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ARTICLE
Year : 2010  |  Volume : 51  |  Issue : 2  |  Page : 70-77 Table of Contents     

Quality assurance in medical education: The Nigerian context


Office at the Provost, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria

Date of Web Publication27-Nov-2010

Correspondence Address:
Akinyinka O Omigbodun
Office at the Provost, College of Medicine, University of Ibadan, University College Hospital, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Background: The ultimate goal of medical education is to improve the health of the community. To ensure that medical training achieves this objective, its quality must be assured.
Objective: The aim of this presentation is to attempt a definition of quality assurance in the context of medical education, explore its linkage to improved services and outline a framework for its application in Nigeria.
Methods:
A review of published articles and policy documents on quality assurance in higher education and medical training from different parts of the world, identified through an internet search, was done to distil the current ideas on the subject.
Findings:
There is a consensus that graduates from training institutions must attain an agreed minimum standard in the quantum of skills and knowledge, as well as the attitudinal disposition that they are expected to acquire in the course of their medical education. This applies to both undergraduate and postgraduate professional training. There is no guarantee that the quality assurance that is implied in enforcing such minimum standards necessarily leads to an improvement in the quality of care that the community receives. Nonetheless, quality assurance should be seen as a first step towards quality improvement. Sustained improvement requires that stakeholders demand quality in service delivery and a credible process of clinical audit, with widespread dissemination of evaluation results, to ensure accountability and maintenance of quality. However, this can only happen if the medical professionals are properly trained in all accredited institutions, a situation that can best be attained by agreement on a common core curriculum and the systematic use of improvement tools, especially the continuing professional development (CPD) of trainers. The National Universities Commission (NUC) and the Medical and Dental Council of Nigeria (MDCN) are the two bodies that have the legal mandate for the accreditation of medical and dental schools in Nigeria. Both have published separate policy documents on minimum standards of training. There is however no system of audit or formalized CPD in place yet.
Conclusions: For proper quality assurance and service improvement in Nigeria, the NUC and the MDCN need to achieve a consensus on the implementation of minimum standards for trainees and trainers, with the former leading the way on curricular issues while the latter sets the pace on quality of training facilities, the credentialing of trainers and their continuing medical education and self development.

Keywords: medical education, quality assurance, Nigeria


How to cite this article:
Omigbodun AO. Quality assurance in medical education: The Nigerian context. Niger Med J 2010;51:70-7

How to cite this URL:
Omigbodun AO. Quality assurance in medical education: The Nigerian context. Niger Med J [serial online] 2010 [cited 2021 Feb 28];51:70-7. Available from: https://www.nigeriamedj.com/text.asp?2010/51/2/70/70999


   Introduction Top


The ultimate goal of medical education is to improve the health of the community. To ensure that medical training achieves this objective, its quality must be assured. The training of doctors has always been marked by the need to meet defined criteria with regard to knowledge and competencies required to provide acceptable care to members of the community. These are also prominent features of what is known today as "Quality Assurance" . Other terms that are sometimes used for the same exercise are quality improvement or quality management although, strictly speaking, these terms are not synonymous. There is the belief in some quarters that quality assurance sets the stage for quality improvement. Quality improvement is defined as "a continuous process to review, critique and implement changes" [1]. Thus, while quality assurance in the education of medical and health personnel is an important means of ensuring quality healthcare, we are urged not stop at quality assurance but move to quality improvement in order to keep up with the changing needs of healthcare [1],[2].

First, we need to define what is meant by 'quality'. A quality (from Latin qualitas) is an attribute or a property. In this context, attributes are ascribed to a subject while properties are possessed by the subject. We can also define 'quality' as the "characteristics of a function, process, system or object that are fulfilled when compared to predefined goals or standards". For instance, the quality of medical practice is the extent to which the properties of the delivered medical care meet the current criteria and demands of care as accepted by the profession and society at large; and this is generally a function of the quality of education of practitioners.

