The document discusses accreditation, licensure, certification and revalidation processes for physicians. It notes that accreditation aims to ensure quality medical education and competent graduates to ensure patient safety. Licensure and certification provide assurance that physicians are qualified to practice medicine. Revalidation processes aim to ensure physicians maintain up-to-date skills and knowledge throughout their careers. While these processes aim to promote quality and safety, the document notes there is limited evidence on their effectiveness and impact on patient outcomes. Further research is needed to validate these processes and identify best practices.

1. Ensuring high-quality patient care:
the role of accreditation, licensure, specialty
certification and revalidation in medicine
JIBRAN MOHSIN (MHPE Student)
Additional Required Course on Issues in Health Professions Education (ARC – IHPE)
Department for Educational Development (DED)
The Aga Khan University (AKU)

2. Outline
5. Meaningful critique
6. Application to own practice
7. Evidence of External reading
8. Summary
1. Introduction
2. Accreditation
3. Licensure and Certification
(Registration)
4. Revalidation of Credentials

3. Introduction
• Proper functioning accreditation system (MEDICAL REGULATORS)
• Disease - Poorly functioning doctors
• Prevention - Skilled competent professionals (patient safety) – continuing
educational activities
• Cure – Cost of poor health care delivery

4. Introduction
• Accreditation
• Medical education programs – (under)graduate
• Challenges – implementation / administration / validation.
• Licensure, specialty certification, and revalidation of credentials
• Continuous KSA for safe and effective practice throughout the career
• Public (stakeholder) – right to know the quality of their healthcare.

5. Accreditation
• Definition
“ A process by which a designated authority reviews and evaluates, on a cyclical
basis, an educational program or institution using clearly specified criteria and
procedures”
• Purpose:
• Ensure quality of basic medical education curricula and subsequent training
programs across the learning continuum.
• Competent medical graduate – patient care
• Minimal standard and quality improvement

6. Accreditation
• Scope
• Mandatory vs voluntary reviews
• Generalized (whole higher education) vs profession specific or both
• Government vs independent body
• Provincial vs National vs Cross-National level
• Board vs limited (within the same profession)

7. Accreditation in USA
• Two accreditation bodies
• LCME (MD degree)
• COCA (Osteopathic (DO) degree)
• Besides some variations, no quality issues

9. Accreditation in USA
• Graduate Medical Education
• Residency training (3-4 years)
• ACGME (allopathic)
• AOA (osteopathic)
• Six general competencies (inter-independent)

11. Accreditation globally
• FAIMER (DORA)
• 104 / 177 countries (Feb 2013) - basic medical education accreditation active
system

13. Accreditation globally
• Developing countries
• Trend towards instituting robust quality assurance procedures
• Prevalence and characteristics of accreditation systems limited to
documentation.
• RELATIVELY LITTLE evidence to quantify their utility with respect to
improving educational practices.

14. Validity of accreditation
1. Student performance (1st attempt USMLE pass)
2. Performance on other exams including board certification
3. Skilled competent doctors - Patient care
(long-term impact)

15. Validity of accreditation
• Few studies on the effectiveness and appropriateness of specific
standards or protocol of accreditation.

16. Cost vs Benefit (Accreditation)
COSTS BENEFITS
• Lack of transparency in the process
• Variability in methodology
• Lack of standardization
• Marked improvement in students outcomes during
internal preparation for accreditation by external body
• Direct cost (accreditation fee)
• Indirect cost (changes)
• Economic argument?
• Credible, meaningful and trustworthy by stakeholders
• Faculty time away from educational activities • Prestige in a crowded field (India – MCI / NAAC)
• For GME, graduation from accredited school required

17. Cost vs Benefit (Accreditation)
COSTS BENEFITS (DOCTOR MOBILITY)
• Enhanced clinical clerkship / elective opportunities
• Foreign students /migration (Accreditation comparable to
NCFMEA)
• Meta-accreditation (WFME / FAIMER)
• License to practice (recognition of international accredited
medical schools)
NET EFFECT = POSITIVE (STUDENTS IN TERMS OF EDUCATION QUALITY AND THE INSTITUTION)

18. Licensure and Certification (Registration)
• Define the profession (Variable but strict practice regulation)
• Assurance to society - competent physician

19. Licensure and Certification (Registration)
Criteria
Credentialing Assessment
Licensure Government Initial entry in profession • Medical school attendance
and graduation
• Accredited medical school
• Verification of diploma
USMLE
COMLEX-USA
Certification Nongovernment agency
(specialty or board)
High level of qualification • Above
• PG experience
• In-training exam
• Speciality / board
exam
• Variable, must modify with time as needed
• Local ≠ International trained doctors.

