Dr. E. Van Gessel, MD – MER, chair of HVTAP Joint ESA-EBA Committee
In 2016, at the ESA Congress in London, a symposium of the Hospital Visiting and Training Accreditation Program (HVTAP) took place entitled “The future of accreditation … where should we go?”
Many relevant and sometimes bothersome questions were posed to the four prestigious speakers invited.
First came our former secretary general of UEMS (Union Européenne des Médecins Spécialistes), Edwin Borman. What is a “Hospital Visitation”? What are we talking about, i.e., is it really an appraisal and accreditation based on the European training requirements? Isn’t the 1997 UEMS charter a bit “old”? Are there amendments or updates to be made?
We then asked our speakers to give their points of view and arguments on the following subjects, which we think are of utmost importance to observe and acknowledge during an HVTAP onsite visit.
- How do you ensure access to training for residents or even better selected guide trainees, and what is the right balance to observe between core curriculum and multidisciplinary requirements?
- What is an optimal balance between practical patient work (learn by doing), simulation, and theoretical courses?
- And last but not least, what professional qualifications should we aim for? Should future anaesthesiologists also become leaders, managers …?
I have taken the opportunity to publish below summaries of the four presentations that took place at our London meeting in 2016; these were provided by the authors themselves, and I hope they will contribute to a better understanding of the actual work of the HVTAP and its future strategies in terms of hospital appraisals.
However, above all I believe they will give the readers an insight on what composes today’s training of a specialist in anaesthesiology. One can summarise this with the following statements:
- proper training of the specialist in anaesthesiology must be based on constantly evolving quality standards,
- the concept of training itself should be a continuum or rather a career-lasting process of education and professional development, not only in the specialty itself but also in other areas such as medical education,
- quality and safety of care preclude using only “learning by doing” and should include a balanced use of different pedagogical tools for learning (such as simulation) but also for evaluation,
- training a specialist in anaesthesiology is more than just training a medical expert; it is training an individual with new responsibilities in different areas of medicine.
A. Hospital visitation or appraisal and accreditation of European training requirements; the 1997 UEMS charter
Author: Edwin Borman, The Shrewsbury and Telford Hospital NHS trust, UK
In my lecture, on “Hospital Visitation”, and as the former secretary general of the UEMS (Union Européenne des Medicins Specialistes), my fundamental question is, “What is the best way of assuring quality in healthcare?”. I have tried to explore this in the context of hospitals that provide medical training.
Most forms of quality assurance in healthcare are based on monitoring performance against defined standards, a concept familiar to all as part of the audit cycle.
Two main documents for me are references, which provide standards for such reviews: the UEMS Charter on the Visitation of Training Centres  and the European Training Requirements for Anaesthesiology . The assurance of the quality of training is the primary objective in both. Given the dates of these standards – 1997 and 2013 – they also provide an opportunity for comparison and reflection on how concepts have evolved during this period.
The UEMS Visitation Charter is based on an “invited, formative review” model, in which the centre being visited is assessed against defined standards that include direct and proxy markers of the quality of training. Following both self-assessment and peer-review, which emphasise the resources for and commitment to training, and the educational experience of trainees, a report is provided that focuses on areas of good quality and suggests areas for improvement.
The document setting out the UEMS European Training Requirements is more extensive, as it covers standards for training and assessment, for the training of trainers, and also for the accreditation of training centres. There is some linkage between the standards for trainees that provide detailed requirements for general and specific core competencies – the standards required of trainers, and those required of training centres. The document also sets out the model of the Hospital Visiting and Training Accreditation Programme (HVTAP), which is a more detailed standards-based, peer-review assessment process.
In both cases, the approach of Donabedian  of “structure, process, and outcome” is implicitly applied. Visitation, like the audit cycle, has the advantages of being standardised, reliable, applicable in a wide variety of contexts, and replicable. However, visitation systems have the disadvantage of being “one-off” assessments, which can only determine performance at a particular time. It is evident that the last two decades have seen an increase in both the extent to which standards are evolving, emphasising the need for continued monitoring of the quality of delivery of training in keeping with the dictum that quality is best achieved by getting every detail right, all the time.
- Charter on the Visitation of Training Centres (1997), at www.uems.eu, under policies.
- Training Requirements for the Speciality of Anaesthesiology, Pain and Intensive Care Medicine (2103), at www.eba-uems.eu, under education.
- Donabedian, A. Explorations in Quality Assessment and Monitoring, 1980, Health Administration Press.
B. How to ensure access to training and the right balance between core curriculum and multidisciplinary requirements?
Author: Lennart Christiansson, MD, PhD, DEAA, EDIC, FCCP
President of the UEMS section and Board of Anaesthesiology, Sweden
A lot of work has been done in the last couple of decades on structuring and quality assurance of specialist training. The time has now come to look at training as a continuum that seamlessly makes training the start of a career-lasting process of education and professional development. Many mechanisms come into play for harmonisation of training and competency requirements (Figure 1).
