The future of accreditation of continuing medical education (CME)-continuing professional development (CPD) in Europe: harmonisation through dialogue and consensus

ABSTRACT

In Europe, there are currently some 30 different jurisdictions and no overarching legislation regarding CME-CPD accreditation, since legislative competency related to national health-care systems lies with national authorities. Thus, public demonstration of professional agreement regarding the principles, rules and practice of CME-CPD as well as its accreditation is a highly desirable professional and political objective in Europe, where free movement and freedom to offer professional (medical) services is a key feature of the EU vision of the single market. The newly formed association of independent European accreditors, Continuing Medical Education - European Accreditors (CME-EA) is committed to offering a platform for dialogue between individuals and organisations involved in definition of professional codes in general, and accreditation of CME-CPD in particular on the national level. The aim is to reach a European consensus on principles and rules applied in planning and delivery of CME-CPD. This includes consensus on constituent characteristics of accreditors as well as principles and practice of accreditation.

KEYWORDS:

• Continuing medical education (CME)
• continuing professional development (CPD)
• accreditation
• Europe
• continuing medical education-European accreditors (CME-EA)

In Europe, there are currently some 30 different jurisdictions and no overarching legislation regarding continuing medical education-continuing professional development (CME-CPD) accreditation, since legislative competency related to national health-care systems lies with national authorities. In the past, this has favoured an inward perspective, which encouraged each country to act in isolation and take non-harmonised approaches towards CME-CPD accreditation practices [1]. However, regardless of differences in the legal, professional and political framework in which they are currently working, European physicians still all belong to the same profession and share the same ethical values and principles of professional practice [2]. Thus, to demonstrate professional consensus on this point should be an important professional political objective to achieve, particularly because mutual recognition of professional qualifications represents a basic requirement for free movement and freedom to provide services, both cornerstones of the single European Union (EU) market [3].

Although we probably can assume that the principles and rules for planning and conducting independent CME-CPD activities, as practised by medical professionals in their home country, are similar in EU countries, this is at present not obvious to the profession or to the public due to lack of a unifying approach to documentation and external assessment (accreditation) of CME-CPD activities. We are well aware that this is mainly because physicians have to refer to and are bound to the national legal framework in the country in which they are practising.

However, the lack of an international, Europe-wide transparent approach carries risks that doubts may be raised, as to whether medical professionals in Europe really align their professional practice in the field of CME-CPD to an agreed set of principles, as laid down in country-specific professional codes and that politicians, though themselves responsible for legal fragmentation of regulations on CME-CPD, may conceive the medical profession to be similarly fragmented regarding national frameworks for principles and rules for CME-CPD. Therefore, the political power of the profession will inevitably be weakened, and commercial players might take the lead by a Europe-wide coordinated and unifying approach [4].

Thus, since CME-CPD constitutes the longest period of learning in a medical professional’s life, how to deal with CME-CPD represents a cornerstone of credibility for the profession, not only in a particular European home country, but also on the EU level.

The newly formed not-for-profit association of independent European accreditors, Continuing Medical Education – European Accreditors (CME-EA, www.cme-ea.eu) aims to harmonise planning and delivery of CME-CPD by dialogue and consensus. In this regard, it proposes a model for individuals as well as institutions, involved in standard setting, for planning and delivery of CME-CPD on the European national level, and for European international accreditors to align to a “credibility cascade” (see Table 1). This cascade offers several development steps:

• from private to public commitment, to external assessment of the commitment (accreditation), and participation in the development of a Europe-wide approach to define principles and rules for planning and delivery of CME-CPD including its accreditation

• from a highly fragmented approach, related to the fundamental differences between EU countries, to a harmonised vision, and harmonised principles and rules for the planning and delivery of CME-CPD

• from no political influence of the profession to the development of unified principles, to be used in political lobbying for the creation of a Europe-wide harmonised standard, which will probably be limited by the regulations of national authorities in several EU countries.

Table 1. The credibility cascade.

1.Self-commitment

2.Publicising professional practice

3.External assessment

4.Commitment to a unifying approach

Thus, the Credibility Cascade ranges from attitude of the individual (self commitment) to making professional practice public, then making it amenable to external assessment (accreditation), and finally participating in a structured process to define a consensus approach, which will be applied to all activities on the national level.

Self-commitment of the individual physician is indeed the most important requirement in this model and is key to the translation of recognised principles into individual behaviour. However, in the context of public discussion of professional principles, it remains a private action, at best documented by national professional codes. This may be the only level of the cascade relevant to countries which have no formal definitions in place for planning and conducting CME-CPD, or in which accreditors cover only a small part of all national CME-CPD activities.

The authors strongly agree with a recent statement from the World Medical Association on Quality Assurance in Medical Education, that “… a better outcome will more likely be achieved by also including a second dimension of review that includes an external perspective” [5].

Thus, publicising national activities in a format acceptable for international discussions is the next inevitable and logical level in the Credibility Cascade. This may include a European CME-CPD calendar and access to major national documents relevant for planning and delivery of CME-CPD.

