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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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5

Moving Forward

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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CORE COMPETENCIES THAT APPLY TO ALL HEALTH PROFESSIONS: “QUICK TAKES”

Pamela Jeffries, dean of the George Washington University School of Nursing, led the “quick takes” session that emphasized short responses in rapid succession. The panelists drew from three different professions and included Judith Halstead of the National League for Nursing Commission for Nursing Education Accreditation; Rick Talbott, representative of the Association of Schools of Allied Health Professions; and Peter Vlasses of the Accreditation Council for Pharmacy Education.

This session focused on how accreditation could be used as a mechanism to advance interprofessional education (IPE) and health care quality, and to illuminate potential core competencies. It included four questions that were answered by the three panelists in “quick-takes.” Each panelist had 2 minutes to respond to a question, and then the floor was opened for audience participation. The following sections are the speakers’ responses to the questions and the ensuing discussion that involved the entire audience.

Question 1: How Can Including Core Competency Concepts in Accreditation Standards Be Linked to Improved Quality in Education and Health Care Systems?

Panelist Responses

In her response, Halstead focused on how to actually link core competency concepts to improved quality. For accreditation standards to be in a position to include core competency concepts, there first needs to be agreement on what those core competencies should be; to achieve this, said Halstead, collaboration across disciplines and a linkage between education and practice has to exist. Second, she believes that a long-term vision is key. She suggested that stakeholders first answer the following questions: what does improved quality mean, how is it identified, and what are some

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

evaluation strategies to measure it? The value, she said, lies in the process of getting to where those competencies can be identified and then included in the accreditation standards.

Talbott then responded, beginning with defining competency:

the cluster of related knowledge, skills, and abilities that affects a major part of one’s job (a role or responsibility), that correlates with performance on the job, that can be measured against well-accepted standards, and that can be improved via training and development. (Parry, 1996, p. 50)

The goal, he said, is well agreed upon by most stakeholders, but how can quality of education be improved by including the core competencies? The U.S. Department of Labor has addressed this issue with a pyramid of competencies.1 The base represents the basic competencies for someone interested in health care, such as general education requirements from any university. Each tier of the pyramid becomes more specific. At the top of the pyramid, he said, are the specialized accrediting competencies that need to be defined and analyzed by each professional association. Talbott believed that starting with a strong foundation and moving forward in small steps is the best way to reach the goal.

Peter Vlasses immediately followed Talbott. For his response, Vlasses brought up the Interprofessional Education Collaborative (IPEC) competencies,2 published in 2011 (IPEC Expert Panel, 2011), that have been incorporated across the Health Professions Accreditors Collaborative. He presented a case study of the Canadian system, specifically the University of Toronto, where the medical school and the main hospital have collaborated to foster interprofessional education and collaborative practice. There is a single payer (government) system in Canada, as opposed to the multipayer fee-for-service model in the United States that is evolving to be more value-based. Canada, he said, understands that health education should result in good financial and patient outcomes. The medical school and hospital collaboration in Toronto made the commitment to establish competencies and standards agreed upon by all stakeholders. In addition, the university committed to prepare team-based people who can be better practitioners and can give better patient outcomes. Vlasses commented that this idea is more than preservice education, but also it emphasizes continuing education.

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1 For more information on the U.S. Department of Labor’s pyramids of competencies, see www.careeronestop.org/CompetencyModel (accessed September 21, 2016).

2 Developed by six different professions that make up the original IPEC, these are the knowledge, skills, and attitudes needed to demonstrate effective teamwork across professions (IPEC Expert Panel, 2011).

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Group Discussion

Jeffries then opened the floor for audience participation. Eric Holmboe from the Accreditation Council for Graduate Medical Education agreed with Vlasses on the value of the IPEC competencies. He saw this as “low hanging fruit,” since there is already work going on in this area. He then asked the panel about their thoughts on competencies that accreditors need, which is a question that was triggered by the conversation with Christine MacDonell earlier in the workshop about the Commission on Accreditation of Rehabilitation Facilities and the competencies needed by the site visitors (see p. 58). With the current changing dynamic, Holmboe believes this is an area for greater exploration. Vlasses responded to Holmboe by noting the requirements of the U.S. Department of Education and the Council on Higher Education Accreditation. Accreditors must adhere to these requirements and standards in order to make sure processes are in place, are fair, and are not arbitrary. In addition, these standards help ensure that accreditors make good decisions. Board members of the Accreditation Council for Pharmacy Education (ACPE) include practitioners, educators, regulators, and a public member. According to Vlasses, they consider multiple perspectives and are willing to learn. The accrediting agency also allows them to take good ideas and implement these.

