accreditation Overview of accreditation of undergraduate medical education programmes worldwide

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1 accreditation Overview of accreditation of undergraduate medical education programmes worldwide Marta van Zanten, John J Norcini, John R Boulet & Frank Simon CONTEXT There is significant variation in the structure and quality of undergraduate medical education around the world. Accreditation processes can encourage institutional improvement and help promote high-quality education experiences. METHODS To investigate the overseeing of medical education from an international perspective, the Foundation for Advancement of International Medical Education and Research (FAIMER Ò ) has developed, and continues to update, the Directory of Organizations that Recognize Accredit Medical Schools (DORA). The directory includes information on the presence of national accrediting bodies and related data. Medical education accreditation information was pooled by World Health Organization (WHO) regions. RESULTS Although over half of all countries with medical schools indicate that they have a national process for accrediting medical education programmes, the nature of the various authorities and levels of enforcement vary considerably. DISCUSSION Despite global trends indicating an increasing focus on the quality of education programmes, data linking accreditation processes to the production of more highly skilled doctors and, ultimately, better patient care are lacking. Investigating current accreditation practices is a necessary step for further research. To this end, we will continue to gather data on medical education around the world and will explore opportunities for relating these processes to outcomes. Foundation for Advancement of International Medical Education and Research (FAIMER Ò ), Philadelphia, Pennsylvania, USA Correspondence: Marta van Zanten, Foundation for Advancement of International Medical Education and Research (FAIMER Ò ), 3624 Market Street, Philadelphia, Pennsylvania 19104, USA. Tel: ; Fax: ; KEYWORDS education, medical, undergraduate *standards; *accreditation; quality control; multicentre study [publication type]; schools, medical *standards. Medical Education 2008: 42: doi: /j x INTRODUCTION The science and art of treating patients and preventing disease is complex and multi-dimensional. Offering students rigorous, high-quality education and training in the science and skills involved in the provision of care is the goal of undergraduate medical education programmes. Regional and cultural differences in medical education traditions and theories, disease preponderance, clinical guidelines, available resources, doctor)patient relationships, etc. mean that there is considerable variation in the medical education experiences offered in institutions around the world. 1 Questions continue to arise regarding the most appropriate way to assess the quality of education provided at a particular institution in relation to standards appropriate for that particular country or region. There are inherent challenges in creating a meaningful and defensible system which is not prescriptive and which allows for variability necessitated by local situations, resources and needs. The accreditation of medical education programmes is a way of promoting an appropriate learning environment, and may ultimately impact the quality of medical care provided to patients. The term ÔaccreditationÕ has various meanings, but, for the purpose of this paper, it is defined as a process by which a designated authority reviews and evaluates an educational institution using a set of clearly defined criteria and procedures. Despite the recent focus on the need for accreditation of medical education programmes, and the 930 ª Blackwell Publishing Ltd MEDICAL EDUCATION 2008; 42:

2 Undergraduate medical education worldwide Overview What is already known on this subject Medical education accreditation processes can encourage institutional improvement and promote appropriate learning environments. Few data are available on the existence of accreditation systems worldwide and the nature of the authorities that provide them. What this study adds Processes for overseeing medical education in 91 countries are described. Accreditation systems vary in scope, structure and governance. Suggestions for further research Future research should provide additional qualitative and quantitative details describing the various accreditation systems, and link this information to individual medical schools. These baseline data describing current practices could be used to support the investigation of links between accreditation processes and the quality of medical care provided. increasing globalisation of the medical profession and migration of health care workers, there are few data pertaining to medical education quality assurance from an international perspective. A report based on a 1996 World Health Organization (WHO) survey of ministries of health and deans of medical schools, indicates that almost two-thirds of medical schools are accredited by an external body, but does not provide detailed data depicting the various processes. 2 A study comparing medical education accreditation systems in nine developing countries located throughout the world concludes that the trend towards instituting rigorous quality assurance procedures is spreading to some developing countries, where protocols similar to those used in the USA and Canada have been developed and implemented. 