Medical school clinical affiliates — from an accreditation perspective

Note to the reader: The piece below addresses something I have been thinking about for some time. As I began preparing these comments, I learned that LCME Co-Secretary Barbara Barzansky had recently discussed this topic in a webinar, Clinical Faculty and the Medical School Accreditation Process, hosted by the Alliance for Clinical Education (find their webinars here). That excellent discussion examined accreditation and clinical education from the perspective of the clinical educator and the clerkship course director.  The comments below are geared toward the accreditation oversight office. I think the perspectives are complementary, and I urge you to watch the recording of the webinar, which can be found here.

Note that the comments below are my reflections. The LCME provides myriad helpful resources for accreditation information, including their Connecting with the Secretariat Webinar series, and I recommend making use of them.  As the LCME has noted on its website, “The LCME Secretariat and the publications on [the LCME] website are the only official sources of information regarding LCME policies, procedures, and issues related to the intent of elements.” – Lois Margaret Nora, MD, JD, MBA

Medical schools are responsible for all aspects of their educational programs, yet evolving models for US healthcare mean that direct oversight of clinical training by the medical education office can be limited. While some schools continue to center clinical training in their own teaching hospitals, it’s increasingly common for schools to have multiple clinical affiliations with hospitals and health systems outside of their direct control and often geographically removed from the school.

While Element 1.4 mentions clinical affiliates specifically, these important partners are best viewed through the lens of multiple LCME standards.  In this note, I share some thoughts on how a variety of standards and elements intersect with clinical training, whether at the school’s home location or a clinical affiliate.

Standard 1: Mission, Planning, Organization, and Integrity

Clinical affiliate partners should be considered in your CQI processes (1.1).  Ongoing communication about accreditation requirements is important, as is sharing of relevant data. For example, if your CQI team is monitoring an accreditation element, are relevant affiliates reporting on the necessary metrics?  And are they getting feedback about their performance on those metrics?  

Element 1.4 is the most obvious LCME accreditation element that deals with clinical affiliations.  This element requires alignment around the allocation of clinical training-related responsibilities on the part of the school and the clinical affiliate.  Periodic review of affiliation agreements provides an opportunity to clarify responsibilities for resources — physical and educational — as well as the shared responsibility of providing a professional learning environment.  

When completing the DCI, start by checking that affiliation agreements are signed and that names, dates, page numbers, and other details from the agreements are reflected correctly in the DCI and its attachments.  The DCI explicitly asks where to find language about specific requirements; make sure that your document is clear and that the page numbers listed are correct.  The AAMC Uniform Clinical Training Affiliation Agreement is a useful document.

Standard 2: Leadership and Administration

If clinical affiliates are part of a regional campus, elements 2.4-2.6 may be involved.  Key considerations include clear reporting lines into and out of the dean’s office, meaningful integration of regional faculty into the committee structure of the school, and adequate resourcing of faculty, education, and student support functions on the regional campus. 

Standard 3: Academic and Learning Environments

A close relationship with clinical affiliates can be a tremendous help in working toward your school’s diversity goals (3.3).  The faculty, residents, and staff at clinical affiliate sites contribute to diversity in the learning environment, and these settings offer students opportunities to experience a variety of clinical care settings.  Affiliated residency programs also offer an opportunity to build forward-leaning pathway programs (medical school to residency to faculty).

When a school is experiencing challenges with the learning environment and/or student mistreatment (3.5, 3.6), the clinical environment is often implicated.  Ensure that there is a clear policy stating that mistreatment and retaliation are not tolerated and that the school makes faculty and residents aware of this policy.  Student mistreatment issues should be reported centrally, even if handled locally, and there must be clear protocols for follow-up when issues are reported.  Incorporating questions about faculty and resident professionalism (similar to those on the AAMC Graduation Questionnaire) in your annual student survey can offer important insights beyond those gathered through individual student reports alone.  

Concerns about professionalism may be handled in different offices, depending on the source of the complaint (patient, student, resident, staff, etc.) and the subject of the complaint (attending physician, nursing staff, employee, resident, student).  Offices that handle complaints are appropriately concerned about confidentiality and fairness to all parties.  However, bridging information silos when appropriate may be helpful for ensuring issues are fully recognized and addressed. Hence, communication channels between the school and the affiliate offices that handle issues of professionalism should be in place. 

In addition to identifying issues, schools and clinical affiliates should consider systems-level approaches to challenges in the learning environment.  Professionalism and mistreatment matter to both the school and its clinical affiliates, and jointly sponsored communication and education may be helpful. Some schools have found cross-institutional UME-GME committees valuable for addressing and creating meaningful faculty development opportunities around professionalism in the clinical learning environment.   

Standard 4: Faculty Preparation, Productivity, Participation, and Policies

Element 4.1 speaks to the adequacy of faculty. Attention to this topic in terms of faculty numbers and availability at clinical affiliate sites during clerkships is important, as is a clear process for orienting them to their roles, their responsibilities and the relevant policies they must follow.  Oftentimes, faculty at affiliate sites serve on a voluntary basis.  While Standard 4 focuses heavily on traditional, salaried faculty, aspects of this standard are important for voluntary faculty, as well.  Work published by voluntary faculty at affiliate sites can be included in your scholarly productivity data (4.3).  Faculty appointments should be current, and faculty should receive meaningful feedback on their performance.  Many voluntary faculty aspire to promotion, and pathways for promotion in their faculty track should be available.