Moving a step further, various meanings have been ascribed to quality assurance (QA) but generally, QA refers to a programme for systematic monitoring and evaluation of the various aspects of a project, service, or facility to ensure that pre-set standards of quality are being met. The 'quality' referred to is determined by the programme designer or sponsor. QA cannot absolutely guarantee the production of what will be universally regarded as a quality product. Two key principles stand out in trying to ensure QA in any setting:

  • the product should be suitable for the intended purpose
  • errors should be eliminated
The whole purpose of QA is to improve and stabilize production (and associated processes) to avoid, or at least minimize, issues that could lead to defects in the product. The need for quality assurance programmes for medical education worldwide has been recognized by the World Federation for Medical Education (WFME) [3].

My main objective in this article is to explore the issue of quality assurance in the context of Medical Education, explore its linkage to improved services and outline a framework for the application of QA in the training of medical personnel in Nigeria. A review of published articles and policy documents on quality assurance in higher education and medical training from different parts of the world, identified through an internet search, was done to distil the current ideas on the subject.

Quality Assurance in Medical Practice

Every person wants to be confident that when they are stricken by illness or are unfortunate enough to be involved in an accident that threatens their well-being, there will be competent professionals to look after them and help restore them to health. Hence in most societies and nations, organizations have evolved, by convention or by statute, to establish standards of care that are expected of individuals or institutions that offer to provide medical care to people in such communities. Such organizations set criteria to be fulfilled by those aspiring to provide care and often monitor the delivery of such care to the public. In short, such bodies, which are usually made up of practitioners themselves, generally regulate the practice of the profession. The quality of medical practice is the extent to which the properties of the delivered medical care meet the current criteria and demands of medical care as accepted by the profession, as embodied in the regulatory body set up by or for it, and by society at large. This quality of practice is generally a function of the quality of education of practitioners. Thus, one of the primary ways of ensuring quality in practice is to assure and improve quality in medical education.

Quality assurance, based upon assessing and adjusting performance in medical practice, is an ethical obligation for every doctor throughout the entire professional career. Quality assurance is a professional concept, initiated and controlled by the profession itself. It is the sum of the processes of assessing and stimulating the quality of medical practice by measuring outcome and comparing it with current criteria and demands of medical care. Quality assurance projects could either be initiated by the doctor himself, in a bottom-up approach, or by professional institutions in a top-down approach. A creative combination of both is needed for efficiency and effectiveness. When a doctor takes up personal responsibility for the audit of his/her professional activities, it creates a platform for continuous readjustments and alterations in what they do (and how they do it) that should improve patient outcome. However, since not all practitioners would have the self-discipline to do this on a systematic and consistent basis, institutions have to set mechanisms in place for clinical audit and correction of lapses in practice [4]. Quality assurance should ensure that medical activities are systematic and controlled. Aspiring practitioners have to be introduced to these principles right from the period of their training. Quality in practice can best be achieved if it has a foundation of quality in education

Different Types of "Quality" in Medical Education

Having defined 'quality' as both attribute and property, it is to be expected that there would be various aspects to the issue of quality in medical education. Some of these aspects are outlined below [5]:

Different Types of Quality

Structure Quality

  • Educational Environment
  • Teaching Competence
  • Innovation Potential
Process Quality

  • Teaching Performance of Academic Staff
  • Organization of Teaching
  • Learning Performance of Students
Outcome Quality

  • Achievement of Educational Objectives
The educational environment is fundamental to the quality of the overall educational experience of trainees. The physical facilities in terms of buildings and equipment, the basic qualifications of the teachers, the quantum of teaching and technical staff available for student instruction and the teacher-student ratio, which is an index of the quality of student supervision, all contribute to the quality of medical education. Another structural issue pertaining to the quality of education is the competence of the teachers. This is not a direct function of their basic qualifications as one may be tempted to assume. There are many scientists and practitioners who are highly knowledgeable but are unable to impart knowledge or assist others to learn. There is greater awareness now of the need to have medical teachers undergo formal training in educational methods to improve their competence. The other structural issue that needs to be addressed is whether, or not, allowance is created for students to be innovative. With the fresh perspectives young people bring to situations, allowing them to express new ideas and try them out in the context of their learning experience is a time-tested way of creating new knowledge. Students should be encouraged, right from the earliest stages of their training to develop an interest in research and innovation.