3 The World Federation for Medical Education (WFME) has developed a Trilogy of Global Standards for Quality Improvement. These resources include a document aimed at assessing the quality of medical schools leading to an undergraduate allopathic degree in Standards in Basic Medical Education. This document is not designed to be used restrictively, but instead is intended to function as a template for national agencies interested in developing accreditation procedures. 4 The WFME standards have been widely endorsed and are being used in countries throughout the world as a model for establishing national and regional accreditation procedures. 5 The purpose of this paper is to provide an overview of medical school accreditation processes in countries around the world, highlighting variations by region. These baseline data for current worldwide accreditation practices are a necessary preface to future studies investigating relationships between accreditation processes and medical outcomes. METHODS Data The Foundation for Advancement of International Medical Education and Research (FAIMER Ò ) has developed and continues to update a Directory of Organizations that Recognize Accredit Medical Schools (DORA). This database is freely available on the FAIMER Ò website (http://www.faimer.org/ orgs.html). DORA contains a list of countries with identified accreditation authorities, the names of the organisations, and website links if available. More than one authority is included for a small number of countries. Information on whether the process is mandatory or voluntary and on whether the accrediting body is an independent entity or a government authority is provided, if known. This information is gathered using a variety of methods, including surveys of ministries and medical schools, a review of the published literature, Internet searches, and personal communication with medical educators around the world. Although attempts are made to ensure that the information on the website is up to date and accurate, rapid changes in medical schools and government policies may result in some discrepancies. Thus a feedback form and link is provided requesting DORA visitors to comment on entries or to provide information on accreditation authorities not presently included. It is important to note a number of issues pertaining to the inclusion of a national accreditation authority in DORA. The listing of an organisation does not imply that all medical schools in that country have undergone an accreditation process. In some instances the scope of the accreditation authority is limited to a certain type of education institution, such as publicly funded schools only. When the procedure is indicated as voluntary, sometimes only a small ª Blackwell Publishing Ltd MEDICAL EDUCATION 2008; 42:

3 M van Zanten et al minority of schools in that country have attempted accreditation. Even when the accreditation authority indicates that adherence to its procedures is mandatory, limited enforcement ability or a lack of consequences for non-adherence may mean that occasionally schools will ignore the mandate and continue to function. In some instances the law is relatively new and the regulatory authority has given schools many years to achieve compliance. In addition, some accreditation authorities listed use general criteria appropriate for all higher education institution programmes and do not have specific standards focused on medical education. Finally, the inclusion of an accreditation body in DORA does not indicate that FAIMER Ò has endorsed the authority or verified the level of quality of overseeing provided. FAIMER Ò is not an accrediting agency and has no relationship with the organisations listed. Medical school data come from the International Medical Education Directory (IMED), an up-to-date, web-based directory of the worldõs medical schools maintained by FAIMER Ò (http://imed.ecfmg.org/). The IMED contains information on medical schools recognised by the appropriate government authorities, usually the ministry of education or health, in the countries where the schools are located. Currently, more than 1900 medical schools operating in 168 countries or territories are listed in IMED. 6 The WHO divides the world into six regions: the African region; the Americas; the Eastern Mediterranean region; Europe; South-East Asia, and the Western Pacific. 7 These regional definitions are used for convenience to present pooled accreditation information. Analysis with medical schools listed in IMED were grouped by WHO region and tallied. Accreditation activities in each country were classified according to the following criteria: the presence of a national accreditation system; a national accreditation system in the planning stages, or the absence of a national accreditation system or any information on this topic. RESULTS Table 1 presents information from DORA by WHO region on 91 entities that accredit undergraduate medical education programmes in the countries in which the schools are located. (Data current at 12 November 2007.) There is wide variability in the prevalences of national accrediting bodies across the regions, ranging from 20% in Africa to 75% in South- East Asia. Overall, about half the authorities are government-affiliated, one-third are independent entities, and in a limited number of instances organisations are semi-autonomous, making dichotomous classification difficult, or the governance of the authority is not known. Most countries with accreditation authorities report that the process is mandatory (n = 64, 70%), although