Halstead added to this comment, suggesting that organizations remain dynamic instead of static, and that anyone representing the work of the accreditation body should also be open to change and flexibility as part of their core values. She echoed her original comment about vision, emphasizing the importance of having a clear understanding of what it means to look at a process and an outcome. Talbott reminded participants that the first accrediting body in the United States was developed around 1880. Philosophically, accreditation has kept its focus and mission on protecting public health and safety and acting in the best interest of the public. He suggested that accreditors return to this benchmark of improving public health and safety and addressing public interest. This is a guiding light for future work and improvement, he said. He expressed hope that eventually accreditors will transition from being viewed as the policemen to instead being seen as facilitators and improvers.

Question 2: What Would Be Necessary Components in the Education–Practice–Accreditation System to Improve the Quality of Health Professions Education and Health Care?

Panelist Responses

Talbott led off the responses to the above question. He saw the linkage to improved quality as a necessary component of the health, practice,

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

and accreditation system. The process needs to start with the patient and public trust, he said. From there, stakeholders can work backward to determine what actions need to be taken and what knowledge and skills are necessary for the workforce. From that point, the educational mission can then be aligned to the goal of getting specific knowledge and skills to the practitioners in order to meet public and societal needs. He emphasized the point he made earlier, saying that accreditation should continue to revisit the benchmark of improving public health and safety and addressing public interest, and the system should work backward from that point. He suggested the possibility of creating linkages among licensure boards—the enforcement arms of accreditation in public protection—the accrediting bodies, and the certifying bodies. There is not yet the collaboration and consistency needed to achieve this, he said. Licensure boards are often the main controllers of continuing education and include requirements for continuing education in their licensure requirements; this is because most accreditation bodies do not see continuing education as part of its purview, because it happens after the formal education experience is complete.

Vlasses called for change that is interprofessional in nature and cited the Canadian health care system and specifically the University of Toronto as an example. Shifting to a value-based payment system over a fee-for-service model, they are acknowledging that improvement is important from a financial standpoint as well as a patient outcome standpoint. According to Vlasses, as mentioned, the dean at the University of Toronto and the chief executive officer of their hospital agreed to establish standards for preparing a team-oriented health workforce that can work together to deliver better patient outcomes. He believes that the changing health care financial system is the biggest driver creating urgent need for improved quality of health professions education and health care. To him, good communication and collaboration among stakeholders is critical. In addition, measurement and assessment can help track progress toward goals and ensure that stakeholders are on the right path. However, Vlasses cautioned that waiting for the perfect assessment instrument can sometimes delay and paralyze progress. He believes there should be incentives, such as promotion and tenure for faculty that are doing this work, and that faculty should be encouraged by leadership in a top-down approach. Otherwise, he said, it is a health system likely to fail.

Halstead was struck by the idea William Bazeyo, One Health Central and Eastern Africa, raised about siloes, and how each stakeholder stands side by side without connections. She encouraged others to embrace the notion that this is a system of three interrelated components: (1) education, (2) practice, and (3) accreditation, and it is accreditation that brings the first two components together. She also referenced the diagram that Susan Phillips displayed during her introductory remarks (see Figures 2-1 and 2-2,

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

Chapter 2) that emphasized finding the “sweet spot” and the ideal role for accreditation. She urged further exploration of this notion that could focus heavily on the implementation phase and the details of finding the ideal role for accreditation.

Group Discussion

Having heard the views of her panelists, Jeffries then encouraged the wider audience to contribute their thoughts and feedback. Patricia Hinton Walker, Uniformed Services University of Health Sciences, started off the discussion saying that two examples raised throughout this workshop and other Forum activities—One Health and the social determinants of health—are examples of where stakeholders are changing curricula and their approaches in order to incorporate these topics into education and improve health outcomes. David Benton, National Council of State Boards of Nursing, agreed with Hinton Walker. He asked the panelists if they would consider the issue of core competencies differently if the competencies focused on well-being and health instead of health care. Vlasses responded by first quoting a colleague who said, “It’s not health care, it’s health and care.” Standards have been written in such a way that prevention, coaching, and chronic disease management are seen as being similar to inpatient care. There are specific rotations in each of these areas, requiring both learners and practitioners to be exposed to topics and experiences focusing on wellness and well-being, in addition to their exposure to secondary and tertiary care. He saw opportunities in digital communications, which can aid stakeholders and individuals in having more frequent communication and in trusting each other.

Halstead reflected on the shift from an emphasis on health care to one on well-being, and what effect that would have on curricula. Concepts of well-being are included in curricula, she said, but they are not currently the predominant focus for the majority of professions. It would be a significant shift to redesign curricula to meet that goal. Jeffries added to this statement, commenting that the emphasis on quality health care is part of the health provider culture. It will have to be a whole culture shift to move this focus to One Health, wellness, and health promotion, requiring curricula adjustments for all professions. John Weeks, Academic Collaborative for Integrative Health, stated that often health care systems focus more on production of services than on disease management or health care. This is important to consider, he said, in context of the movement toward the Triple Aim and value-based medicine. Health care delivery, in his opinion, can involve three separate elements: following the production values of industry, focusing on reacting to disease, or seeking to bring the person to health. He urged participants to be conscious of their language in denoting the difference

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

between reactivity to disease and on creating health. Health, he said, has many different definitions, and he challenged participants to analyze their interpretation of health to see if they mean health care, managing disease, or prioritizing what is good for the industry.