While the structure is fundamental to success, the process followed is also crucial. While the teachers are expected to have the basic qualifications to take up the positions, performance on the job is another matter entirely. The diligence with which the teachers apply themselves is a better predictor of outcome than their educational attainment [6]. Medicine is both Science and Art; accordingly, the education of future practitioners should not just be about their knowledge and skills but also about attitude and empathy. Traditionally, medical education often followed an apprenticeship model, but the sheer quantum of knowledge that has been created in the field over the past century and a half dictates that teaching has to be highly organized and systematic. There must also be a well-designed programme for the systematic assessment of student progress and learning, especially in terms of the competencies they have achieved at each stage of training.

Ultimately, quality is judged by output. In quality control, it is by testing the product that the process is judged. It is the performance of medical graduates on the job that testifies best to the quality of education they had received. If the right educational objectives had been set and the students had been properly guided through their training, they would provide the right quality of service to their patients and their communities [7].

Standards and Quality Assurance

The training and practice of doctors has always been marked by the need to meet strictly defined criteria with regard to systematic work, documentation and the evaluation of the results of their practice. These are also prominent features of QA - setting of standards and monitoring to see how far they are met. Standards are often measured by the competencies achieved by the graduates of educational institutions. Generally, the competencies to be achieved in the course of medical education include:

  • Medical Knowledge
  • Communication Skills
  • Team Work & Leadership
  • Professionalism
  • Commitment to Life-long Learning
The WFME recommends the following set of international standards in basic medical education [3]. The standards are structured according to nine areas with a total of thirty-six sub­areas. Areas are defined as broad components in the structure and process of medical education and cover:

  1. Mission and Objectives
  2. Educational Programme
  3. Assessment of Students
  4. Students (Inherent Ability)
  5. Academic Staff/Faculty
  6. Educational Resources
  7. Programme Evaluation
  8. Governance and Administration
  9. Continuous Renewal
There are two main types of standard that medical educators ought to consider:

Basic Standard: This is the minimum standard expected to be met by every medical school and fulfillment demonstrated during evaluation of the school. Basic standards are expressed by a " must".

Standard for Quality Development: This standard is in accordance with international consensus about best practice for medical schools and basic medical education. Medical schools should be able to demonstrate fulfillment of some or all of these criteria, or that initiatives to do so have or will be taken. Fulfillment of these standards will vary with the stage of development of the medical schools, their resources and educational policy. Even the most advanced schools might not comply with all the standards set.

Standards for quality development are expressed by a " should". Setting the appropriate standards make quality assurance and quality improvement possible. Quality Assurance [QA] therefore is a way to ensure that the predefined "standards" are met. Quality Improvement [QI] is defined as "a continuous process to review, critique and implement changes"[1]. The first sets the stage for the second.

For quality assurance to lead to quality improvement, certain ingredients have to be in place. To get the process started, stakeholders must demand quality. There must be clearly defined process of clinical audit, one of the most important tools for improving practice [8]. Evaluation reports must be published for all stakeholders to be aware. This is one way of ensuring accountability. Once people are aware that they are going to be evaluated, it informs their approach to the execution of their duties. Finally, there is no way standards can be maintained; neither can quality be assured unless there is a properly established system of continuing professional development. Where standards are not responsive to dynamic changes in medical knowledge, or where the accreditation exercises are not accompanied by accountability on the part of the institutions or individuals being accredited, and where continuing professional development is not demanded by the profession, there can be no quality improvement. On the contrary, standards are likely to slip further and further in such a situation until it becomes quite apparent that practice in such an environment is failing to meet up with what is considered to be the minimum standards in global terms.

