Accreditation of Training Programmes by the West African College of Surgeons

Abstract

The establishment of surgical training programmes of the West African College of Surgeons started in six teaching hospitals the early 1970s in Nigeria and Ghana; it was championed by College Fellows, surgeons who had returned to the sub-region after having trained in Europe and America. Surgical programmes accreditation, captured in the College’s constitution and mission statement, uses objective guidelines in the identification and encouragement of suitable institutions for surgical training through periodic peer-review audits of installed manpower, facilities, clinical services and academic programmes. This pan-regional model adopted by the five Anglophone countries of West Africa has standardized and nurtured surgical training in the disciplines of surgery, obstetrics and gynaecology, ophthalmology, otorhinolaryngology, dental surgery, radiology and anaesthesia. It has also proven to be a useful template in the current drive for the ongoing harmonization of surgical training programmes with Francophone West African as a prelude to an integrated sub-regional accreditation body.

This paper details the evolution of surgical programmes accreditation in West Africa, its progress, challenges, opportunities and future trends.

Introduction

Training programmes accreditation is a formal, quality assurance tool employed periodically by an external body to audit the facilities, personnel and educational format of an institution under its purview to determine if set standards are met¹. It is a process commonly employed by councils of many professional bodies to improve the service and academic outcomes of their member organizations. In the five Anglophone countries of West Africa, the West African College of Surgeons (WACS) has been at the forefront of postgraduate surgical training by administering uniform training and examination curricula across the sub-region. Because of its unique sub-regional origin, the College has also gathered enormous experience in surgical training, examination and accreditation - a knowledge which has come useful when collaborating with other national and sub-regional stakeholders in Africa and beyond. In West Africa, the National Postgraduate Medical College of Nigeria (NPMCN) and the Ghana College of Physicians and Surgeons (GCPS) are sister Colleges and stakeholders with whom the WACS collaborates in training and accreditations. Similar collaboration has begun with the Francophone block as the WACS now regularly nominates Francophone Fellows as part of many accreditation visitations. The WACS recognizes the Certificat d’Etude Spéciale (CES) diploma as equivalent to its Fellowship degree and appropriate programmes harmonization are needed to bring the two main sub-regional linguistic training blocks closer and integrate their activities.

Historically, the Association of Surgeons of West Africa (ASWA) which was formed in 1960 voluntarily transformed into a college in 1973. To commence surgical training, existing university teaching hospitals in the Anglophone West Africa were deemed suitable in manpower and human resources. Thus, the University College Hospital in Ibadan, Lagos University Teaching Hospital in Lagos, University of Nigeria Teaching Hospital in Enugu, Ahmadu Bello University Teaching Hospital in Zaria, University Teaching Hospital Complex in Ile-Ife and the University of Benin Teaching Hospital, Benin (all in Nigeria) as well as the Korle Bu Teaching Hospital, Accra, Ghana commenced training of their registrar cadres, driven mainly by local faculties all of whom were Fellows of the College. Other institutions were later invited to apply as training centres by the newly formed West African Postgraduate Medical College (WAPMC) which supervised postgraduate training in Anglophone West Africa for the next 25 years. While the criteria for accreditation of these new centres were drafted and standardized by the constituent Faculties of the WACS, the process was under the administrative apparatus of the WAPMC. Blanket accreditation was given to pioneer institutions at inception of training and the first two years during which candidates were tutored on surgical anatomy, physiology and other basic concepts were also employed to ginger the training establishments to improve their facilities, manpower and service process to gain fuller training status. The quest for a training institution status became a must-have for all teaching hospitals and well established government hospitals (in countries with no teaching hospitals). Thus, a formal accreditation process was developed by the College for the WAPMC, setting standards and terms which were embraced by the sponsoring authorities of these institutions (governments).