For Lemmietta McNeilly, American Speech-Language-Hearing Association, focusing on prevention of diseases and disorders and the activities that are involved with it were important components for improving education and health care quality. Currently, she said, the health care system in the United States is a fee-for-service model that pays health care providers to assess and treat a problem; it does not pay for problem prevention, nor reward engagement in healthy behaviors. McNeilly stated that the majority of health care dollars are spent at the disease end of the care continuum, and until priorities and resources are more overarching and include healthy living, these changes will be much more difficult to implement. However, she emphasized encouragement for individuals and organizations to proceed with efforts that include strategies targeting health and well-being into academic curricula, clinical practice, and accreditation standards.

Mary Beth Bigley, Health Resources and Services Administration, agreed that there is a lack of definition on what the education, practice, and accreditation system actually is. These have not been thought of as an entire system, she said. They each have different missions and values, and so effort and time is required to bring stakeholders together to decide what an education, practice, and accreditation system means.

Question 3: Should Accreditors Play a More Active Role in Fostering Faculty Development in Education Program Quality Improvement?

Panelist Responses

Vlasses took the lead in responding to the question stated above. He said that the ACPE has a standard for faculty development. Once someone becomes a member of the faculty at an educational institution, he said, they need to develop as educators and as researchers, and they need to understand what IPE is and how to provide it. New faculty hires may not have been initially trained in IPE, and so they may not have a vision for it; therefore, topics such as these are an important part of faculty development. Because a large percentage of curricula is external, said Vlasses, this standard has now been extended to external preceptors because preceptors need to be kept continually up to date on what the school is doing. Preceptors also must be aware of what the school standards are trying to accomplish, what competencies are being included, how they are being assessed, and the importance of working together with other health professions in order to model interprofessional behavior for their students.

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

Halstead agreed with Vlasses that faculty development is an acute need. She shared her perspective of how to play a more active role in fostering faculty development in program quality and improvement. Many faculty members may not understand what program quality improvement is. For faculty who only know their experience as clinical experts or experts within their discipline, it can be very challenging to enter an educational system where they are expected to consider accreditation and the meaning of accreditation standards. Concepts of program evaluation and continuous quality improvement should be outlined for faculty so they understand their role. Accreditation does have a role in helping faculty to understand these concepts, but Halstead believes that education in practice also has a responsibility to do this. Many are comfortable with their own individual contribution to the system, but they lack an understanding of how this contribution affects the entire system. There are also many novice educators entering the workforce, as well as a high turnover due to retirements; because of this, accreditors can play a significant role in faculty development related to program quality and improvement, she said.

Agreeing with the comments made by Vlasses and Halstead, Talbott focused on the term active in the question posed. From his perspective, accreditors should focus on the goal rather than the mechanism to get there, which would mean faculty development can include everything from improving research capabilities to gaining funding opportunities. When it comes to the role of the accreditor, however, Talbott believes this should concentrate on outcomes. If an institution is not developing faculty and this is interfering with quality improvement and therefore with outcomes, then accreditors should play an active role, he said. However, Talbott qualified this by stating that he does not believe accreditors should play a role in specifying the mechanisms by which faculty development is executed.

Group Discussion

Bjorg Palsdottir from the Training for Health Equity Network echoed Vlasses’s point, saying that faculty may have mostly technical skills because of their experience, and they may not have skills involving education elements such as community engagement or communication. Referencing Talbott’s point from earlier in the discussion, she said that institutions should start with a focus on the needs of the patients and communities, and then move toward what competencies the faculty should have in order to train or mentor their students in how to address these needs.

Elizabeth Hoppe from the Association of Schools and Colleges of Optometry raised the difference between having a standard requiring faculty development and having an accrediting body serving as a resource with services and support to develop faculty members. In some cases, the

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

professional accrediting bodies may be conducting workshops on the role of accreditation and on how to perform a site visit and a site review. In these situations, the accreditors are relying on faculty volunteers to do the work of accreditation, so accreditors are motivated to hold these workshops. These same accreditors may receive questions from faculty members relating to specific issues or questions dealing with faculty development but refuse to respond because they do not think it is their role to serve as consultants. There is a gap, said Hoppe, between what is possible and what would be beneficial to institutions with limited resources that are struggling with faculty development. Talbott responded to her point, saying that there is almost a complete lack of homogeneity in accrediting bodies. From his experience, institutions are often responding to several or even dozens of accrediting bodies. He sees a difference among these accreditors and what they see as their role. Agreeing with Hoppe, he said that many times accreditors will refuse to answer a question or give their advice because they do not see this as part of their job. However, he has also seen accreditors finish an accreditation process and then offer to help the institution with whatever questions they have or advice they are seeking. According to Talbott, coordination across the different accrediting bodies is needed in order for their role to be clearly defined and understood.