Quality Assurance in Undergraduate Medical Education

Quality assurance in medical education is the key to providing wholesome health care for the community for if the foundation is defective, the superstructure cannot be sound. If basic medical education is not well taken care of, specialist training is likely to be a greater challenge and its output less than optimal. To enable basic medical education achieve its main purpose, there ought to be a comprehensive set of educational objectives for the whole programme which can be framed as outcomes to guide teaching, learning and assessment. Sound contemporary medical school curricula generally fulfill this requirement. In order to ensure that all training institutions meet their obligations in this regard, it is common to have minimum standards being set out by bodies that are charged with the task of maintaining the standards of academic and professional training in each jurisdiction.

In Nigeria, that task is given to two bodies: the National Universities Commission (NUC) for ensuring academic standards and the Medical and Dental Council of Nigeria (MDCN) for professional standards of training and practice. Each of these bodies has published guidelines for such standards [9],[10]. Unfortunately, some of the stipulations in the two documents seem to be in conflict with one another. It is highly desirable to harmonize the activities of the two bodies in order to assure quality in medical education throughput the country. In this regard, efforts should be made to define a core curriculum which all accredited training institutions must incorporate into their own individual curricula. Of course, such a core curriculum cannot be all-embracing but should concentrate on establishing a basic minimum that all medical and dental trainees must be exposed to in the course of their training. Such a core curriculum will be common to all students in all institutions in the country. It must cover competencies that leaders of the profession agree are essential for professional practice, including knowledge, skills and attitudes. It must also establish minimum levels of proficiency by the students. It should be arranged in a way that allows for knowledge to be acquired in a graduated fashion, stipulating what must be learnt at a stage before moving on to the next, in order to ensure an acceptable level of mastery by the students.

Quality Assurance in Specialist Training and Practice

While quality assurance is essential in undergraduate medical education in order to set the right tone for quality of practice in the nation, it is indispensable in post-graduate medical training because those who complete such training are expected to practice at the highest level of care where proficiency is at a premium and the demands made on the ability of individual practitioners can be daunting. Specialists are expected to drive the move for quality in their own practice. Therefore, training in the basic requirements of quality assurance, such as data collection and analysis, as well as practical exercises in the implementation of quality assurance projects should be part of the regular activities of postgraduate training. Professional scientific organizations are required to develop quality criteria in their specialty that can be used by individual specialists and in group practices, both within and outside hospitals. The medical specialist should be required to audit his/her own performance on a regular basis. This involves purposive preparation for the review of activities within the practice. The practice should be organized in such a way that outcome review is possible because this is a well recognized method of maintaining standards in practice [11]. Data about examinations, diagnoses, treatment and follow-up should be collected in a structured manner and be open for quality assurance projects (both internal and external), subject to patient confidentiality.

Practitioners in the various specialities of medicine and dentistry should also keep records activities related to their Continuing Medical Education (CME) or Continuing Professional Development (CPD) - the preferred contemporary term. In any case, the Medical and Dental Council of Nigeria will soon require all practitioners to provide evidence of participation in CPD activities before the renewal of their annual practicing licenses. It is therefore in the interest of every specialist to evolve a structured approach toward participation in such activities and keeping a record of such involvement.

The responsibility for setting the standards for postgraduate professional training in Nigeria and in Anglophone nations of the West African sub-Region has been left in the hands of the postgraduate medical colleges. The relevant ones that are operational in Nigeria are the National Postgraduate Medical College of Nigeria (NPMCN), the West African College of Physicians (WACP) and the West African College of Surgeons (WACS). Since their establishment more than three decades ago, these institutions have developed viable postgraduate training programmes with appropriate tools for the accreditation of training institutions and for the examination and certification of Fellows. There is however room for improvement in the manner these functions are carried out and lessons can be learnt from the practice that has been adopted in the United Kingdom over the past five years.