some have a noncompulsory system (n = 27, 30%). A limited number of countries have a voluntary, independent process in addition to a mandated, government-authorised accreditation system. Table 1 Undergraduate medical education accreditation systems in countries with medical schools listed in the International Medical Education Directory (IMED) by World Health Organization region African region (n = 35) The Americas (n = 38) Eastern Mediterranean region (n = 20) European region (n = 48) South-East Asia (n =8) Western Pacific region (n = 19) National accreditation system in existence National accreditation planned No national accreditation system or data unknown 7 (20%) 26 (68.4%) 11 (55%) 32 (66.7%) 6 (75%) 9 (47.4%) 1 (2.9%) 6 (15.8%) 5 (25%) 3 (6.3%) 0 3 (15.8%) 27 (77.1%) 6 (15.8%) 4 (20%) 13 (27%) 2 (25%) 7 (36.8%) 932 ª Blackwell Publishing Ltd MEDICAL EDUCATION 2008; 42:

4 Undergraduate medical education worldwide The African region There are 35 countries with medical schools listed in IMED in the WHOÕs African region. Only seven of these countries have known accreditation authorities. These are Ethiopia, Ghana, Kenya, Nigeria, South Africa, Tanzania and Zambia. In six of these, a government authority is responsible for enforcing mandatory quality assurance procedures; the accrediting organisation in Ghana is independent of the government. For some nations in the African region, information regarding the presence or absence of an accrediting body, the scope and process of higher education quality assurance, and data related to this issue are difficult to locate. The experience of Nigeria is notable as the country has a relatively large number of medical schools and a history of accreditation practice, and a large proportion of its doctors emigrate to other countries to practise. 8 The Medical and Dental Council of Nigeria (MDCN) and the National Universities Commission (NUC) are the two organisations responsible for overseeing medical schools. 3 These two authorities work in tandem and each has its own focus. The MDCN concentrates on reviewing adequacy of infrastructure for clinical services, quality of student selection and pass rates, institutional funding and other issues. Both the MDCN and the NUC publish similar information regarding curriculum content, specifying what should be taught in the various years of medical training. This curriculum content is not mandated, although most medical schools follow the NUC suggestions. The NUC also reviews higher education administrative issues (C Okoromah, personal communication, 2007). The Americas There are 38 countries with operating medical schools listed in IMED in the Americas. This WHO region encompasses countries in North America, Central America and the Caribbean, and South America. Accreditation systems are in place in 26 countries, and practices vary widely across the region, in both scope and structure. In North America, the Liaison Committee on Medical Education (LCME) has a relatively long history of accreditation practices. 9 The LCME is nationally recognised as the accrediting authority for medical education programmes leading to the Doctor of Medicine (MD) degree in both the USA and Canada. The recent proliferation of new schools in Central America and the Caribbean makes this region of particular interest in the context of monitoring medical education quality. In some countries, such as Costa Rica, the Dominican Republic and El Salvador, accreditation is conducted by independent entities charged with the review of higher education institutions across the board. Other countries rely on government authorities created specifically for monitoring medical education programmes, such as the Medical School Accreditation Committee in Belize, and the Medical School Accreditation, Approval and Monitoring Committee in Saint Lucia. In Mexico, the independently run Mexican Board for the Accreditation of Medical Education (Consejo Mexicano para le Acreditación de la Educación Médica, COMAEM) reports that it has accredited approximately half of the eligible schools. The organisation has recently acquired new authority to force non-accredited schools to comply with requirements, as students from non-accredited institutions will soon not be eligible for public health system clinical site placements and training. 10 National accreditation activities are in the planning stages in various countries, including Nicaragua and Panama. Collaborative efforts have taken place in the region. For example, an independent organisation, the Accreditation Commission on Colleges of Medicine (ACCM), has accredited medical schools located in various Caribbean countries A new organisation, the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM- HP) was created by the Caribbean Community (CARICOM) in 2004 in response to the void left by the UK General Medical Council (GMC) when the GMC abolished its policy of recognising overseas institutions. The CAAM-HPÕs scope covers medical schools within the CARICOM union. 14 The Central American Accreditation Council (Consejo Centroamericano de Acreditación, CCA) integrates and compares general higher education accreditation and quality assurance initiatives in the area. The CCA oversees and validates individual accreditation organisations: in other words, it accredits the accreditors. The CCA is a new entity and has recently begun accepting solicitations for its accreditation process. 15 In South America, most countries have a system of medical school accreditation. The authorities charged with overseeing medical education in this continent are a mix of government bodies and independent agencies. Most of the accreditation processes are mandatory, albeit with varying levels of ª Blackwell Publishing Ltd MEDICAL EDUCATION 2008; 42:

5 M van Zanten et al enforcement. In Brazil, the word ÔaccreditationÕ is not used per se, but a two-part process of medical education quality assurance is in place. Medical schools first go through a process of authorisation carried out by the Ministry of Higher Education, which allows graduates to sit for the national examination. The second step in the evaluation process is recognition, conducted by the National Institute for Educational Research, also a government body. This recognition process usually takes place when a school has been in operation for a number of years (F Menezes, personal communication, 2007). Accrediting agencies in Argentina, Brazil, Paraguay and Uruguay are involved in the Experimental Accreditation Mechanism of Programmes (Mecanismo Experimental de Acreditación de Carreras, MEXA), which aims to certify the quality and equivalence of university degrees in agronomy, engineering and medicine across the region. 16 Eastern Mediterranean region This region includes 20 countries with currently operating medical schools listed in IMED. They include Middle Eastern and some North African nations. Eleven countries in this region are known to have systems of medical school accreditation. Of these, five have government bodies that provide mandatory higher education quality assurance measures, such as the ministries of education in Jordan, Pakistan and Sudan. Syria and Yemen are in the consideration stages of developing similar processes. 17 The Gulf Co-operation Council (GCC) Medical DeansÕ Sub-committee of Accreditation is an independent organisation reviewing medical education quality in Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates. The WFME Standards for Basic Medical Education document was used as a guide in the development of the GCC Medical Deans Sub-committeeÕs accreditation standards and procedures. The overall aim of this initiative, which began in 2000, is to assess the medical school programme against the schoolõs own goals and objectives, provided that these are in concordance with the principles developed by the committee. 18 Currently 10 schools in the region have undergone this voluntary accreditation process (H Hamdy, personal communication, 2006). European region The European region includes 48 countries with medical schools listed in IMED, giving this area the largest number of countries of all WHO regions. The diversity of medical education accreditation processes in the European region reflects the variations in culture and tradition in this area. More than half these countries (n = 32, 67%) have known national medical education accreditation authorities, almost all of which (n = 29, 91%) enforce mandatory compliance. Some of these entities are government-affiliated, such as those in Bulgaria, Israel, Poland and Russia. The Czech Republic, Hungary, the UK and others have well established, independent bodies charged with overseeing medical education quality assurance. Other countries have quality control methods in place in lieu of national accreditation, such as the common mandated curriculum in France 19 and the system of state education review in Germany. 20 In some European countries, the scope of accreditation is complex as it is based on the criteria of various education institutions. For example, the Austrian Accreditation Council, an independent agency, is responsible for accrediting private schools in Austria, including one medical school. 21 The Austrian Federal Ministry for Education, the Arts and Culture covers public institutions and is therefore the accreditation authority for the three medical faculties which are part of public universities. 22 In Belgium, the Accreditation Organisation of the Netherlands and Flanders covers Flemish-language schools, 23 but not those located in the French-speaking part of the country. South-East Asia Eight countries in this region have medical schools listed in IMED. In most of these, accreditation authorities function in a variety of capacities. Bangladesh and South Korea both have independent entities which conduct mandatory accreditation of medical education institutions. Government-run organisations in Indonesia and Nepal accredit medical schools on a voluntary basis. In Thailand, a government body is charged with a required accreditation process. Medical school quality assurance in India is extremely important because of the large number of medical schools in the country and recent growth in new schools. Currently, 219 open medical schools in India are listed in IMED. 6 Private sector institutions comprise almost half of all medical schools in India. Most of these private sector schools have opened recently in relatively wealthier and healthier Indian provinces. 24 Confusion arising from differences in terminology is especially problematic in this area, because in India the word ÔaccreditationÕ is often used to describe a process of rank ordering of institutions, 934 ª Blackwell Publishing Ltd MEDICAL EDUCATION 2008; 42:

6 Undergraduate medical education worldwide whereas quality assurance procedures are generally referred to using the terms ÔinspectionÕ and ÔrecognitionÕ. 25 Despite these variations in vocabulary, India has a well established policy of quality assurance of medical education. Mandatory accreditation is conducted by the Medical Council of India (MCI), a government agency. The National Assessment and Accreditation Council (NAAC), an autonomous body established by the University Grants Commission (UGC), also accredits higher education institutions. Accreditation by the NAAC is required for the five schools funded by the UGC, whereas other colleges are reviewed on a voluntary basis. 3 Western Pacific region There are 19 countries in this region with currently operating medical schools listed in IMED. Systems of medical education quality regulation vary throughout the region. Some countries have well established medical education accreditation systems. Australia and New Zealand use the same mandatory system, enforced by an independent body, the Australian Medical Council. Malaysia has a government system that functions on a voluntary basis and all 10 schools in Malaysia have complied with its process. In the Philippines, the Philippine Accrediting Association of Schools, Colleges and Universities is an independent entity that voluntarily accredits schools; however, only a small minority of medical schools have participated. Other countries in this region do not have national systems of medical school accreditation. In China, in which 130 medical schools offering MD programmes are listed in IMED, authorities are currently exploring the feasibility of developing and implementing a national quality control process. 26 Chinese standards for medical education are under development, modelled in part on the WFME Global Standards document. Additionally, the Institute for International Medical Education (IIME) has proposed a set of outcome-based standards that have been piloted in a number of Chinese medical schools. 27 DISCUSSION A robust accreditation system, functioning either as an autonomous entity or as part of a governmentõs ministry of health or education, can be useful in encouraging institutions to conduct self-review and improvement. It can also ensure that medical students receive high-quality education experiences based on established standards. Results of this analysis reveal that medical school accreditation is not universal. Although most countries in almost all WHO regions have accreditation systems in place or in the planning stages, the African region is a notable exception. The reasons why many African countries lack medical school accreditation processes are probably complex, and may include political instability, insufficient resources or a perceived lack of need for such systems. In countries where a process of accreditation exists, the scope and nature of the authority can vary considerably. For some countries with established quality assurance entities, such as Chile and Mexico, the current focus is on enhancing the level of credibility in terms of the significance and consequences of attaining accreditation status. Regional co-operation in accreditation activities in various areas, including the Caribbean, Central and South America, and the Gulf Region, is evidence of a growing need to pool resources. This also allows for the direct comparison of education experiences across countries and the mutual recognition of degrees. Initiatives such as the development and widespread adoption of the WFME Standards indicate the spread of globalisation in this area. Although these trends towards an increasing focus on the overseeing of medical education quality assurance worldwide are certainly encouraging, it should be emphasised that there is a lack of published research demonstrating that accreditation activities do indeed contribute to achieving the ultimate goal of producing more highly skilled doctors and, in turn, improving the health of populations. Recently, there have been calls for research linking undergraduate education institution accreditation variables to the quality of doctors produced, and a request that standards and procedures be based on data which clearly demonstrate that schools which adhere to these protocols produce doctors who are more knowledgeable and skilled, and who are ultimately able to provide higher-quality care to their patients Therefore, beyond the perspective of face-validity, the value of accreditation remains uncertain and the question of its legitimacy continues to be problematic for accreditation providers, policymakers, students and researchers. In light of these questions regarding the outcome of accreditation, this FAIMER Ò initiative describing current practices represents a first step towards gaining a better understanding of the overseeing of medical education internationally. Because variations exist in the robustness of accreditation systems and ª Blackwell Publishing Ltd MEDICAL EDUCATION 2008; 42:

7 M van Zanten et al jurisdiction of accrediting bodies, plans are underway to enhance the FAIMER Ò directory beyond its current format by including additional qualitative and quantitative data related to the accreditation authority in each country, and linking this information to individual schools in IMED. There are numerous challenges associated with this ongoing project, which involve confusing terminology, various interpretations of the concept of accreditation, a lack of published data describing processes of accreditation, and, occasionally, reluctance to share information. The continued proliferation of new schools, often located in the private sector and functioning without government jurisdiction, presents additional challenges to the maintenance of up-to-date data. Because of variability in the standards and procedures used, the ongoing nature of the data-gathering process, and