John McCarty from the Accreditation Review Commission on Education for the Physician Assistant congratulated Talbott on identifying the issue of what an “active role” means. To McCarty, the active role that accreditors play is holding institutions responsible for developing faculty and reminding them through accreditation standards. Professional organizations and associations are equally responsible for helping those within their profession and within the educational arm of their profession to develop faculty, he said. Jennifer Butlin, Commission on Collegiate Nursing Education, also was grateful to the speakers for separating the accreditor’s role from the institution or program’s role. She believes that the accreditor’s role is to have a nonprescriptive standard or criteria in place stating that faculty development is an expectation, but these criteria should also allow the program to define faculty roles and faculty’s relation to teaching, practice, service, outcomes, and faculty achievements. The details of faculty development, she said, are the prerogative of the institution and the educational program. At her accrediting institution, there are many workshops and trainings about accreditation that are offered, but they leave consultation and discussion of best practices to their parent professional association.

Jeffries made one final comment about the National Council of State Boards of Nursing Simulation Study, which she called a landmark study that looked at the potential of substituting real clinical time with simulations. The evidence showed that simulations could be substituted, but there were qualifiers—specifically, the faculty needed to be developed, and there

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

needed to be a theoretical basis for debriefing. In October 2015, the National Council of State Boards of Nursing published guidelines that were directed toward faculty development, the pedagogy of debriefing, and the equipment and simulation environment. She believed these guidelines were quite helpful for faculty and institutions who want to implement more simulation but who do not know where to begin.

Question 4: What Commonalities Exist in Health Professions’ Criteria and Principles for Core Competencies, and How Can These Be Leveraged to Drive Quality in Health Professions Education?

For the final discussion question, Jeffries opened the floor to the entire group to participate. Halstead mentioned ethics, moral agency, and cultural sensitivity as issues that cross health professions. Hinton Walker agreed, and brought up leadership, communication, and trust as additional cross-cutting priorities and competencies. Jeffries added patient safety to the list. Vlasses stated several of the aforementioned cross-cutting topics are beginning to appear in coursework. For example, a class about the national health system, health informatics, or big data can be taught across health professions, and perhaps interprofessionally as well. He reiterated that continuing education is an area that requires attention in this space; rather than core competencies, he said, the focus is more on joint commitment to collaborative work. In terms of IPE, he raised the possibility of incentivizing groups and institutions offering interprofessional continuing education by harmonizing the accreditation expectations of continuing education providers. He suggested that instead of being required to have three separate accreditations, a continuing education provider can now have just one accreditation if 25 percent of its continuing education activities were for interprofessional learners. Vlasses’s accrediting agency is now offering joint continuing education provider accreditation with medicine and nursing,3 and 25 organizations have become jointly accredited and are using outcomes-based interprofessional continuing education offerings, especially in the areas of patient safety and medication management. Participants are incentivized to do these projects because they know they also will receive continuing education credits. The jointly accredited continuing education providers are now beginning to measure outcomes coming out of their interprofessional continuing education initiatives, and are seeing changes that are improving the quality of care.

Vlasses provided a second example relating to the United States’ problem with opioids and death. Initially, the government produced a Risk

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3 For more information about Joint Accreditation, see http://jointaccreditation.org (accessed September 22, 2016).

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

Evaluation and Mitigation Strategy that placed responsibility on companies to improve the medication and reduce harm. When told by companies what they had to do, the medical community did not respond well. Therefore, the continuing education community met with the U.S. Food and Drug Administration (FDA) to develop the Conjoint Committee on Continuing Education (of health professions), which evolved from the Conjoint Committee of Continuing Medical Education. This committee is working with the FDA and with drug companies to develop continuing education trainings for practitioners that can receive accreditation. In part because of this, Vlasses said there has been a drop in improper prescription of opioids and a drop in opioid-related deaths during this time frame. Unfortunately, he said, there was a rise in heroin-related deaths in the same time frame. Continuing education, in his opinion, is where change can happen quickly, and it is how attention can be brought to any important public health issue. He believes that focusing on working with practitioners in the field in addition to those in degree programs is the key to influencing outcomes and creating positive change. Hinton Walker added to Vlasses’s points by encouraging stakeholders to consider the larger health professional group when addressing these sorts of problems. Harmonization would consider the contributions many different professional groups can make and therefore could be a way to address these types of problems.

Neil Harvison from the American Occupational Therapy Association participates in a committee that assesses a national competition on outcomes and quality improvement initiatives in institutions of higher education, as well as at a programmatic level. The evaluations for quality improvement focus on the ability of a student to demonstrate particular competencies related to interventions and procedures—a disease management–centric perspective. However, he said, the more distal measures, or what he called “the final step,” is lacking. He stated that these measures apply to all health professions and stakeholders.