Not only is resource allocation and type of healthcare system important but the regulatory framework is undoubtedly crucial. Amongst those are the EU Directives on professional qualifications and on cross-border healthcare, the UEMS Charters on Accreditation and Assessment, the European Training Requirements (ETR–EBA Curriculum), as well as the multidisciplinary Common Training Frameworks. The professional scientific societies, in particular the ESA, play a substantial role, and so does the migration of workforce and knowledge. The EU Directive 2005/36/EC on training was modernised in 2013 and now states that training is to be competency based (ETR) but with a minimum duration retained. Importantly, provision of and support to continuous professional development was made a mandatory responsibility of the healthcare provider/employer.
Training and CPD concept
Anaesthesiology will have to build upon a Competency Based Training Concept of five-year duration, but what exactly should we train for? When delineating this, we need to agree on the future content of the academic specialty of Anaesthesiology. Alongside anaesthesia, all relevant aspects of Perioperative Medicine need to be covered, such as General Intensive Care Medicine, Critical Emergency Medicine, and acute Pain Medicine. In order to include training in Pre-hospital acute care, Multidisciplinary Intensive Care Medicine, and Chronic Pain, the curriculum might have to be extended beyond the five basic years. Furthermore, modules for advanced training can be added to the training programme or at a later stage, as outlined graphically below (Figure 2).
Such an approach would bridge the specialty training with a level-targeted concept for Continuing Professional Development as already partly implemented by the joint efforts of the EBA and the ESA (Figure 3).
Exchange of knowledge
The EU Directive 2011/24/EU on cross-border healthcare foresees in its Article 12 the creation of European Reference Networks, and this process is ongoing. The main objective is to facilitate collaboration on highly specialised care and the management of patients with rare diseases or very resource demanding clinical conditions. Even so, the networks will also have an impact on research, education, and training as well as on exchange of trainers and trainees.
How to select and guide trainees
We can all easily relate to minimum or optimum requirements when it comes to theoretical knowledge as well as practical and clinical skills. However, today we are increasingly aware of the importance of attitudes, ethical commitment, and principles. In addition, other aspects of professionalism are becoming more important for outcome as complexity increases and boundaries for what is possible are constantly challenged. Examples of those are Non-Technical Skills, Quality & Safety Management, Teamwork, and Multidisciplinary aspects.
Among available assessment modalities, the trend is to include more of formative assessments, such as direct clinical or simulation-based observations and in-training evaluations of knowledge with MCQs or vivas. We also move towards self-reflecting Logbooks and Portfolios. To be able to provide appropriate support, follow-up, and feedback to the trainees there need to be clear roles and assignments for tutors and mentors. A compulsory appraisal of the trainee after the first year of training is crucial for best guidance and advice on direction of professional career.
Special Qualifications of the trainers
The EBA has made SETQ validated tools for evaluation of teaching performance an integral part of the training curriculum. Trainers must be able to create a positive learning climate, show professional attitude towards residents, communicate relevant learning goals, evaluate residents’ progress, and constructively feed this back to the residents. Conversely, the trainers have to be assessed by both residents and faculty.
Quality criteria of training centres
Centres must have a sufficient number of patients cared for and an appropriate range of clinical specialties and perioperative medicine for meeting Competency Based Training (CBT) targets. Many other components contribute to the working environment (Figures 4 and 5).
Qualifications of training faculty with a declared commitment to theoretical teaching and practical instruction form the backbone of training, but naturally also the trainee/trainer ratio and availability are vital prerequisites. Departments must run educational activities and provide adequate clinical environment and educational facilities to allow reaching CBT goals as described in the curriculum. A successful programme will also secure sufficient supervised time with tutors and a continuous assessment of trainees’ progress based on a competency-based evaluation system.
On top of structural aspects and resource allocation, sound processes must be in place to ensure that an “educational climate” is created. This encompasses many factors of which can be listed:
- Medico-legal aspects
- Work environment hazards
- Systematic approach to medical audit
- Roster planning and hours on-call compliant with the European Working Time Directive
- Adequate physical working conditions
C. Optimal balance between practical patient work (learn by doing), simulation, and theoretical courses
Author: Klaus Olkkola, MD, PhD, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Many current senior licensed medical specialists have been trained using the “see one, do one, teach one” model. Although this approach may produce specialists with excellent expertise, it exposes the patients to harm because the physicians-in-training lack the required experience, knowledge, and technical skills. Unfortunately, the physicians-in-training often have only limited access to supervision from the experienced clinicians.
In the last few years many efforts have started to address the problem of patient safety. One of the reasons for the change has been the increasing awareness of medical errors caused by inexperience. It is therefore understandable that it has been regarded as necessary to improve the training of the residents. Further driving forces necessitating improvement of the curricula have been the recognition of professional competencies and the implementation of competency-based training in many specialties, as well as the introduction of performance related financial rewarding of residency training from government resources in some countries.