The WACS became an autonomous training body in 2000 and each of its seven Faculties (Surgery, Dentistry, Obstetrics & Gynaecology, Ophthalmology, Otorhinolaryngology, Radiology and Anaesthesiology) has grown exponentially as a result of the visionary idea that emanated from a core group of professionals who have dedicated their time and energy to enshrine the application of a set of training standards in their respective disciplines². Programmes accreditation of the WACS is driven by the leadership and members of each Faculty. The report of all accreditation visits are reviewed twice yearly by the Committee on Higher Professional Medical Education (CHIPMED) of the College whose report is then sent to Council for ratification. With some modifications in observance of the peculiarities of each Faculty, the accreditation process of the College follows a standard format. In addition to teaching hospitals, Federal Medical Centres, Mission Hospitals, Specialist Hospitals and suitable private hospitals in West Africa are actively encouraged by College Fellows and Faculties to seek accreditation from the WACS if they are considered worthy of such a status. Establishments that may not meet the standards are also nudged to upgrade their facilities and meet set accreditation criteria while joint accreditation between institutions within the same geographical zone but with different complementary facilities, manpower and strengths is also considered by the College. Thus, within resource-poor Anglophone West African sub-region, there are 191 training accredited departments by the WACS in its seven Faculties in 2010³. The Faculties of ORL, Ophthalmology and Anaesthesia also run and accredit diploma programmes for middle-level manpower development, with Ophthalmology running a Francophone version of its Diploma programme in Conakry, Guinea. Elaborate accreditation of these several programmes is carried out by the parent Faculties.

The Accreditation Process of the WACS

This starts with a written application from a training institution seeking a visitation by the College for a specific specialty training programme. This may be a new first visit or a reaccreditation at the expiration of a previous one. It should be noted that the WACS does not accredit institutions but programmes within an institution. Thus, an institution may have various degrees of accreditations for its sundry training activities, depending on their levels of competence. A comprehensive, standard accreditation form is also filled and submitted with necessary fees to the College Secretariat after which a visitation date is scheduled by the relevant Faculty. The application form details the profile of the hospital, the structure of its residency training programmes in the discipline(s) for which accreditation is sought, its bed capacity and utilization, library and internet facilities, surgical facilities, caseload, laboratory, radiological and other investigative facilities as well as other ancillary components of a fully functional residency training centre. Data is also provided on the departmental weekly academic activities, extant manpower and facilities in the core specialty and relevant, supportive areas such as haematology, pathology, anaesthesia, microbiology, radiology, radiotherapy, physiotherapy etc.

A visitation team of 4-5 Fellows is chosen from within the Faculty to represent the international and geographical diversities of the College. On an agreed date, the visitation commences with a courtesy call on the Chief Medical Director of the institution visited where the purpose of the accreditation is explained to the hospital’s management team. The accreditation team goes on a comprehensive tour of the facilities and observes daily activities of the surgical out-patient departments, operation suites, wards, accidents and emergency department, side-laboratories, library, radiology, pharmacy, blood bank, medical records, pathology department and other ancillary services. At each station, details of facilities are confirmed from service records and hospital personnel. Ancillary facilities and equipments such as resuscitation trays, training modules, infrastructural layout, call rooms, conveniences, scope and volume of procedures are also inspected and critiqued. A meeting is held with residents (trainees) and a separate one with consultant staff. A final meeting is conducted to obtain the management’s response to issues raised at the meetings with staff and residents.

A comprehensive report is submitted to the relevant Faculty Board of the WACS which then deliberates on the report in February or July before the report is forwarded to Council for ratification or amendments. Thereafter, the institution is formally notified of the visitation outcome by the College Secretary-General. The letter is a comprehensive summary of major findings with commendations on laudable areas of performance and details on aspects in need of corrections. These may range from lack of equipment and personnel to system lapses. Full accreditation is given for a period of 4 years to a programme that has satisfied the minimum training criteria while a 2-year Partial Acccreditation is awarded where the programme is deemed worthy but falling short of the minimum criteria. During this period, the institution is expected to put in place all the recommendations of the College and seek reaccreditation thereafter. Non-accredited programmes are those that do not meet majority of the stipulated training conditions and such institutions may reapply after one year within which the perceived defects must have been corrected. The report is provided to College Council and the General Assembly and is also published on the College website, stating the type of accreditation awarded as well as the number of trainees allowed for each programme⁴. On the whole, an accreditation report is a powerful tool in the hands of an institution when seeking facility upgrades from sponsoring authorities.