Talbott brought up the Council on Higher Education Accreditation’s International Quality Group, which identifies five different competency areas they hope will become common to all international accrediting bodies. These areas include honesty and integrity, accountability, fairness and validity, clarity and consistency, and creativity and innovation. He views this as a good and hopeful step forward for the international accreditation community. Holmboe referenced the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality (2003), saying that this report is a good place to start to respond to the posed question. Vlasses agreed, and shared that ACPE initially adopted the IOM core competencies as part of their standards, and then incorporated the IPEC competencies, which expanded on the interprofessional aspects of the IOM competencies. The desired competencies for health care practitioners will continue to evolve

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

as more professions are involved and as education and health care advance, he said.

Vlasses urged participants and stakeholders to change the mindset that accreditors are barriers to innovation and simply add cost and burden. He believes accreditation can help advance the health professions toward innovation and positive change, and they can also help challenge institutions to continually self-evaluate and improve. One possibility, he said, is if accreditation is part of an ongoing rather than episodic quality improvement process.

To close the session, Jeffries professed that accreditation, to her, brings faculty together, helps highlight gaps, and guides program improvement. She applauded accreditors for their determined efforts to improve health education. Harvison thanked Jeffries and her colleagues, then introduced David Benton to answer the question, “How can accreditation foster innovation?” To respond to this question, Benton described his past experiences in Scotland, the United Kingdom, and most recently in Geneva, Switzerland, where he consulted and then worked for the International Council of Nurses where much of his work focused on nursing and health policy with a focus on regulation, licensing, and education.

MOVEMENT TOWARD COMPETENCY-BASED EDUCATION: HOW CAN ACCREDITATION FOSTER INNOVATION?

David Benton, R.G.N., Ph.D., FFNF, FRCN, FAAN, National Council of State Boards of Nursing

David Benton expressed his appreciation that this workshop provided the opportunity for shared experience and learning and for sharing and understanding the positions of different organizations and the commonalities among these positions. Benton saw both context and timing as critically important dimensions to consider relating to accreditation.

To provide context for his presentation, Benton reminded the participants that competence has been a topic of discussion and of literature since 1959 (White, 1959). He disclosed his personal belief that accreditation redesign is about creating a new paradigm and about thinking differently. Benton thinks accreditation redesign should do the following:

  • Use technology that enables instant communication across the globe.
  • Align to a world where health needs are changing rapidly and where all would derive benefit.
  • Capture data once and use it many times.
  • Invest in tackling the social determinants of health to improve health and well-being.
Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

Benton described a common assumption that legislation prevents innovation and creativity. From Benton’s perspective, if an idea is in line with the general mission of an organization and if there is no explicit statement in the bylaws or legislation that does not prevent a certain activity, then why not try? He recommended that accreditors liberally interpret the regulations and rules that exist instead of viewing them as limiting growth and potential. “It is not organizations that reach agreement,” he said. “It is individuals.” To Benton, innovation in accreditation begins with new perspectives. By bringing people together with different perspectives, he said, one can see the problem in a different way, and devise more robust and more exciting solutions.

Reducing the Burden of Scrutiny

Benton pointed to the challenges and causes of the burden of scrutiny. There are now multiple layers of activities, perspectives, and regulation, but there is little communication among these various layers. Because of this, the similarities and the opportunities for collaboration are not discussed or even evident. There are also changing environments within institutions that can affect the way issues are viewed, can cause new burdens, and can provide new relief. In addition, continuing competence and continuing education is a challenge that regulators are being asked to pursue to ensure competence of health professionals. Revalidation as part of the regulatory, accreditation, and certification process should be considered, he said. While there are issues with this idea in terms of data collection, it would provide a systems perspective rather than simply viewing a single part.

Innovation in Accreditation

Innovation in accreditation, Benton argues, requires capturing data once and using it many times. He cited a common frustration of many health professionals in university teaching systems, who have to fill out numerous, time-consuming reports for accrediting agencies. They feel hard-pressed to deliver the education they need to provide to their students because of this bureaucracy. The added frustration is that often, their collected data and information is never reviewed or used for any research purposes or program improvement initiatives. When this happens, a great deal of time is lost that could have otherwise been directed to purposeful endeavors. Benton emphasized the need to streamline accreditation processes.

Working across sectors is another opportunity for innovation. Societies are changing the health and social interface, and this is becoming increasingly problematic with the aging population and nuclear families become more blended. The ability of families and communities to support each

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

other is changing, and this should be considered when it comes to solution generation.

