outcomes and whether the proposed exit licensing examination would ensure that these graduate outcomes are measured.

Converting this document into learning experiences, although guided by the Curriculum Implementation Support Program of the NMC, still leads to varying interpretation by the universities and its affiliated colleges due to their varying institutional ethos and will take time to become of uniform acceptable standard across this vast country unless driven by accreditation regulations that start scrutiny of educational processes and stated outcomes. Absence of this scrutiny beyond specified minimum inputs and leaving universities to do the testing of graduate outcomes that use yet to be addressed faulty examination systems will lead to questionable “job readiness” of graduates in managing cases commonly seen at primary care and ambulatory settings. They are also expected to provide leadership and management of health teams, and plan, implement, and monitor national health programs.

This is also reflected in the shared concern of all stakeholders. Patients are vary of approaching basic MBBS graduate doctors as they are not sure and apprehensive about them: “Will s/he be able to diagnose and treat?”. The parents of students seeking admission to a medical college also worry: “Is the institution “recognized” by the Council? Is just doing MBBS enough?”. The medical colleges, particularly those in the private sector, are also subject to fierce competition for students and resources in a competitive and well-informed medical education “market,” and so, it is imperative that medical colleges need to maintain and improve quality so as to be highly sought after by academically brighter students. Thus, maintaining quality assurance (QA) and engaging in continuing quality improvement are also critical for the survival of the medical school. Besides, the processes involved in QA and quality improvement such as use of educational research and program evaluation also help inform institution's academic leaders and other stakeholders whether their “Vision and Mission” statements and “Goals” with which they started the institution are being met or need mid-course correction.

Another area of concern for the IMG is whether the qualification and license to practice in India are accepted globally. Informally, some IMGs completing their medical education from certain institutions in India are “recognized” and accepted, whereas those from other institutions are not. Thus, there is need for global recognition of India's National Accreditation Agency as being robust and trustworthy so that institutions recognized by them assures institutions in other countries to accept that IMGs are products of an educational system where the quality checks and systems are in place that measures outcome competencies and so can be trusted with patient safety and standard of care.

 Quality, Quality Control, Quality Assurance, and Quality Improvement



For measuring quality, we need to have standards against which attainment of quality is measured. Quality control (QC) is used to verify quality of output of an educational system of the product at the workplace and is done by supervisors and other immediate stakeholders. It is a term mostly used in industry where the products, if not meeting predefined standards, are rejected. In health and medical education, the preferred term is QA so that pre-identified, defined, and measurable educational including graduate outcomes (as identified and needed to meet community's health needs) are met to ensure that the product of the educational system is competent professionals, addresses patient safety concerns, and contributes to improving health of the people.

The UK Higher Education Agency defines QA as “the totality of systems, resources, and information devoted to maintaining and improving the quality and standards of teaching, scholarship, and research and of students learning experience.” Moreover, this involves “the systematic monitoring and evaluation of learning and teaching and the processes that support them, to make sure that the standards of academic awards meet the Expectations set out in the Quality Code, and that the quality of the student learning experience is being safeguarded and improved.”[2],[3]

For institutions aiming to improve the quality of medical education in a systematic and effective way, it is imperative to initiate QA as the first step. Quality improvement is often the next step for institutions to aim for after they have set up measures and processes that ensure QA. Moreover, since context, times, needs, and expectations change, it is prudent not to determine the level of quality at a fixed point in time but to initiate quality improvement as a continuing and dynamic process to review, critique, and change to make medical education even better than it currently is.

 Quality Assurance System: Internal and External



There are two important components of QA in the QA system, namely the internal and the external QA process. The internal QA system is more important since the educational dynamics among the student, the teacher, and the educational environment and facilities in which this happens is within the institution, and so, a system aimed at improving the processes would require frequent periodic reviews and remedial action has to be initiated from within. It is good practice for the institution to invite external educational experts to assist it with carrying out this internal review to bring in an outsider's perspective to “see” and address. The other component is external QA practiced in many countries through accreditation. This external scrutiny confirms that the medical school is adopting the right methodological approaches that ensure quality for all stakeholders, including the community that depends on the medical school for producing safe, effective, and caring doctors.[3]

 Some Guiding Frameworks to Understand the Process of Quality Assurance



A. Systems approach framework

Since educational institutions are systems, a systems approach framework (inputs–processes–outputs and outcomes) fits well as the lens to examine the educational system with, study the various factors influencing it, and thereby offer systemic interventions to ensure quality output and outcomes and use the feedback loop to improve it.