However, the more developed form of assessment is represented by accreditation, which also occupies the next level of the Credibility Cascade. Accreditation merely describes a process of assessment and approval [6], and its value is entirely dependent on rigorous application of appropriate principles and rules. Thus, the International Association of Medical Regulatory Authorities recommends CME-CPD accreditation, whenever “robust, independent accreditation is available and affordable” [7].

Implementation of accreditation nowadays is a highly justified professional demand, since the medical profession in many countries is under pressure to demonstrate that its practice aligns to professional codes which include lifelong learning. Accreditation will also attest to the independence of the CME-CPD and to its relevance to clinical decision-making.

As long as the EU Commission does not issue any regulation on CME-CPD including accreditation, implementation of an accreditation system is primarily at the national level in Europe, where it is up to national authorities to approve accreditors. However, the legal status of organisations involved in accreditation on the national level in Europe shows wide variation [1].

Organisations offering supranational accreditation (so-called European international accreditors like members of CME-EA, other European Specialty Accreditation Boards, or the European Accreditation Council for CME, EACCME) similarly lack a legal mandate either to define the principles and rules of accreditation or to centralise CME-CPD accreditation on the European international level.

The key objective therefore is to harmonise principles, rules and their application in national accreditation procedures through consensus based on dialogue on a Europe-wide basis and not to centralise the accreditation process itself at the European level.

To achieve this objective, there is a need for commitment of individuals/organisations from European nations to contribute to and apply a unifying approach (as defined in the last part of the Credibility Cascade).

In recent years, there have been several initiatives, which have addressed selected aspects of the framework and practice of CME-CPD accreditation, e.g. the International Academy for CPD Accreditation [8], an informal network of accreditors with global attendance, and also informal collaboration of so-called European Speciality Accreditation Boards [9], or the Cologne Consensus Conference [10], and the UEMS-EACCME Education Conference. Thus, the mission of CME-EA is to devote its activities to offering a platform to all organisations/individuals involved in accreditation on the national level, to meet for dialogue and to work on consensus. Fragmentation should not be the European answer to the global community of providers and mobile learners in CME-CPD [11].

Furthermore, harmonisation of the conceptual framework of accreditation relates to the role of the accreditor itself. Thus, we would also like to offer a unifying definition of the constitutional characteristics of accreditors as well as of the accreditation procedure.

Accreditation in CME-CPD is a process of assessment of educational activities and/or CME providers, attesting that a defined set of requirements has been met to ensure independent, high quality and learner-centred CME-CPD [6]. Clearly the independence of the accreditor itself is critical to maintaining the integrity and value of the accreditation [6].

Currently, CME-CPD accreditors in Europe have mostly been created according to applicable national law or as non-governmental organisations based on civil law (the latter applies to all European international accreditors).

While in the former case, public authorities define terms and conditions regarding composition, principles and rules as well as regulation of the accreditor, the latter mainly rely on self-commitment.

The independence of accreditation bodies in CME-CPD relates (particularly with regard to those based on civil law) to the following:

1. Statutory issues: All decision makers involved in corporate governance including accreditation need to be independent. They should have experience in professional self-regulation. As reviewers, they should also be experts in their field, and they should have an acceptable record of interests. Professional political and/or scientific organisations in medicine may propose candidates for any position with the accreditor, but may never be able to impose someone on, or withdraw someone from the accreditor, regardless of the position he or she holds. Rules and standard operating procedures of the accreditor have to ensure that accreditation occurs independently of any third-party influence, in particular of professional political and/or scientific organisations and/or providers and/or sponsors and/or other commercial interests.

2. Finances: Accreditors finance themselves by fees paid by those seeking accreditation. Donations from any commercial interest in medicine (including individuals representing or having a role in a commercial interest [9], as well as from providers) are not acceptable. Donations from any public authority or professional political body or scientific organisation may be acceptable as long as they do not compromise the independence of decision-making by the accreditor.

3. Accreditation procedure: Accreditation decisions should be exclusively identifiable with the accreditor. Thus, rules and procedures for accreditation need to be defined in a way that accreditation decisions can solely be made by the legitimate members of the accreditation body themselves. Third parties can never be involved in individual accreditation decisions.

In summary, public demonstration of professional agreement regarding the principles, rules and practice of CME-CPD as well as its accreditation is a highly desirable professional and political objective in Europe, where free movement and freedom to offer professional (medical) services is a key feature of the EU vision of the single market.

The newly formed not-for-profit association of independent European accreditors, CME-EA, is committed to offering a platform for dialogue between individuals and organisations involved in definition of professional codes in general, and accreditation of CME-CPD in particular on the national level. The aim is to reach a European consensus on principles and rules applied in planning and delivery of CME-CPD. This includes consensus on constituent characteristics of accreditors as well as principles and practice of accreditation.

As a first step, corresponding to level 2 of the Credibility Cascade, CME-EA suggests establishing a European CME-CPD calendar, publicly to demonstrate the multiple professional activities in the field of CME-CPD in Europe.