The Postgraduate Medical Education and Training Board (PMETB) is an independent statutory body which has been responsible since September 2005 for establishing and securing standards of medical education and training in post-foundation years in the UK [12]. The statutory objectives of the PMETB include safeguarding the interests of patients and ensuring that the needs of both trainees and their employers are met. The PMETB has set a number of generic training standards and, in consultation with each of the relevant Royal Colleges, has developed a detailed curriculum for each specialty. Rather than depend on the traditional College-led and visit-based accreditation system, its quality assurance programme places greater emphasis on quality management systems at the level of the postgraduate deans. The quality assurance process of PMETB aims to ensure that the training standards are met within each deanery, so that training programmes can continue to receive approval. No such framework exists yet in Nigeria, but it may be worth pondering upon. A network of accredited training institutions grouped by states or senatorial zones may be created to serve as units for such a quality management approach. Residency Training Co-ordinators could then be appointed for each unit of grouping that is agreed upon who would have primary responsibility for quality management. A series of nine domains within which standards can be set and assessed has emerged and has become a pivotal component of the quality assurance process [13]. It is important that those involved in the delivery of specialist training are aware of these domains.

Domain 1: Patient Safety - the duties, working hours and supervision of trainees must be consistent with the delivery of high quality safe patient care. Trainees must be appropriately supervised by clearly identified, competent and accessible trainers; and the terms and conditions of their posts must be consistent with the delivery of high-quality, safe patient care.

Domain 2: Quality Assurance, Review and Evaluation - the quality control of postgraduate training must be carried out locally by Residency Training Co-ordinators, working with others as appropriate, but within an overall delivery system for postgraduate medical education for which they are responsible. Training institutions must have processes for local quality control of all postgraduate posts and programmes to ensure that the requirements of established standards for training, assessment and curricula are met.

Domain 3: Equality, Diversity and Opportunity - postgraduate training must be fair and based on principles of equality. Training programmes must comply with all employment laws

Domain 4: Recruitment, Selection and Appointment - processes for recruitment, selection and appointment must be open, fair and effective. Selection panels must consist of individuals who have been trained in selection principles and processes. Panels must select candidates through open competition and use criteria and processes that treat eligible candidates fairly.

Domain 5: Delivery of Curriculum and Trainee Assessment - the requirements set out in the curriculum must be delivered. Each training post should enable the trainee to acquire appropriate competence. Trainees must be able to access training days, courses and other material constituting a training programme. The curriculum should include a system for assessment of trainees, who should receive feedback on their performance and training progress within each post.

Domain 6: Support and Development of Trainees, Trainers and Local Faculty - trainees must be supported to acquire the necessary skills and experience through induction, effective educational supervision, an appropriate workload, personal support and time to learn.

Domain 7: Management of Education and Training - education and training must be planned and sustained using transparent processes and clear assignment of responsibility at each stage.

Domain 8: Educational Resources and Capacity : the educational facilities, infrastructure and leadership must be adequate to deliver the curriculum. There must be a suitable ratio of trainers to trainees and access to educational facilities (library, meeting rooms), as well as educational resources (the internet, audio­visual aids).

Domain 9: Outcomes - the impact of the standards must be tracked against trainee outcomes and clear linkages should be reflected in developing standards. The use of these domains should greatly assist the quality assurance process and it shares considerable overlap with the standards described for postgraduate medical education by the WFME [7]. The areas described, which are similar to what was described for undergraduate education, are:

  1. Mission and Outcomes
  2. Training Process
  3. Assessment of Trainees
  4. Trainees (Inherent Ability & Foundation Training)
  5. Professional Staff
  6. Training Settings and Educational Resources
  7. Evaluation of Training Process
  8. Governance and Administration
  9. Continuous Renewal
The basic principles set by both standards are non-prescriptive, should foster innovation and generally set the stage for quality improvement in medical education.

