Quality assurance in medical education

Medha A Joshi 
 Quality Assurance Unit, Health Sciences, Gokula Education Foundation (Medical), M.S. Ramaiah Campus, BEL Road, Bangalore, India

Correspondence Address:
Medha A Joshi
Quality Assurance Unit, Health Sciences, Gokula Education Foundation (Medical), M.S. Ramaiah Campus, BEL Road, Bangalore
India

Full Text

A physician, well-versed in the principles of science of medicine but incompetent in his art because of want of practice as well as the physician, experienced in his art but short on the knowledge of Ayurveda, is like a one-winged bird that is incapable of soaring high in the sky

- Shushruta Samhita 300-400 BC

Throughout the ages, doctors have been revered by the society because of their capabilities and competence. Thus, it is the responsibility of each physician to maintain this trust, based on professional competence and high ethical standards. Standard of medical education, as adopted and maintained by the educational institutions, go a long way in shaping the medical practitioner of today and tomorrow. Social and economic factors have impacted the medical education to such an extent that time has come to take a fresh look at the quality of medical education. The significance of medical education in delivering quality healthcare is assuming greater importance as many stakeholders have realized that without addressing quality in medical education, improving healthcare delivery is not possible.

Defining "quality" is difficult as it is subjective and dynamic. It has different meaning for different stakeholders. Quality in medical education can be defined in relative terms as state of reaching required standards as prescribed by the external agencies and it meets those standards time and again. [1] Other ways of looking at different definitions of quality in education are [2]:



Quality as value for moneyQuality as deemed fit for research and teaching in educational institutions, andQuality as transforming force for fulfilling the vision and mission of an institution

Quality assurance is implied in all these definitions; in the first definition, quality assurance is implied as an accountability to the public and meeting the requirements of the external standards, whereas in the second and third definitions, it is seen as essential for enhancing and maintaining the quality of teaching and learning at an institution.

An education can be compared to a service industry. In education, quality can be considered at both the production side i.e., the creation of the next generation of appropriate medical graduates, and the perceptual side, which is the maintenance of the values and principles of the medical educational institutions. [3]

Quality control is a procedure or set of procedures, intended to ensure that a manufactured product or the performed service adheres to a defined set of quality criteria or meets the requirements of the client or customer. [4] In quality control, one looks at the end product to check if it is according to the requirements. If we extend this industrial definition to medical education, we need to make sure that the students admitted to the course are as per the standards, the curriculum is delivered as planned, the teaching-learning activities are of specified standards and the teachers who help the students to reach the final stage are qualified to do so. In our institutions and the universities, Medical Council of India (MCI) takes care of these quality control procedures. Whereas, Quality Assurance is defined as a procedure or set of procedures, intended to ensure that a product or service under development (before work is complete, as opposed to afterwards) meets specified requirements. [2] It has also been defined as the product that is not only as per specifications but also fit for the purpose. [3] Quality assurance is a continuous process which involves measurement, judgment and steps taken for improvement in the process so that the final product meets the specifications of quality. This systematic, structured and continuous improvement helps in ensuring that the product is always relevant to the current demands. In educational institutions, the curriculum, the teaching learning methods, and the assessment methods should be reviewed and revised on a continuous basis to satisfy ourselves and our stakeholders that quality is assured during each and every stage of student's career. Quality assurance is a broad-based range activity under which both quality management and quality control are included. It includes all the policies, standards, systems and processes that are in place to maintain and improve the quality of medical education and training. Quality assurance can be managed through an institutional monitoring that should include the course evaluation, peer evaluation and the assessment. For an external quality assurance, accreditation standards by international agencies such as World Federation for Medical Education (WFME) are to be followed.

Feedback at regular intervals from the students and alumni on the courses offered, a structured and objective peer evaluation, and the use of wide range of assessment methods will improve the quality of doctors produced, which in turn should improve the healthcare delivery to the society. Methods, employed to evaluate knowledge, skills and attitudes, with well-defined learning outcomes that are made known to students, help in aligning the teaching and learning to assessments. A reliable and valid assessment adds to the quality assurance system.

In the background of an intense competition and globalization of the medical profession, it is imperative that our graduates and postgraduates are ready to face the challenge to take up professional positions anywhere in the world. They need to be knowledgeable, clinically competent and demonstrate professionalism. The medical educational institutions have to establish quality standards and constantly strive to enhance them through innovations and regular monitoring. The motivation to maintain quality may come from external agencies such as regulatory bodies, which prescribe minimum requirements or from internal impetus.

Internationally, the World Health Organization and World Federation for Medical Education (WFME) have decided to establish a joint policy on improvement of health system performance through improvement of the education of health professionals. The overall mission of WFME is to improve the health for all through promotion of high-quality medical education. [5] Over past few years, a number of initiatives have been taken internationally to ensure quality assurance in higher education, establishing accreditation standards for basic medical education, [6] postgraduate medical education [7] and continuing professional development of medical doctors. [8]

Accreditation is a process, widely used in higher education to evaluate the quality educational programs. Quality can be assured by transparent selection procedures, well-established entrance examinations, centrally regulated curricula, self-evaluation and academic audits conducted by the institutions themselves, appointing external examiners and requirement of national examinations before licensure. [9] If we examine the medical education in India in this light, the initiatives taken by MCI recently in their Vision 2015 document [10] meet most of these criteria for quality assurance. MCI has proposed common entrance examinations, the curricula are regulated by MCI, and it has also proposed a national common licensure examination to be implemented from 2015. The final university examinations are conducted by using external examiners. One aspect, that is partly addressed, is the self-evaluation and monitoring. Though MCI conducts periodic inspections, they are limited to verification of resources in terms of manpower, infrastructure and hospital bed strength. The curriculum implementation, innovations in teaching-learning processes and assessment are rarely looked into. If our educational standards have to meet the global standards, quality assurance measures need to be put in place.

More than 70 countries in the world are following the quality assurance and accreditation systems based on an external review. [9] In India, National Assessment and Accreditation Council (NAAC) was established in 1994, by the University Grants Commission (UGC), to assess and accredit higher education institutions in the country. NAAC's vision and mission focus on making quality assurance an integral part of the functioning of higher education institutions. [11] Although NAAC has addressed the issue of accreditation of health science institutions, not all the medical colleges are eligible for external review by NAAC. To remain in competition with global institutions, the medical education in India needs to catch up with international accreditation standards, based on WFME global standards.

Medical students play a pivotal role in quality assurance in medical education. During accreditation, independent reports of the students get considerable weightage. [12] A validated and regular feedback from students on the course and teaching are considered essential and integral part of quality assurance. [13] This data should be both qualitative and quantitative and expected to be focused on learning and improvement. Other stakeholders such as patients, medical professionals and society will also play an important role in quality assurance. Inputs from these stakeholders will go a long way in shaping the mission and vision of an institution. Their views will have an effect on the competence, a medical graduate should possess.

Quality assurance is a process that requires transparency and dissemination of results to all the stakeholders. Constructive feedback and establishing the systems to continuously review and implement the changes based on scientific conceptual framework will help the medical education to move from quality assurance to quality improvement. Striving for quality means entering a circle where continuous quality improvement is required. Quality education is the responsibility of all, the teachers, students, administrators and management of the institution. Our ultimate goal should be to improve the quality of healthcare and that will happen only if we take care of the quality of medical education.

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