Innovative ideas

Programmes accreditation was part of a number of visionary steps taken by the largely post-colonial specialist doctors who saw the need for quality assurance in the newly established post-graduate college they had established in the West African sub-region over three decades ago. The template has become a suitable model for other sub-regions in resource-challenged parts of the world. The idea of one sub-regional body overseeing the standardization of training curricular and facilities in Nigeria, Ghana, Liberia, Sierra Leone and The Gambia was a winning formula, especially as it applied to seven different Faculties. It is on record that at inception, some Faculties of the WACS had as few as only 3 or 4 Fellows (“small” Faculties) and could not have been viable if left on their own. These were nurtured into robust entities over the years under the administrative umbrella of the College.

Developments

The WACS accreditation template serves as a model for the ongoing project aimed at integrating sub-regional training programmes and accreditation processes between the Anglophone and Francophone linguistic blocks of West Africa. Fellows from different Faculties of the WACS have helped in advisory capacities in the ongoing process of harmonizing the curricula and training programs of the countries of Francophone West Africa spearheaded by the West African Health Organization (WAHO). It is hoped this will form the basis of a pan-regional harmonization of curricula and accreditation programmes. The WACS has worked harmoniously with the NPMCN and the Ghana College of Physicians and Surgeons to streamline duplication of efforts and formulate common strategies in the furtherance of postgraduate medical education in Anglophone West Africa. Collaborations in the accreditation of training institutions and programmes is robust between these sister organizations.

Directions

The non-availability of facilities to sustain training programmes with set minimum standards has been a sub-regional concern of the WACS^5. The College has therefore mapped out in its Strategic Plan for 2007-2012 an adaptive method whereby the accreditation of national training centres may be reviewed to permit the recognition of hospital groups within a country for training in one or more specialties. It is hoped this will lead to the planned expansion of the list of accredited institutions by at least 20% within the 5-year period. The WACS has also been involved in ongoing accreditation of institutions outside its traditional boundaries and areas of influence outside of West Africa. The process is hard and slow but the prospect is bright. The College also periodically updates its list of minimum criteria as driven by new innovations and global current best practices enunciated by Faculty Boards.

Misdirections

There is always room for improvement. Since the WACS became autonomous and took over its administrative functions from the erstwhile WAPMC in 2001, it has obtained less than 5% of its total budgetary projections from sponsoring sub-regional government agencies. The College therefore finances its accreditation visits through accreditation fees and other allowances paid by the institutions to be accredited. This, though less than ideal, is a necessity until the financial fortunes of the College improves. This will require a greater drive for external funding from international agencies, an area long neglected by the College. The WACS also hopes to evolve a more reliable system of continuous assessment and unannounced spot-checks as part of comprehensive monitoring which will bridge the 4-year gap in between accreditations and reduce the impact of possible window-dressing by institutions to be accredited

Areas which need to be explored

There are many exciting aspects of programmes accreditation that should be explored for future improvement. Trans-regional accreditations and exchange of external teams is one such area. It will bring players within contiguous regions of Africa together and training Colleges in Eastern, Central, Southern, Northern and West Africa to be able to evolve virile programmes on a common platform to share ideas and benefit each other on training accreditation. The push for modernization of facility such as Magnetic Resonance Imaging (MRI), Computerized Axial Tomography (CAT), Lapraroscopy, bronchoscopy, endoscopy, versatile use of information technology etc should form part of accreditation in order to raise the bar in a sub-region that has been considered underdeveloped for far too long. The College needs to apply gentle but persistent pressure to make sponsoring bodies realize the need for such improvements in our hospitals and the equal importance of manpower training to man these services.