The inputs include the entry-level academic background and capabilities of students, the faculty strengths, i.e., student–teacher ratio, qualifications and capabilities, and the availability of infrastructure and learning resources needed for teaching–learning. The process includes the type of curriculum; the systems of teaching–learning and student assessment; the institutional leadership and system of governance; the educational environment and student support for progression, including mentoring system; teachers engaged in continuing professional and faculty development activities; the quality improvement activities and systems including promotion of education research; and program evaluation including use of feedback from students and other stakeholders. The output from the system in terms of the competencies and the professional attributes of the products – the Graduate of the Educational System.

Standards for each of the components of the above educational system (input–process–outcomes) in measurable forms are required to be laid down before the formal process of institutional accreditation is initiated. While laying down these standards, the country's relevant agency entrusted with the task of laying down the standards first begins with laying down the quality standards of the product, i.e., the graduate of the educational system in the country (based on the health needs and the attributes of the professional as done in “Tomorrow's Doctor” document, the answer to the question “What kind of a doctor you would like to be treated by when you fall sick?”).[4] Then, a backward planning exercise using the logic planning model can be undertaken to identify the quality standards of the processes, i.e., the system needed to produce the type of outcome graduate to finally, arrive at the standards for the inputs needed to make the process systems work. This will allow the CIPP Model of Program Evaluation to be used for quality assessment.[5]

B. The Comprehensive Quality Improvement Framework in the UK

A system for ensuring quality of medical education in the educational system in the country that has been put in place to ensure competent doctors and thereby ensure patient safety in the UK is comprehensive and is in play at three levels.[6]

1. Quality assurance at the national level by general medical council

This involves putting in place policies, standards, systems, and processes in place to maintain and enhance the quality of medical education in the country at all levels and stages of medical education and training. Approval of institutions is done by it by assessment against standards.

2. Quality management at the medical educational institutional level

All educational institutions need to set up quality monitoring and management system that ensures compliance with standards at the institutional level and at the local educational provider level and submit compliance reports with evidence on compliance with standards to the general medical council (GMC). It engages in quality management (QM) on a continuing basis via internal action plans and remedial action taken for ensuring quality within the institution as mandated by the standards. Besides, internal review by internal educational experts, use of external examiners, and external educational experts are also involved to review the quality of curriculum delivery to ensure comparability of standards with other institutions and share good practices.

3. Quality control at the affiliated local educational provider level

The local educational providers (LEPs) are the places where the clinical training of students takes place under close supervision and assessment by specialists. They are required to have a local officer who is accountable to ensure that students receive education and training that meets local and professional standards and provide evidence that GMC's requirements and standards are fulfilled.

Key Components of Quality Improvement Framework in the UK

There are four principal elements of the accreditation system with key elements of shared evidence to ensure transparency in the process for all stakeholders:[6]

Approval against standards: Standards for education and training are the essential element of quality improvement framework (QIF) against all other elements being developed and measuredShared evidence of compliance to the standards and requirements and about effectiveness of QM system being implemented in the institution and quality control at sites of clinical trainingSite visits including checks are carried out by a multistakeholder team of medical educationists, specialists, training program directors, employers, medical students, and lay members so that compliance with standards, requirements, and outcomes at the medical school and clinical training level can be verified and activities of internal QM and QC reviewed. They also undertake supporting activities, including sharing of good practicesResponses to concerns about deficiency in evidence regarding quality. Raising a concern is a nonpunitive process to resolve training problems before considering withdrawal of approval. If there is evidence of concern about risk to patient, student, and trainee safety, it provides for quick proactive remediation.

 Comparison of Some Exemplars of Accreditation Models



With the view to understand and adopt some good practices among working models, a comparison of various key elements is made and is shown in [Table 1].{Table 1}

It shows that the current system of accreditation of medical schools in India remains at the stage of verification of the inputs needed for an educational system that aims to produce the IMG. It is being assumed that if inputs are in place, the desired outputs and outcomes will be achieved. This is further compounded by the existing system of summative assessment with pass/fail decisions arrived at by the respective universities that fail to capture and verify attainment of all the competencies expected of the IMG. The current system is more of the “QC of the inputs type” rather than QA and quality improvement followed in the other systems of accreditation. For QA system to be more effective, there is need for a closer scrutiny of educational processes and outcomes measurement. In addition, the verification of existence of a functioning system of quality management and QC within the institution will ensure speeding up of changes needed for quality improvement within institutions. It will also ensure that the patients, students, and trainees are not put at risk and remedial measures are undertaken in a dynamic way internally.