Quality Assurance in Continuing Professional Development (CPD)

With the requirement that professionals continually update themselves in terms of knowledge and skills in their area of practice comes the obligation to set standards for the provision of such programmes. The requirements to be met in establishing credible standards at this level differ somewhat from what is necessary for the more formalized undergraduate and specialist medical education. The areas for standards-setting are quite similar to what had previously been outlined for undergraduate and postgraduate medical education and these are [7]:

  1. Mission and Outcomes
  2. Learning Methods
  3. Planning and Documentation
  4. The Individual Doctor
  5. CPD Providers
  6. Educational Context and Resources
  7. Evaluation of Methods and Competencies
  8. Organization
  9. Continuous Renewal
While the issues of Mission, Outcomes and Continuous Renewal are common to all the levels of education, some of the important components vary greatly. In the context of CPD, a lot of attention is needed in certifying those who are to be CPD providers so that the whole exercise can be meaningful and this is not as straight forward as it is for undergraduate and postgraduate medical education where there are clear-cut criteria for the credentialing of academic staff and consultant staff who are responsible for training. In fact, as far as CPD is concerned, the accreditation of CPD programmes and their providers is probably the most important area where standards must not be compromised. It is particularly important to ensure that those who are allowed to mount CPD activities are not doing so purely with the motivation to make profit. Record keeping and authentication of certificates issued by accredited providers also merit attention.

The Quality Assurance Process

The quality assurance process is the method by which quality assurance is carried out in practice. The process can be internal, in which case a doctor, a group of doctors or an institution review their own results, or external, where an external professional body reviews the data of the institution or the professional practice (peer review).

Several different approaches have been advocated but the components of these different methods are quite similar [7],[14],[15],[16] and they follow the general principles of monitoring and evaluation. One sequence that could be followed, which incorporates most of the steps that are generally agreed upon, is:

  • identifying and selecting a quality problem,
  • identifying the indicators,
  • specifying criteria,
  • preparing tools for the acquisition of data,
  • collecting data,
  • analysing and assessing quality on the basis of the registered data,
  • comparing the results obtained with agreed criteria,
  • taking steps to improve quality on the basis of the results
  • checking the outcome of the measures taken to improve quality,
  • identifying a next quality problem on the basis of the evaluation of the result
To follow through on the process, appropriate tools must be deployed.

Tools of Quality Assurance

The increasing international interest in assuring and recognizing quality in medical education has called for a number of initiatives, including promotion of national accreditation systems, establishment of international partnerships, collaboration in fora and conventions, publication of global databases and meta-recognition of accredited institutions and programmes [7]. Some of the tools for implementing the quality assurance process that have emerged from these initiatives will now be explored.

Establishing Minimum Standards

The most important tool of quality assurance is the establishment of minimum standards. This sets the pace for all other activities in the quality assurance process. The WFME has established such standards and published same in the International Guidelines on Quality Improvement in Basic Medical Education [3]. There are advantages to publishing such global standards, including serving as a baseline for national evaluation, providing an opportunity for educational research, serving as the basis for accreditation and being an incentive for improvement [7]. However, there are also drawbacks, with many institutions having concerns about loss of autonomy, loss of individual character or institutional culture, disregard for local differences and increased likelihood of 'brain-drain' because of universal conformity.

In Nigeria, both the MDCN and the NUC have a major role to play in setting and monitoring standards (knowledge, skills and attitudes), issuing guidance to support implementation of standards and, in the case of the MDCN, provisional and full professional registration. The delineation of roles between the two institutions is not always clear and this is an issue that requires resolution as soon as possible so that set standards will be unambiguous.

Accreditation

Accreditation is the most commonly used tool to ascertain whether or not standards are being met. It is a peer review process of quality assurance based on standards for process and outcomes. It addresses functions, structure and performance and is designed to foster improvements in institutions and programmes.