Presently, programmes accreditation is focused mainly on training, without a correspondent emphasis on the efficiency of hospital service output which is only captured indirectly in the assessment exercise. It is hoped a professional Board of Hospital Accreditation will emerge someday to rate, grade and tie efficient service delivery to both funding and accreditation status.

Future outlook

With time, other players and stakeholders will emerge as the untapped business potential of healthcare gradually transforms from a government-sponsored burden into a commercial mega-venture. With improved educational and economic status of the citizenry, the present College-driven audits of training programmes will be consumer-driven and better funding and manpower will replace the present largely voluntary process. Continuous assessment, financial independence of team and spot checks can only lead to better process of accreditation. It is hoped that a harmonized accreditation format will be developed to eliminate multiple visits from different bodies as presently obtains.

Our accreditation process grew from a few teaching hospitals to almost 200 departments in the West African sub-region in 7 Faculties over the past 25 years. This was in part due to the ambitious establishment of Federal Medical Centres by the Nigerian Government to provide secondary and tertiary care in every state of the country, given the nationwide collapse of second-tier State General Hospitals. A number of credible private hospitals have also emerged to fill the yawning gap for qualitative care in various segments of healthcare delivery in the sub-region. Managing such growth in a College run by a corps of dedicated honorary officers created bottlenecks and imperfect record-keeping. The College now has a full-time officer dedicated to the administrative requirements of this programme. The accreditation process itself requires to be periodically audited. This is being addressed by the College.

Personnel

The Accreditation process of the WACS is Faculty based. The Chairman of each Faculty and the Faculty Board organize the visits, nominating Fellows for each inspection. With increased harmonization with the NPMCN, teams from both Colleges sometimes pay joint visits to training institutions to reduce the logistic burden. The Administrative Secretary of WACS forwards all correspondences to the College Secretary General while the compilation of the master list of accredited institutions is done by the Assistant Secretary General who has been designated by Council as the Accreditation Officer to handle the increasingly busy schedule.

The Accreditation Officer

Updates the Accreditation Spreadsheet as soon as any correspondent is received

Inform Faculty Chairman of letters of invitation from institutions

Informs each institution 3 months ahead of an accreditation visit

Informs Members of an Accreditation Team 2 months ahead of proposed visit

Collects report of Accreditation Visits from Faculty Chairman and updates databank

Writes all institutions once a year immediately after October Council Meeting, notifying them about accreditation status:

Full Accreditation

Report includes the number of trainees approved for each programme, the date by which a new visit is due, any areas in need of improvement, commendations.

Partial Accreditation

This requires that the trainees may only complete their programme up to the Part I level in that institution after which the part II training must be done in another institution approved and certified for this aspect. The appropriate recommendations are sent along with this status.

Revoked Accreditation

This is a drastic step usually reserved for institutions that persistently fail to remedy obvious lapses in their performance after a series of warnings. It shows the bite of the accreditation process and a revoked status is made public, usually to the embarrassment of the management of such an institution and its sponsoring authority. In two recent instances when recalcitrant institutions got their accreditation status revoked by the College, there was so much national and international uproar which resulted in swift and drastic positive changes from the sponsors of the affected hospitals.

Not recommended for Accreditation

This may occur when an institution’s present state fall far short of minimum training standards. Such an organization may reapply later after the lapses have been rectified.

Lapsed Accreditation Status

A notice is sent ahead of the due date for re-accreditation but sometime, logistics may prevent a visit before the exact date which may then necessitate a grace period of 1-3 months after which a tardy institution may be informed its candidates may not be allowed to sit the College examinations until the accreditation status is renewed

Valid Status

This is when an institution has a valid Full Accreditation and the notice is to remind the management of the institution of when the status would lapse.