Benton asked, how will individuals and systems be accredited in the future? Nursing and perhaps other professions have been moving from a model that looks at the regurgitation of knowledge to an ability to learn and to apply skills, and finally to judgment, said Benton. He presented a map of what the potential next generation of assessment will look like, developed by his director of testing, Phil Dickison (2016), and his team (see Figure 5-1). They see it as developing into an unfolding case study where

Image
FIGURE 5-1 The assessment model of NCJ (nursing clinical judgment) with the multilayer representation of NCJ.
NOTES: Layer 0 represents the observation layer. Layers 1–3 are the construct layers—the unobservable elements in these layers may “generate observable ‘outcomes’ that are measurable and scorable; however, these outcomes differ from the clinical decision entity in Layer 0.” Layer 4 is the context layer—this layer contains “factors that may affect the performance of cognitive operations in above layers.” The individual factors are represented by grey circles, and the environment factors are represented by white circles.
SOURCE: Dickison et al., 2016, as presented by Benton on April 22, 2016.
Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

individuals have to identify cues and determine how technology can test their clinical judgment as part of that process. These kind of changes, said Benton, need to be reflected in the way that education systems are accredited. Change can be used as a vehicle to drive innovation and accreditation.

Examples of Innovation in Europe

Benton discussed the Lisbon4 and Copenhagen Agreements and the Bologna Declaration,5 stating that these are documents that are driving a large portion of the alignment within Europe and beyond. European ministers recognized that Europe has an increasingly elderly population, and they want to draw youth into Europe and make Europe more economically competitive. To achieve this goal, they decided to make education systems in the European Union more competitive. Benton described what they developed as a “tuning framework.” This addressed three cycles of education: first, reviewing principles and reflecting on how to define a bachelor’s degree, a master’s degree, and a doctorate degree; secondly, agreeing on this definition across the member states, and examining the common core competencies associated with the bachelor’s degree preparation of any discipline (such as theology, engineering, nursing); and third, listing subject-specific competencies within each discipline.

Benton described Directive 55,6 a piece of European legislation that has existed in various forms since the late 1970s and has evolved over time. Within that legislation is a framework that facilitates the mobility of health workers, and it has started to deal with some of the standardization of approaches. The European Credit Transfer and Accumulation System (ECTS) facilitates movement from one educational institution to another without having to go back to the beginning of the process. ECTS is a tool of the European Higher Education Area for making studies and courses more transparent and thus helping to enhance the quality and portability of higher education. ECTS modularized programs and recognized prior learning through accreditation. These decisions were motivated by the desire to make education more competitive and also more mobile. The Directorate-General (DG) internal market and DG Sanco (Health and Consumer Affairs) supported this idea, and approached DG Development to spread the idea more widely. Many other countries use this “tuning framework,” including 19 Central and Latin American countries, 44 countries

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4 Lisbon Agreement for the Protection of Appellations of Origin and their International Registration (amended September 28, 1979).

5 Bologna Declaration: Joint declaration of the European Ministers of Education. June 19, 1999.

6 For more information about Directive 55, see eur-lex.europa.eu/legal-content/EN/TXT/HTML/?uri=CELEX:32013L0055&from=EN (accessed September 21, 2016).

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

in the wider Europe,7 Australia, New Zealand, and countries in North Africa and Asia. While often individuals use the term harmonization to describe these goals, Benton called it calibration—fitting different ideas and programs with one another to see where the gaps are, and then visit opportunities for harmonization.

Benton encouraged participants not to restrict themselves to their specific disciplines or specific countries, but rather reach out to each other, learn from each other, and apply and adopt innovations from other settings into new contexts. This is how to increase momentum to achieve goals. Benton sees an opportunity for individuals to view accreditation differently. He challenged participants with a request, saying “If you as an individual can change the way that you see accreditation, you can change the accreditation that we collectively see.”

FINAL THOUGHTS

Over the course of the workshop, individual participants talked about the benefits of accreditation, and also having an effective system with quality offerings in higher education. In addition, individual speakers and breakout group leaders discussed topics such as accreditation criteria through the institutions and programs, guidelines for best practices, and standards and expectations for student outcomes.

Pamela Jeffries offered her interpretation of key concepts and ideas she heard throughout the conversation she led. Bringing stakeholders together and fostering collaboration may be the first step in linking core competencies to the health system and accreditation. She added that using a common base, such as the U.S. Department of Labor competencies, can be the starting place for moving this forward. In addition, institutions can encourage faculty to understand and accept core competencies; however, in doing so, stakeholders would have to remember to keep a focus on the goal of accreditation—to protect public health and safety. Jeffries then reflected on the suggested common competencies that could be promoted among all professions and accreditors such as One Health and the social determinants of health. She also noted that accreditors can help with program quality improvement and can hold institutions responsible for faculty development. Lastly, she encouraged a change in perspective, believing that institutions can greatly benefit from accreditation, and should see accreditation as an aid and a guide rather than as a costly burden.