 The World Federation for Medical Education Global Standards for Basic Medical Education and Its Recognition of Accreditation Agencies program



To address the concerns regarding the quality of medical education at the global level, the World Federation for Medical Education (WFME) was established in 1972 by the World Medical Association (WMA) and the World Health Organization (WHO). The WFME Global Standards in the three phases of medical education (basic, postgraduate, and continuing professional development) emerged from three taskforce meetings of 60 medical education experts from the six WHO-WFME regions of the world was piloted, validated, and got published in 2003 and underwent revision in 2012 and 2015. The WFME standards are endorsed by the WHO,[7] WMA 2004 Resolution,[8] and the International Association of Medical Regulatory Authorities (IAMRA Statement 2016).[9]

Recognizing that not all WFME standards will be relevant in every country's setting, to gain wider acceptance across the world, the WFME has again revised the Basic Medical Education Global Standards in 2020 to make them broader in terms of educational principles-based standards that are intended to guide the regulatory agency of that country in development and evaluation of medical education in the settings unique to that country.[10] The compelling logic of this “principles-based standards” approach to be used by regulators is based the observation by Black et al. that “firms and their management are better placed than regulators to determine what processes and actions are required within their businesses to achieve a given regulatory objective. And so, “regulators, instead of focusing on prescribing the processes or actions that firms must take, should step back and define the outcomes that they require firms to achieve. Firms and their management will then be free to find the most efficient way of achieving the outcome required.” Thus, “principles-based regulation means moving away from reliance on detailed, prescriptive rules and relying more on high-level, broadly stated rules or principles to set the standards by which regulated firms must conduct business.”[11]

This approach to framing of regulations for ensuring standards makes perfect sense since in India MCI/MNC has moved to outcomes-based competency-focused curriculum to produce the IMG, and so, we need to generate the evidence and measure them to assure all stakeholders that the country's medical colleges and the educational system therein are indeed producing the competent IMG and that that they can be entrusted with the life of patients they would be treating.

 Use of World Federation for Medical Education Standards by Medical Schools



The eight areas that constitute the WFME standards for quality improvement[10] provide a template to the internal quality managers of medical schools to ask the right questions and seek solutions and measures to act as a lever for quality improvement. They can also be used by QC managers and faculty supervisors of training facilities in the medical school's teaching hospital to measure and test attainment of stated outcomes of the students and trainees undergoing the training program under their supervision [Table 2].{Table 2}

 Use of World Federation for Medical Education Standards by the National Accreditation Agency, i.e., the National Medical Commission



The WFME Standards will help them become more in line with their own transition to competency-focused outcomes-based medical education curriculum and thereby keep up with global trends in QA. It will help them move from their current narrow “inputs-level QC-like approach to regulation of medical education” to a more comprehensive one. This must include promotion of institution's internal systems for QA and QI as well as verification of attainment of curriculum outcomes that aim at producing a competent IMG. The new principles-based approach standards of WFME will enable MNC to develop India's own standards guided by WFME's QIF and systems.

 The National Assessment and Accreditation Council Quality Improvement Framework



Within India, we have the National Assessment and Accreditation Council (NAAC) model instituted in 1994 by the University Grants Commission, which has elements of quality improvement for higher educational institutions. To meet the felt needs for quality by educational institutions in the health sector, the NAAC has developed a Health Sciences User Manual in 2006 that is being updated periodically to guide such institutions to apply for NAAC Accreditation.[12] The good elements in the NAAC accreditation process are that it has process elements such as scrutiny of curriculum aspects, student support and progression, governance leadership and management, as well as recognition of innovations and good practices. Although it has gone beyond the pilot stage, it does not have enough inputs from best practices that are time-tested globally in the field of medical education like what WFME has done. Hence, there is need to adopt the good elements in it by combining the processes it uses with standards developed from good practices in the field of medical education developed by the WFME for a mandatory accreditation by the NMC.