Number of trainees allowed

The College uses a maximum ratio of 1 consultant to 2 registrars and two senior registrars in allotting maximum number of trainees allowed per programme.

The Faculty Chairmen

Choose visiting team members in consultation with other Board Members and coordinate the trips. The use of internet facilities and the widely available mobile telephony has simplified what used to be frustrating journeys into the remote corners of the hinterland. Faculty Chairmen must also identify and contact suitable training centres, encouraging them to upgrade their facilities, establish academic programmes and apply to the College to be considered for accreditation visits.

Funding

The WACS charges a fee payable by each institution to be accredited. Each visiting accreditation team member is given an honorarium of $200 while the institution is responsible for the airfare, local transportation, accommodation and feeding of the team members. The College presently has no grants or external funding to run this important programme.

Over the past few decades, the WACS has been running a programmes accreditation process that started with the big Faculties of Surgery and Obstetrics & Gynaecology. These Faculties served as exemplary templates for other Faculties to learn from each other by proximity and constant interaction under the watchful eye of the College Council. Standardization cuts across Faculty lines and must be maintained up to WACS levels in all Faculties. Although the accreditation process is self-sustaining, it is yet to be embraced by sub-regional governments.

The College strives to contain the cost of this service by scheduling accreditation visits around the following periods of College conclaves:

February -Annual Conference

April and October -Examination periods July -Mid-year meetings

Where feasible, local Fellows resident in the region to be visited are co-opted into the visiting team.

Challenges

Although the West African College of Surgeons was formed as part of the defunct WAPMC by the collective decision of the Heads of State in the 5 Anglophone West African nations, its contributions have largely gone unnoticed by these sub-regional governments. The lack of funding for the College’s many laudable programmes is a key problem confronting the expansion of such programmes. The reluctance by some Governments to invest in healthcare and benefit of accreditation is perceived to be from the many layers of bureaucracy between the governments and these laudable projects. In this respect, the College needs to develop better relationships with the governments of this sub-region and get its story told more often where it really matters. The governments should be made to realize that in matters of programmes accreditation, the College is working on their behalf and appropriate funding should be made available.

The economic blight in West Africa following the wake of the global recessions in the past two decades wrought untold damage to the health sector, an area often considered a drain on the economy. Many years of zero growth and deficit budgets led to depletion of installed capacity while wars in Liberia and Sierra Leone devastated both the facilities and indigenous manpower in these countries. Thus, there is an uneven balance in the number of accredited and accreditable institutions in West Africa. Efforts are actively in progress to redress this imbalance.

The Autonomy of the accreditation process should be preserved. We hope that a time will come when a whole division of accreditation will be created in the WACS to cater for all programmes accreditation matters. Such an office will be manned by a full-time senior Fellow who will coordinate all issues of accreditation and whittle down the time between activities to achieve a proactive format. Such an office will run a tight programme and will not depend on fees paid by an institution before moving in to do what is due. Thus, institutions will have no leeway to bargain on when they wish the visiting team to come in. This will give less room for window-dressing.

Internal & External Assessors, Curriculum review

Inputs from these sources are considered as part of the College’s deliberations on programmes accreditation to maintain a proactive process^6,7. The gradual re-engagement of our colleagues from the Diaspora in training programmes is further raising the bar as this new crop of trainers demands higher standards to bring ours closer to acceptable international norms.

Conclusions

The programmes accreditation activities of the WACS has been a valuable process for the improvement of training activities by ensuring compliance with recommended standards by training institutions. It has contributed immensely to facility upgrades, standardization of curricula, pooling of human resources and exchange of trainees. It entails enormous sacrifice on the parts of College Fellows who undertake many accreditation trips for paltry honoraria. Accreditation programmes will continue to impact the quality of surgical training and should be well funded by all stakeholders if its full potential is to be realized.