  • The major objectives of a sound accreditation exercise include the following:
  • to certify that a medical education programme meets the prescribed standards, of structure, function and performance
  • to promote institutional self-evaluation and improvement
  • to assure society and the medical profession that graduates of accredited schools meet the educational requirements for further training and for the health care needs of the people
A prerequisite for a sound accreditation process is validated and regular course evaluations. The evaluation process should include both quantitative and qualitative reviews which allow for feedback in a constructive way. Being convinced of the crucial interface that exists between medical education and health care delivery, a World Health Organization (WHO)/World Federation for Medical Education (WFME) Strategic Partnership to improve medical education was formed in 2004. In addition to working on reform processes, capacity building, and evaluation of medical education at the regional and national levels, the partnership in 2005 published guidelines for accreditation of basic medical education [7]. Only a minority of countries have quality assurance systems based on external evaluation, and most of these use only general criteria for higher education. The WHO/WFME Guidelines recommend establishing accreditation that is effective, independent, transparent, and based on criteria specific to medical education. Examples abound from different countries on the adaptation of these criteria to address local needs.

In the United Kingdom, the General Medical Council (GMC) assumes overall responsibility for the task. It has adopted the tool of accreditation as part of its Quality Assurance in Basic Medical Education (QABME) initiative. The GMC sets up QABME teams consisting of clinical and non-clinical academics, National Health Service clinicians, educationalists, lay members, medical students and staff from the GMC to carry out the exercise [17]. The teams collect information such as basic data (student profile, staff & resources), curriculum, admission processes, student support, assessment and progression, student health and conduct and institutional strengths and weaknesses. Facilities are visited and there are interactions with staff and students including direct observation of teaching and assessment.

In the United States, undergraduate allopathic medical school programmes are accredited by the Liaison Committee on Medical Education (LCME), ensuring the quality and consistency of the educational experience of U.S. medical graduates. Comparison of the standards used by the LCME and those set by the WFME shows a high degree of congruence and mutual consistency[18]. Most of the WFME standards for quality development are included in the LCME standards. The LCME standards are however more detailed and take into account specific US traditions and needs.

Before 2003, the University of the West Indies (UWI) in Jamaica and its associated campuses located in Barbados and Trinidad and Tobago were accredited by the General Medical Council (GMC) located in the United Kingdom. When the GMC ceased accrediting programmes located abroad, the Caribbean Community (CARICOM) member states established the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP) in 2004 as an independent regional accreditation authority to fulfill this need[19],[20],[21]. The medical schools which have voluntarily undergone the accreditation process have reported that the task of compiling information and carrying out a critical and comparative analysis has been extremely useful. The highly structured nature of the required processes necessitated a very detailed review of all aspects of the functioning of the medical schools exceeding that which accompanies internal reviews. Faculty members have become more aware of how data should be stored, sorted and requested in the future to allow for retrieval of accurate information in a timely and efficient manner [19]. Generally speaking, the schools have also acknowledged the importance of regular accreditation for quality assurance and the maintenance of international standing. In both the short and long-term, the accreditation exercise has served the purpose of improving the educational programme and the quality of the graduates of the respective programmes. Overall, the cyclical process of institutional self-study and assessment, coupled with external validation by a team of professional peers provides a mechanism for on-going quality improvement. That quality assurance focus is closely linked to licensing requirements for medical practice and access to postgraduate education [20],[21]. In South Africa, the focus has been on developing objective tools for accreditation 22. This is based on the premise that the results of accreditation are only as good as the tools employed and there is a need to minimize the human subjectivity that tends to attend such exercises. In Nigeria, both the NUC and the MDCN undertake accreditation of institutions providing undergraduate medical and dental training. Sometimes, there is no congruence in their requirements. Occasionally, the accreditation status granted to the same institution by the two bodies may be in conflict. This is a situation that is totally avoidable and there is an urgent need for the two bodies, which were set up by the same federal Government, to harmonize their activities so that such ambiguities cease to exist.

Maintenance of Health Records

The maintenance of health records is particularly important for clinical audit and other forms of evaluation. This is of crucial importance for quality assurance in specialist training and practice. Without maintenance of health records (preferably in digital easily retrievable forms), there can be no proper clinical audit [8],[23] and quality improvement will remain a mirage.