the lack of readily available information in a limited number of countries, this paper presents a broad, yet incomplete, description of the quality assurance of medical education. Despite these limitations, descriptive data reflecting the majority of medical education systems and institutions around the world are provided, from which broad inferences and trends can be identified. As part of our mission to inform the development of health care policies, FAIMER Ò will continue to update and expand the information gathered on accreditation procedures and standards worldwide, and will explore opportunities for associating these data with the quality of doctors and the care provided. Contributors: MvZ designed the study, gathered and analysed the data and wrote the first draft of the paper. JJN, JRB and FS provided intellectual content support and contributed to further drafts. All authors approved the final manuscript. Acknowledgements: none. Funding: this study was funded by the Foundation for Advancement of International Medical Education and Research (FAIMER Ò ), Philadelphia, PA, USA. Conflicts of interest: none. Ethical approval: not applicable. REFERENCES 1 Karle H. International trends in medical education: diversification contra convergence. Med Teach 2004;26 (3): Boelen C, Boyer MH. A view of the worldõs medical schools: defining new roles the-networktufh.org/publications_resources/ furtherreading.asp. [Accessed 6 August 2007.] 3 Cueto J Jr, Burch VC, Adnan NA et al. Accreditation of undergraduate medical training programmes: practices in nine developing countries as compared with the United States. Educ Health (Abingdon) 2006;19 (2): World Federation for Medical Education. Basic Medical Education: WFME Global Standards for Quality Improvement. Copenhagen: WFME Office, University of Copenhagen Karle H. Global standards and accreditation in medical education: a view from the WFME. Acad Med 2006;12 (Suppl): Boulet JR, Bede C, McKinley DW, Norcini J. An overview of the worldõs medical schools. Med Teach 2007;29 (1): World Health Organization. The Country Logbook. [Accessed 6 August 2007.] 8 Hagopian A, Ofosu A, Fatusi A, Biritwum R, Essel A, Gary HL, Hart L, Watts C. The flight of physicians from West Africa: views of African physicians and implications for policy. Soc Sci Med 2005;61 (8): Kassebaum DG. Origin of the LCME, the AAMC) AMA partnership for accreditation. Acad Med 1992;67 (2): National Committee on Foreign Medical Education Analysis of the Report submitted by Mexico. Washington, DC: US Department of Education National Committee on Foreign Medical Education Analysis of the Report submitted by the Cayman Islands. Washington, DC: US Department of Education National Committee on Foreign Medical Education Analysis of the Report submitted by St Maarten. Washington, DC: US Department of Education National Committee on Foreign Medical Education Analysis of the Report submitted by Saba. Washington, DC: US Department of Education Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP). Overview and Status of the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions. Kingston, Jamaica: CAAM-HP World Education Services. World Education News and Reviews. July [Accessed 6 August 2007.] 16 Lamarra NF. Higher education, quality evaluation and accreditation in Latin America and MERCOSUR. Eur J Educ 2003;38 (3): World Health Organization. World Health Report 2006: Working Together for Health. Geneva: WHO Gulf Co-operation Council Medical Colleges DeansÕ Committee. Recommendations and Guidelines on Minimum Standards for Establishing and Accrediting Medical Schools 936 ª Blackwell Publishing Ltd MEDICAL EDUCATION 2008; 42:

8 Undergraduate medical education worldwide in the Arabian Gulf. Bahrain: Secretariat of the GCC Medical Colleges DeansÕ Committee Segouin C, Jouquan J, Hodges B, Brechat PH, David S, Maillard D, Schlemmer B, Bertrand D. Country report: medical education in France. Med Educ 2007;41 (3): Medizinischer Fakultatentag der Bundesrepublik Deutschland. [Accessed 6 August 2007.] 21 Austrian Accreditation Council. akkreditierungsrat.at/. [Accessed 6 August 2007.] 22 Austrian Federal Ministry for Education, the Arts and Culture. [Accessed 6 August 2007.] 23 Creusy C. The Implementation of the Bologna Process in Medical Education. Brussels: European Medical Association Mahal A, Mohanan M. Growth of private medical education in India. Med Educ 2006;40 (10): National Committee on Foreign Medical Education Analysis of the Report submitted by India. Washington, DC: US Department of Education Field M, Geffen L, Walters T. Current perspectives on medical education in China. Med Educ 2006;40 (10): Stern DT, Friedman Ben-David M, Norcini J, Wojtczak A, Schwarz MR. Setting school-level outcome standards. Med Educ 2006;40 (2): Davis DJ, Ringsted C. Accreditation of undergraduate and graduate medical education: how do the standards contribute to quality? Adv Health Sci Educ Theory Pract 2006;11 (3): Braithwaite J, Westbrook J, Pawsey M et al. A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-organisational design for researching health sector accreditation. BMC Health Serv Res 2006;6: Joly BM, Polyak G, Davis MV, Brewster J, Tremain B, Raevsky C, Beitsch LM. Linking accreditation and public health outcomes: a logic model approach. J Public Health Manag Pract 2007;13 (4): Received 15 August 2007; editorial comments to authors 25 October 2007; accepted for publication 21 January 2008 ª Blackwell Publishing Ltd MEDICAL EDUCATION 2008; 42:

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