20. Validity of Licensure and Certification
• Content validity
• Possible only if the assessment of competencies required in real-time medical
practice is done.
• USMLE score
• Residency selection
• Post-graduation performance / licensure (weak)
• Real-time medical practice/quality of patient care
• Certification
• Better patient care

21. Revalidation of Credentials
• Re-registration / Recertification / MOL / MOC
• Quality assurance initiative (performance based) – patient safety
• Evidence of up-to-date status of KSA of physician – fit to practise
• Counter decline/decay of KSA with time

22. Revalidation of Credentials
• How frequent?
• Lifetime  5 or 10 years?
• Components
• CME / CPD
• Assessments (Patients / Peers)
• Examinations
• Doctor re-entry into clinical practice

23. Licensure / Certification / Revalidation
• Introduction of new assessments
• Well constructed
• Meaningful (related to practice)

24. Licensure / Certification / Revalidation
COSTS BENEFITS
• Expensive (direct, indirect, recurring/maintenance) • Low cost of public health
• Database of all doctors required • Importance / value (marker of competency)
• Time away from patient care to collect data
• Early retirement/leave specialty (shortage)

25. Licensure / Certification / Revalidation
• No globally accepted best practices
• Local standard – probably necessary and certainly appropriate
• Considerable variation in medical practice
• “SOCIALLY ACCOUNTABLE DOCTOR”
• Licences Revoked – escape current screening assessments
• Modify criteria accordingly

26. Meaningful critique
• Burning issues of accreditation, licensure, certification, and
revalidation have been comprehensively assessed.
• Although published in 2014, the issues discussed are still valid to
date.
• Main focus on USA and UK medical education systems. Minimal
examples of developing countries
• These issues are generalizable and applicable to all systems globally.

27. Meaningful critique
Questions for future research?
• Accreditation
• Validity in terms of patient safety (longitudinal studies)?
• Best practices in the development and implantation of protocols?
• Psychometric characteristics of tools used to assess the effectiveness of
standards employed?

28. Meaningful critique
Questions for future research?
• Licensure, certification, and revalidation
• Validity of licensure and revalidation in terms of patient safety (longitudinal
studies)?
• Globalisation of medicine & medical tourism
• Common Licensure pathway?

29. Application to own practice
• Scope of accreditation in Pakistan

30. Application to own practice

32. Application to own practice
• Accreditation (limited to documentation, far away from reality)
• Lack of transparency in the process
• Variability in methodology
• Lack of standardization
Currently, most private and some public medical schools accredited by PMC are
substandard producing suboptimal graduates and risking the life of patients
they will serve in real-time practice.

33. Application to own practice
• Licensure
• Assessment (NLE) for licensing needs to be improved and data from real-time
medical practice in Pakistan must be incorporated.
• Many students have cleared NLE and got a license, but they still lack the basic
knowledge and skills.
•

34. Application to own practice
• Certification
• Credibility of certification examination of Pakistan is minimal.
• Unless you don’t have international certification, local certification is not
valued.
• Re certification
• PMC took the initiative of CME a few years back but was reversed.
• Certain doctors who graduated 20 -30 years are currently at the top rank in
the medical hierarchy but they are still stuck to their old outdated concepts.
• Same is true for doctors working in the periphery.

35. External Readings (accreditation)

36. External reading
(Licensure / certification)

37. External Readings (Re validation)

38. Summary
• Assessment of a doctor’s fitness to practice medicine is both complex and
difficult.
• Accreditation, when implanted and followed in its true spirit, has a positive
impact on students (quality of education), and institutions ensuring patient
safety.
• Licensure, certification, and re-validation are markers of competent skillful
doctors ensuring patient safety throughout their career.
• Further studies are needed to quantify and determine the causal
relationship of all these activities in terms of patient safety.

39. THANK YOU