As you are aware the COVID-19 global pandemic as declared by the World Health Organisation (WHO) in March 2020, has posed serious challenges for the operations of CAAM-HP and medical schools in the region. CAAM-HP was forced to postpone several site visits which were scheduled for 2020/2021.
Medical schools in CARICOM countries and the Dominican Republic were forced to switch to e- learning, a move that requires effective learning management systems, video conferencing facilities and instructors experienced in e-learning and assessment. Additionally, many schools reported that clinical students were forced to discontinue their rotations in keeping with requests from affiliated hospitals in the USA and the Caribbean. Another significant consequence of the COVID-19 pandemic was suspension of international travel, closure of national borders and quarantine requirements to limit spread of the virus. All of these situations have had a major impact on the work of the CAAM-HP and made it impossible to maintain the traditional accreditation processes, particularly those that address the clinical programme.
Regulatory agencies have put forward a number of suggestions to deal with accredited programmes These have included extension of the terms of accreditation, suspension of accreditation processes and timelines, postponement of accreditation visits and use of ‘virtual’ visits with the requirement for an in-person follow-up visit whenever practical. Given the prolonged and uncertain course of the pandemic, a realistic and acceptable approach will need to be developed that will allow a degree of flexibility while at the same time maintaining the requirement for all standards and policies to be adhered to.
In developing a way forward, an important consideration for the CAAM-HP is the position of the World Federation for Medical Education (WFME) that provides recognition of accrediting agencies such as the CAAM-HP. The WFME has reiterated its position that whatever course of action is taken, actual site visits are indispensable and must be a part of the process for determination of full accreditation.
CAAM-HP at its Annual General Meeting in 2020 discussed the challenges as it sought to find an appropriate way forward. In order to gather information from the schools regarding their responses to the pandemic and to hear their concerns, the Secretariat staged two Webinars via Zoom in July 2021 with the participation of representatives of the ECFMG and the WFME. The response from the schools was enthusiastic with twenty-five making presentations and participating in the discussion.
In summary, the schools’ response to the pandemic was remarkably uniform. Most had been forced to reconfigure their academic calendars and all had taken steps to strengthen and upgrade their online learning platforms and to retrain teachers to deliver courses in the virtual space. Management of the clinical programmes was a huge challenge and most schools had adopted a blended approach using a variety of technology applications and simulation software.
CAAM-HP’s Response – The Way Forward
Following the webinars, the ECFMG, in mid-August 2021, held further discussions with the Chair and Executive Director to determine how best the agency could support CAAM-HP at this difficult time. The president was concerned for the international medical graduates who need to qualify for ECFMG certification in order to pursue residency training in the USA. Bearing in mind the investment made by both the schools and the students and the importance of maintaining confidence in CAAM-HP, he proposed that CAAM-HP consider virtual visits with a ‘time limited provisional’ accreditation status for a maximum of two years until face-to-face site visits become possible (whichever came first), at which time schools would then receive a final accreditation decision. Physical site visits should take place within six to twelve months of restrictions being lifted.
Following discussions with the World Federation for Medical Education (WFME) we were assured that there would be no issue with this approach but the CAAM-HP would need to accept this temporary arrangement and create the necessary policies and guidelines for schools to follow.
It was agreed that the new CAAM-HP policy and arrangements would need to be made very clear to the schools which would be required to state clearly that their status is ‘provisional’ without guarantee of eventual accreditation. Reference was made to best practices being used by other accreditation agencies, for example, the Liaison Committee for Medical Education (LCME) which had been doing virtual visits since the summer of 2020. It was proposed that further discussion would take place at the Annual General Meeting in September 2021 which would include further participation by the ECFMG and, arising from discussions at that meeting, a small working group was convened to draft regulations and procedures to guide virtual/hybrid site visits.
Report of the Working Group
The Report of the Working Group was presented and discussed at an Extraordinary General Meeting of the CAAM-HP held on January 20, 2022.
The Working Group acknowledged that while the ideal situation for scrutiny would be in-person visits with all stakeholders of the school, in light of the unprecedented effects of the pandemic, and the resultant government restrictions on travel, consideration should be given to the use of virtual or hybrid site visits. It was also recognised that other events, such as ‘Acts of God’ might also require an alternative to an in-person format.
After careful analysis, the Working Group determined that there would be no need to change certain aspects of the procedures for site visits, e.g. notice of the CAAM-HP visit, submission of pre-survey documents by the school within a specified timeline, composition of the survey team, student participation, complete confidentiality of the process, administrative costs, timeline for the survey report and honoraria for the survey team. However, there would need to be amendments to the modality of the interviews and information sharing depending on whether the site visit was full or limited in scope and in some financial areas whereby expenses for virtual visits should reflect the elimination of costs for travel, accommodation and meals and rental of meeting rooms for team meetings.
In scrutinizing the current procedures for the CAAM-HP site visits to schools it was determined that certain activities within the visit could be organised effectively and securely using video-conferencing technology. These include conversations and interviews with faculty academics, senior officers of the university, faculty administrative colleagues and students. These persons would be agreed with the school ahead of time and virtual meetings conducted via appropriate teleconferencing platforms.
The Working Group defined:
- A virtual visit, as one where the team is unable to meet in person and interactions with members of the school are conducted through a virtual process, i.e. interviews, tours of the facilities and infrastructure.
- A hybrid visit, as one where the team is able to have a blend of virtual and in-person interactions with the school.
It was acknowledged that the use of videoconferencing technology in both virtual and hybrid visits would, at the very least, allow a more selective approach, thereby reducing the time (and travel costs) associated with in-person site visit procedures.
The Working Group made recommendations for the conduct of virtual/hybrid site visits in four areas:
- For the implementation of measures to secure the integrity of the visit, such as strict guidelines for the verification of the attendees, roving cameras permanently turned on to ensure only authorized persons would be present at the interviews and timely submission of missing information requested by the CAAM-HP
- In respect of the nomenclature for the accreditation ensuing from the virtual/hybrid visit, it was recommended that the school would be granted ‘interim accreditation’ for a specified period, pending validation by an actual site visit as soon as possible thereafter.
- On the issue of revocation of decisions, suggestions were made as to what action could be taken in cases where an actual, follow-up site visit revealed significant differences to the findings of a virtual site visit. Such action might include extending the interim accreditation period, withdrawing accreditation altogether, or consider another accreditation designation to be decided by the Authority.
- On the matter of the duration of the interim accreditation arising from virtual/hybrid visits, the period recommended was two years, during which time a limited face-to-face visit would be arranged to confirm the findings of the virtual visit and to assess the progress made in addressing any shortcomings identified by the CAAM-HP site visit team.
Representatives of the ECFMG and WFME who participated in the discussions endorsed the recommendations of the Working Group. The ECFMG representative gave assurance that they would be able to handle instances where interim accreditation was revoked after follow-up verification visits, since measures were already in place for such situations. Students affected by such a situation would be given a grace period to make adjustments. Furthermore, in respect of the interpretation of the designation, ‘interim’ ECFMG guidelines included the acceptance of conditional accreditation status, whether ‘provisional’ or ‘interim’.
CAAM-HP is now in the process of incorporating these recommendations on virtual/hybrid visits into a set of relevant guidelines and regulations governing virtual site visits which will be published on its website. It was agreed that webinars will also be arranged for all schools as well as those site visitors who had agreed to serve in 2020/2021 so that everyone is made aware of the changes to the current process and have the opportunity to pose questions and clarify concerns they may have. Schools whose scheduled site visits were cancelled in 2020/2021 will be required to update their previously submitted documentation.