Medical Licensing Examinations

One quality assurance measure that has been discussed within Europe is the implementation of a common licensing examination [15]. It has not found much support at present. The degree of variance over Europe between the current medical education systems is too great to be measured in a standardized examination without having first established standards such as a common core curriculum. If a common licensing examination is to be adopted in Nigeria, the issue of a common core curriculum will also first have to be addressed. In the foreseeable future, it is recommended that more efforts should be directed at proper accreditation of training institutions rather than diverting attention to licensure examination. Such examinations should continue to be restricted to graduates of foreign medical schools as they are now.

Continuing Professional Development

Continuing medical education (now more often called continuing professional development) is a fundamental requirement for the maintenance of the quality of medical practice. The participation of medical specialists in CPD programmes should not only be encouraged, it should be a requirement for licensing, a practice that has already been adopted by the MDCN. A credit point system operated by a department charged with that task in the MDCN should ensure that the minimum criteria set for participation in CPD activities is met by individual medical practitioners. In CPD programmes, quality assurance of medical practice should be emphasized and should be part of the programmes that are offered by CPD providers.

Audit

Medical audit and continuing professional development (CPD) are now the mainstays of quality assurance in hospitals [23]. The single most important step is the selection of essential or scientific criteria that relate process to outcomes [8],[11]. Medical audit and CPD can effectively improve care by improving health care practitioners' performance. The purpose of auditing is to assure that patients with specified conditions are receiving the full benefit of medical care with the least possible number of complications.

Quality Control

Quality control emphasizes testing of products to uncover defects. In the context of medical education, this can be taken care of by licensure examination and periodic re-examination. The Nigerian situation is not yet ripe for the introduction of such practices until the institutions that would implement such programmes have been sufficiently strengthened.

Financing of Quality Assurance

Quality Assurance in medical practice is an essential element of state of the art medical practice. Therefore the necessary expenditure on quality assurance must constitute a natural and mandatory element in the general expenditure on health care taking into account the socio-economic context. Payments by the patient, either directly or in the form of insurance contributions and taxes should ideally contain an element for this purpose [14],[15]. This will be difficult to actualize in the Nigerian context at present, but resources must be found to finance quality assurance programmes. The profession may include a small levy for this purpose in the annual practicing fee of practitioners.


   Conclusion Top


It is important that all efforts be joined in the endeavour to create effective and reliable tools for quality assurance in medical education, whether undergraduate, postgraduate or continuing education. One urgent need in achieving this in Nigeria is the harmonization of the activities of the NUC and the MDCN which are the two bodies that have a role in setting standards for medical education in the country. For proper quality assurance and service improvement in Nigeria, the NUC and the MDCN need to achieve a consensus on the implementation of minimum standards for trainees and trainers, with the former leading the way on curricular issues while the latter sets the pace on quality of training facilities, the credentialing of trainers and their continuing medical education.

 
   References Top

1.International Federation of Medical Students' Associations (IFMSA) & European Medical Students' Association (EMSA). Quality Assurance in Medical Schools: Moving from Quality Assurance to Quality Improvement. Communiquι from EMSA/IFMSA Quality Assurance Workshop, Copenhagen (Denmark), July 6- 10, 2005.   Back to cited text no. 1
    
2.European Medical Students' Association (EMSA). The Bologna Declaration and Medical Education: A Policy Statement from the Medical Students of Europe. Medical Teacher, 2005; 27 ( 1): 83- 85.   Back to cited text no. 2
    
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10.Medical and Dental Council of Nigeria (MDCN). Guidelines on Minimum Standards of Medical and Dental Education in Nigeria. Abuja, Nigeria, MDCN, 2006.   Back to cited text no. 10
    
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13.Postgraduate Medical Education and Training Board (PMETB) Generic Standards for Training. Available at http:// www.pmetb.org.uk/media/pdf/h/s/GenericStandardsFor TrainingFinal 05April 06___ 1.pdf, 2006 23.   Back to cited text no. 13
    
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21.van Zanten M., Parkins L. M., Karle H., Hallock J. A. Accreditation of Undergraduate Medical Education in the Caribbean: Report on the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions. Academic Medicine, 2009; 84( 6): 771- 775.   Back to cited text no. 21
    
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