To become an expert in any medical speciality requires much more than knowledge of the science of medicine. Physicians-in-training must recognize the many roles of physicians. CanMEDS (Canadian Medical Education Directives for Specialists) has defined that optimal health and health care outcomes require the physicians to understand their role as medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. It is the best way to prepare physicians to be effective in the rapidly changing health care environment and truly meet the needs of their patients.
It is obvious that “learning by doing” cannot make the physicians-in-training acquire all the required competencies and understand all the roles. The use of simulation in training has proven invaluable because it allows the adoption of many technical and non-technical skills before practical patient work. Theoretical courses are also indispensable in increasing the knowledge of the physicians-in-training.
The optimal balance between practical patient work, simulation, and theoretical courses is a difficult question that cannot be answered unequivocally. It is of vital importance that the development of competencies and entrustable professional activities are followed individually. Entrustable professional activities in this context are defined as tasks or responsibilities that are essential to the practice of the speciality. It is imperative to obtain feedback from both the residents and their tutors, and modify the training programme and/or individual training plans as needed. Differences of local resources should also be taken into consideration. The optimal balance between practical patient work, simulation, and theoretical courses depends both on the resident in training and local resources.D.
D. What professional qualifications should we aim for?
Author: Thomas J Sieber. Department of Anaesthesia, Emergency Medicine and Intensive Care, Chur, Switzerland.
In recent years, time-based training has been replaced by competency-based training in many medical specialities in Europe. This is based on broad evidence, but the driving force behind these changes lies in the accountability to the public.
Anaesthesiology has been at the forefront of these developments. The advantages of a competency-based training lie in the shift from knowledge acquisition to knowledge application and in the paradigm that the attained competence is the key rather than time-in-training. On the downside is the fact that the art of medicine has to be broken down into a detailed list of competencies taken out of context and that the definition of “roles”, “competencies” (core, specific), “levels of acquisition”, and learning objectives is a comprehensive and complex task.
A very helpful tool for implementation of competency-based training is the Dreyfus model of skill acquisition (Figure 1). The utility of this model lies in helping the teacher understand how to assist the learner in advancing from one level to the next.
Figure 1. The Five-Stage Model of Adult Skill Acquisition [Dreyfus SE, Bulletin of Science Technology & Society 2004;24:177].
Over the last few decades, the role of the anaesthesiologist has extended from the operating room as the main area of competence to new responsibilities outside the operating room in other areas of medicine. The initial tasks, which included assessment and evaluation, maintenance of organ function, and analgesia and amnesia for all patients undergoing diagnostic, therapeutic, or surgical procedures, have changed. Anaesthesiology has gone towards larger, deeper, and more holistic competencies in the perioperative period, in multidisciplinary intensive care medicine, emergency medicine, and pain medicine, which in many countries are now an integral part of the clinical specialty.
Five most important roles for anaesthesiologists
Four to five generic competencies or roles have been identified by a committee of the EBA as being most important for European specialists in anaesthesiology, derived from the CanMEDS framework that defines seven roles for any physician.
1. Medical expert
As a medical expert, the specialist in anaesthesiology must be familiar with anaesthetic and medical technology, general medicine, including diagnostic and therapeutic methods based on thorough basic knowledge of applied respiratory, circulatory, and central nervous system associated physiology and pharmacology. The main field of an expert in anaesthesiology is perioperative medicine, and he should acquire all necessary competencies enabling him to fulfil this expert role and function in a multidisciplinary setting.
2. Communicator, “team expert”
As a leader of an often diverse and interprofessional team, the specialist in anaesthesiology should have competencies in communication, including the interaction with patients and their relatives. Part of this role is also conflict management and mastery of “human factors”, a very important but often neglected field in safety management.
The role of anaesthesiology in management cannot be overemphasised and is the field where our speciality can most expand its influence in a hospital. Anaesthesiologists have unique skills that make them the ideal candidates to serve as leaders and managers of operating rooms. Other topics are quality management, patient safety, and health economics.
As a scholar, it is the specialist’s responsibility to develop and maintain a high degree of professional competence, to facilitate development of colleagues and other groups of professionals, and to promote development of the specialty itself. Lifelong learning and reflective thinking are indispensable for continuous professional development.
The profession of anaesthesiology requires irreproachable behaviour and high standards of reliability, accountability, and ethical decision making.
In addition to the above mentioned five main roles, an anaesthesiologist should be highly self-motivated and have the ability to withstand long working hours. A considerable number of consensual factors (time constraints, excessive and fluctuating workload, complexity of task, lack of job control) can cause stress during professional life, resulting in a high burn-out rate among anaesthesiologists. Professional resilience is not an innate ability but has to be fostered throughout professional development and career.