Standard 5: Educational Resources and Infrastructure

Standard 5 includes many elements that relate to clinical affiliates.  These elements can be particularly challenging to manage, given that they are often outside the direct control of the medical school.  However, the school remains responsible, even where direct oversight is limited.

Elements 5.5, 5.6, 5.8, 5.9, and 5.11 speak specifically to resources available for clinical education.  Patient volumes vary over time, and this can often be handled by adjusting student numbers on a given service.  Note that the tables in the DCI should reflect the number of patients by clinical discipline.  More often, issues arise over the adequacy of call rooms and space for secure storage, relaxation, and education.  Hospitals are under real space constraints.  Providing clarity about expectations — to all involved — is important. Elaborate student-only lounges are not expected; access to secure storage space and reasonable study and relaxation space is.

Element 5.7 deals with safety and security, and the school should be comfortable with security at all clinical locations.  The safety of students in parking lots after hours is one of the most frequent concerns, and access to security escorts can go a long way toward resolving it.  Particular attention should be paid to clinical rotations where students may encounter violent patients or angry family members.  Ensure students are oriented to safety protocols at the various hospitals and establish guidelines that require security-related episodes to be reported to the main campus.

Standards 6-9: Competencies, Curricular Objectives, and Curricular Design; Curricular Content; Curricular Management, Evaluation, and Enhancement; Teaching, Supervision, Assessment, and Student and Patient Safety

Teaching and assessment elements to keep in mind for clinical affiliates involve comparability of the education program across sites (8.7); mechanisms for identifying issues that may interfere with completion of required clinical experiences (6.2); expectations involving mid-clerkship feedback and timely submission of grades (8.6, 9.8); meaningful formative feedback (9.7); and availability of policies on these and other key topics (e.g., supervision (9.3), duty hours (8.8)).  Ensuring that expectations are met across affiliate sites requires ongoing communication and benefits from collegial working relationships among education leadership, faculty, and staff at the affiliate sites and the central medical education office.  Technology assistance, standardized operating procedures, and clear communication channels can help ensure adherence to policies.  Central monitoring of many of these activities can provide early warning if they are not being done or, conversely, provide evidence that they are occurring if student data suggests otherwise. 

Central monitoring is also important to ensure that residents have been appropriately trained in methods for teaching and/or assessing students (9.1) and that faculty and residents are provided with information about learning objectives and policies.  Even if residents are in a hospital or hospital system outside the school’s direct control, it is important to ensure that you are comfortable with that institution's resident-as-teacher program and that their residents receive and understand the school’s relevant policies.  Use central monitoring to prospectively ensure that physician-teachers have a current faculty appointment before they are assigned students (9.2). Clinical faculty and other nonfaculty educators, such as respiratory therapists and midwives, must be aware of and follow expectations regarding the teaching and supervision of medical students (9.3).

Standards 10-12: Medical Student Selection, Assignment, and Progress; Medical Student Academic Support, Career Advising, and Educational Records; Medical Student Health Services, Personal Counseling, and Financial Aid Services

When students spend substantial time away from campus completing educational requirements, including training with clinical affiliates, it is important that they have demonstrably comparable access to and quality of student support services as students have on campus (11.1, 11.2, 12.1, 12.3, 12.4). Videoconferencing, telehealth, and remote counseling services can be helpful.  We recommend that schools follow up with students who access services remotely to ensure these alternative means of access are effective. 

Clinicians who provide healthcare to students or have another close relationship with students should not have a role in the education/assessment of those students (12.5).  This includes situations where a student wishes to complete an elective in a family member’s practice or return to their pediatrician for an elective.  And there must be a clear — and clearly communicated — process for handling student education-related injuries such as needlesticks in a timely manner, particularly after hours (12.8).

Increasingly, schools are using attestation as a mechanism to demonstrate that residents and faculty are aware of the school’s policies, have received professional development, and are adhering to the requirements outlined in certain elements. This approach may be helpful for demonstrating compliance with these and other components of the LCME standards, provided care is taken to ensure attestation reflects a true understanding of policies and procedures, rather than functioning as a check-the-box exercise.

Making the most of your school’s partnerships

One of the most interesting and challenging aspects of accreditation, particularly for the medical school professionals who play a leading role in the process, is navigating accountability for issues over which they may have little direct control. This is a particular challenge with respect to clinical affiliations.

From my experiences serving as a voluntary clinical faculty member and then as faculty accreditation lead through my years of observing and supporting accreditation professionals, I have seen time and time again the value of legislative leadership skills (e.g., communication, consensus-building, and creating shared mental models, among others). These skills enable us to understand the goals and limits faced by our colleagues at affiliate organizations, clarify our institution’s needs, and build shared models to accomplish our intersecting missions.  Consider, for example, a joint medical school-affiliate learning environment committee that bridges both organizations, as well as undergraduate and graduate medical education. Or a joint working group that addresses issues in the care environment. The benefits of such collaboration typically go well beyond an immediate goal such as compliance with accreditation standards.   

Strong relationships with clinical affiliates frequently benefit when accreditation professionals leverage another leadership skill:  leading up.  Hospital leaders have their own priorities for the use of a facility’s limited space, and a senior medical school leader may be most effectively positioned to point out the shared common goals of accreditation compliance and quality in medical education.  Your ability to engage the dean or vice dean to take the lead on these issues at the appropriate time is important.

I hope these comments and suggestions help underscore the many ways clinical affiliate medical school relationships matter from both an education and student services perspective, and I welcome your input — including anything important that I might have missed.