Malcolm Cox provided broader reflections on the workshop. He gleaned 10 points from the presentations and discussions; he began with the notion that having vision is imperative. “If you don’t know where

___________________

7 “Wider Europe” refers to the European Union and its eastern and southern neighbors.

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

you are going, any road will get you there,” he said, paraphrasing Lewis Carroll’s famous lines from Alice’s Adventures in Wonderland. Without a goal or a destination, discussions on the topic of accreditation are “largely sterile,” said Cox. The operational elements of accreditation and the strategic thinking processes are important, but Cox suggested that the discussion be framed around social accountability, specifically health and well-being, instead of heath care alone. He presented an increasingly accepted vision for health professional education with well-being as its most encompassing element. The overall health and well-being of individuals and populations and the focus of health professional education and training (see Figure 5-2).

There is a critical need to align clinical accreditation with educational accreditation, Cox noted. This point was raised by Karen Sanders in the breakout group led by Miguel Paniagua where she described the issue as two nonintersecting circles. David Benton took a slightly different perspective, picturing a Venn diagram with two circles overlapping. The overlapping section, said Cox, is where new ideas and innovation are likely to emerge. What holds these two circles together, said Cox, is social accountability, including person- and community-centered care and population

Image
FIGURE 5-2 Cox’s vision for health professional education.
SOURCE: Cox, 2016.
Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

health. Essentially, said Cox, these are social accountability issues starting with the individual person and ending with the population at risk.

Conceptual models of accreditation generate many useful ideas and thoughts, said Cox. He referenced Susan Phillips’s conceptual model of accreditation (see Figures 2-1 and 2-2, Chapter 2), which she presented during her brief overview of the accreditation terrain. The model showed the tension among professions, accreditors, regulators, and others. Cox encouraged workshop participants to reflect on Phillips’s model and to use it in their own work and at their own institutions.

Collaborative partnerships diminish tensions and drive change, said Cox. Phillips and several other presenters discussed these benefits of collaborative partnerships. Some of the factors that can be used either strategically or at the operational level to leverage change are team-based care and IPE, he added. Cox specifically saw continuing professional development as the most important focus for IPE. To explain his perspective on the learning continuum and interprofessional education, Cox referenced one section of a model developed by the IOM Committee on Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes (IOM, 2015; see Figure 5-3). In the foundational education stages, students are a captive audience, and IPE is easier to implement but by itself it is rarely enduring. As learners move to the graduate level and become part of the health workforce, IPE can be more difficult to incorporate unless the clinical learning environment is conducive to collaboration and outcomes oriented. By far the longest period of a health professional’s working life is in practice, and it is here that continuing education is so central—not only to individual and collective competence but also the creation and maintenance of a clinical educational environment that nurtures all phases of the educational continuum. While many professional associations and organizations are encouraging IPE in continuing education, Cox believes that more attention is being given to the foundational stages of education and less to the graduate and professional development stages.

Cox sees the need for change as ubiquitous. Despite trying to get out of their silos and to work across barriers, most professions and groups continue to stay where they are most comfortable. Implementation strategies for change are scarce, though not absent; Cox remarked that people are beginning to tackle these challenges. “The what is clear, the how is much less so,” he said. He suggested that individuals and organizations spend time thinking about how to facilitate transformative change.

Cox also saw a need for enhanced outcome measurement, as well as validated measurement toolkits. He believes that assessing distal outcomes—related to individual and population needs—should take precedence over proximal learning outcomes. While changes in behavior such as better

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×
Image
FIGURE 5-3 The interprofessional learning continuum model, adapted by Cox.
NOTE: For this model, “graduate education” encompasses any advanced formal or supervised health professional training taking place between the completion of foundational education and entry into unsupervised practice.
SOURCE: IOM, 2015. Adapted by Cox and presented April 22, 2016.

collaboration and team function are important as arbiters of more distal changes in health and well-being, in and of themselves they provide only an incomplete picture of IPE outcomes.

Blueprints for programs, created through pilot or demonstration projects, can be helpful, but culture will likely determine the transferability (or lack thereof) of these blueprints to different contexts. Sustainability and generalizability are critical concepts that should be more strongly considered, said Cox. In particular, clashing cultures can disturb innovation.

Resource redistribution is essential, said Cox. He warned that increased health professional education funding is unlikely at a time when many nations are struggling with their finances and have competing priorities. Moving funding to where it is most needed might be more successful but will require agreement among key stakeholders, he said. In Cox’s opinion, much thoughtful policy work will be necessary, especially outcomes definition and measurement.

Leadership was another point that was raised by several speakers throughout the meeting. The main task of leadership, said Cox, is to man-

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

age uncertainty and foster collaboration. Not all current leaders have the skill set that is necessary, and he suggested that leaders be chosen largely on the basis of their communication skills and vision.