 Other Good Practices in Quality Assurance



The WHO Guidelines for QA of Basic Medical Education in 2001 recommended the following to be considered by national agencies and the medical school: [3]

Best practices in QA systems

It should include all major stakeholdersIt should be open to external public scrutinyIt should be conducted in a consultative and consensus-building fashionIt should be collegial but not be collusiveShould balance academic priorities with those of regulating authoritiesIt should identify both strengths as well as weaknessesShould encourage innovation and reorientation toward changing health needsShould monitor progress on an ongoing cycle of review

Should focus on achievement of self-specified objectivesIt should encourage a variety of methods of teaching and learningShould ensure there are adequate resources to deliver the curriculumShould be concerned with good outcomes and not just detailed specifications of curriculum content.

Who should be representatives within the independent agency, etc., so that it can function in a “continuous, transparent, and open way”?

Representatives of the medical school universitiesRepresentatives of the medical professionRepresentatives of the healthcare authoritiesRepresentatives of the registration authoritiesRepresentatives of the community.

Who should be the external reviewers who should review and report?

Since the review process needs good understanding of the educational processes and systems as well as should have experience in introducing educational innovations and measure outcomes as well as share best practices and also play a supportive role in providing ideas and suggestions to address concerns from an educational point of view, they should be:

Educationists and experts in the field of medical educationClinical supervisors with capability in outcome competency measurement and monitoring progress.

The above best practices, such as other good practices, have been used as Principles for the WFME Standards also.

 The Way Forward



To address the “Concerns” listed in the introduction, many medical schools and universities, especially in the private sector, have made QA an important part of their system of governance. The way forward is described at two levels based on the GMC's QIF described earlier:

At individual medical school level

Start a quality management system using the WFME standards or the one put in place by NAAC to review processes against standards so that there is continuing quality improvement. Essentially this means that there is institutional commitment to quality that is recognized by it as a critical part for success and recognition for institutional excellence. In order that the student competency progression and march toward targeted graduate outcomes are measured and monitored, clinical supervisors and faculty must be involved in the QC measures along with the remedial measures that the new CBME curriculum encourages so that all graduates are competent and job ready. Having these two (QA and QC) in place in the institution also makes the institution ready for compliance with the comprehensive standards (input–process–outcome) that National Accreditation Agencies requires of all medical schools.

At the national level

In a globally interconnected world, and to address some of the concerns associated with it that were listed earlier, the National Accreditation Agency must take initiative to apply for recognition status with the WFME under its recognition of accreditation agencies program.[13] This WFME recognition is desirable as they are endorsed by the WHO, the WMA, and IAMRA.

Recognition of MCI/NMC by the WFME will make medical colleges recognized by NMC to get included in the World Directory of Medical Schools (ECFMG 2024 deadline) and IMGs eligible to work abroad. The Recognition Criteria of WFME are the minimum basic requirements and allow agencies to determine an appropriate and rigorous standard of performance for the context in which they operate. The WFME recognizes that the country's standards for medical education do not have to be the WFME standards. The WFME standards are intended to be a template from which standards suitable for local use can be developed. Many countries across the six regions of the WHO have integrated WFME standards into their country's accreditation standards.[14] Fulfilling the recognition criteria for agencies accrediting medical schools helps the agency to use comprehensive (input, process, and outcomes) standards for accreditation appropriate to basic medical education. It will make the National Accreditation System's standards to become sufficiently rigorous and appropriate to evaluate the quality of the education and training provided at medical schools. It will also ensure that the agency has a system for periodically reviewing and updating the standards. When WFME comes to evaluate the NMC with a view to recognition, the question will be “are the standards being used comprehensive and appropriate for India?”

India can opt to have its own framework (USA and UK have their own) provided we fulfill the broad WFME criteria for accrediting agencies. Most countries of the world's national accreditation agencies are already recognized by the WFME. India has already moved to curricular reforms that focus on graduate outcomes. We just need to set up a system and start measuring and monitoring attainment of our stated outcomes. Most of the criteria for recognition are already in place, and a knowledgeable committee of experienced medical educators can help decide which WFME standards are applicable locally in context.[15] They could also look at the NAAC standards and use those that are good and beneficial to the institution using them.

 Way Forward for International Recognition of National Accreditation Agency



From the [Table 3] compilation, it is obvious that a special task force for this transition to WFME recognition is needed. It will help make the National Accreditation System more comprehensive and serve the purpose of QA to ensure patient safety within the country as well as globally.{Table 3}

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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