Cox illustrated the complex environment that health system leaders encounter by reference to Figure 5-4. The figure shows clinical micro-systems (in blue), which are embedded in institutional or organizational mesosystems (in green), all of which is encompassed by the education and health care macrosystem (in red). Cox referenced Benton’s description of the patient as the center of, as well as the bridge between, each of these systems. Others have emphasized the centrality of “persons” rather than the more limiting “patient” and have noted the importance of communities or populations as well as individuals. Caring for and about individuals and communities is a major element of care, but Cox also emphasized the importance of the learning that is a result of this care. He sees this as a feedback loop with the patient or the community in the center. As providers care for patients and communities, they improve their skill set, thereby enhancing care as well. This feedback loop of learning and caring that exists within the microsystem is embedded in the greater mesosystem, thus

Image
FIGURE 5-4 Model of the health and education systems.
SOURCE: Cox, 2016.
Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

including both practice redesign and educational reform. However, these potentially transformative efforts are often forestalled by lack of communication between the education and practice bodies. He believes that many of the barriers discussed during the workshop are related to the lack of effective communication between these two groups, and the difficulty in achieving a common vision for the desired outcomes of learning within and across professions. Cox called for greater collaboration between education and practice groups. The linkage between education and clinical practice is in the clinical microsystem, he said—through patient or community.

MOVING FORWARD

To close the workshop, Eric Holmboe from the Accreditation Council for Graduate Medical Education led a discussion on ideas for moving the conversation forward. Cox expressed concern about the slow movement of adopting these core competencies and addressing common issues among professions. In a plea for action, he encouraged participants to think about focused action around policy derivation and specific ways to move this work forward. Rick Talbott shared his respect for the Forum, and called attention to its tremendous amount of brainpower, stakeholder representation, and leadership. He wondered how the leadership present in the Forum members could be harnessed in order for individuals to make a difference in health professional education and accreditation. Marilyn Chow from Kaiser Permanente agreed with Talbott and Cox, saying that because of the rapid development of the health care delivery system, health, and health care, health professional educators are in a difficult position. It is a challenge to change curricula at the speed at which health care changes, she said. She urged the workshop participants to think of small actions they could take to promote positive change. Susan Scrimshaw from The Sage Colleges agreed with Cox and Chow that there is a sense of urgency to transform health professional education. Holmboe added to Chow’s charge to participants by encouraging individuals to start by taking action within their everyday work environment at their organizations. One opportunity is the area of health and well-being, said John Weeks, Academic Collaborative for Integrative Health. This topic is innovative, interprofessional, global, and related to the social determinants of health.

Looking at education, practice, and accreditation as a system was an especially meaningful perspective to Halstead; she believes that these stakeholder groups should be represented in any discussion about health education reform. Cox added to Halstead’s comment that there is an opportunity for the health professional associations to be the platform to bring these different stakeholders together. Other organizations and institutions have the opportunity to create blueprints for actions and recommendations based

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×

on their knowledge, expertise, and shared experience, he said. With a last call by Holmboe and Harvison for individual workshop participants to act upon their expressed convictions, the workshop was adjourned.

REFERENCES

Cox, M. 2016. Reflections. Presented at the workshop: The Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education. Washington, DC, April 22.

Dickison, P., X. Luo, D. Kim, A. Woo, W. Muntean, and B. Bergstrom. 2016. Assessing higher-order cognitive constructs by using an information-processing framework. Journal of Applied Testing Technology 17(1):1-19.

IOM (Institute of Medicine). 2003. Health professions education: A bridge to quality. Washington, DC: The National Academies Press.

IOM. 2015. Measuring the impact of interprofessional education on collaborative practice and patient outcomes. Washington, DC: The National Academies Press.

IPEC (Interprofessional Education Collaborative) Expert Panel. 2011. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: IPEC.

Parry, S. B. 1996. The quest for competencies. Training 33(7):48-56.

White, R. W. 1959. Motivation reconsidered: The concept of competence. Psychological Review 66(5):297-333.

Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
×
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Suggested Citation:"5 Moving Forward." National Academies of Sciences, Engineering, and Medicine. 2017. Exploring the Role of Accreditation in Enhancing Quality and Innovation in Health Professions Education: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23636.
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Next: Appendix A: Workshop Agenda »
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The purpose of accreditation is to build a competent health workforce by ensuring the quality of training taking place within those institutions that have met certain criteria. It is the combination of institution or program accreditation with individual licensure—for confirming practitioner competence—that governments and professions use to reassure the public of the capability of its health workforce. Accreditation offers educational quality assurance to students, governments, ministries, and society.

Given the rapid changes in society, health, and health care, the National Academies of Sciences, Engineering, and Medicine hosted a workshop in April 2016, aimed to explore global shifts in society, health, health care, and education, and their potential effects on general principles of program accreditation across the continuum of health professional education. Participants explored the effect of societal shifts on new and evolving health professional learning opportunities to best ensure quality education is offered by institutions regardless of the program or delivery platform. This publication summarizes the presentations and discussions from the workshop.

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