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Medical colleges’ challenges and coping strategies in implementing accreditation standards in Pakistan

Objectives: To explore the challenges faced by medical colleges and coping strategies used in implementing accreditation standards by Pakistan Medical Commission during accreditation inspection 2019. Methods: In this qualitative case study, four medical colleges and their affiliated hospitals from three cities in Khyber Pakhtunkhwa province of Pakistan were selected through purposive sampling. Data was collected through focus group discussions (FGD) through Open-ended questions, based on CIPP (context, input, process, and product) model. Each focus group comprised of Dean, the Director Department of Medical Education (DME) and the Medical Director of the hospital. Data were thematically analyzed and results were based on the CIPP model. Results: Three themes identified were administrative challenges, accreditation challenges and resource challenges. The administrative challenges theme was further explained under subthemes of rules and regulation challenges, documentation and record challenges, and DME-related challenges. The accreditation-related challenges theme was explored in-depth with subthemes of accreditation process-related challenges, accreditation standards-related challenges and curriculum-related challenges. The resource challenges theme was described under sub-themes of infrastructure-related challenges, human resources and financial challenges. The commonest coping strategies adopted by medical colleges were establishing DME, emergency preparatory meetings of staff, and hiring staff on an emergency basis, to overcome administrative, accreditation and resource challenges respectively. Future suggestions for improving the accreditation process in the local context were highlighted. Conclusion: Main challenges identified were administrative challenges, accreditation challenges and resource challenges. Coping strategies by the medical colleges for these challenges are highlighted. The accreditation body should harmonize the process of accreditation with medical colleges and other stakeholders.


INTRODUCTION
The surge in global demand for health professionals and the resulting exponential increase in the number of health professions education institutions has blurred the international boundaries for medical students and physicians. The wide variations in medical training programs and the lack of robust accreditation systems have threatened the overall quality of medical education worldwide.
Globally, there is increasing realization for developing global medical education standards and accreditation systems to ensure the quality of medical education. World Federation for Medical Education (WFME) published its global standards to guide countries to contextualize and develop their own standards. 1 These standards have been adopted by many countries after necessary adaptations, including the US Education Commission for Foreign Medical Graduates. 2 Accreditation is one of the contemporary methods for quality assurance in many fields including medical schools. 3 However, medical education and clinical training are not uniform across the world. 4 Considerable variations exist in accreditation systems in the form of ownership, the scope of authority, standards, process and level of enforcement. 5 Literature identifies a range of accreditation challenges like too many standards, accreditation infrastructure, financial issues, time constraints, documentation, shortage of staff, added workload, poor survey instrument, quality of evaluators, accreditation sustainability and legal support. 6,7 Pakistan Medical Commission (PMC), as the sole regulatory body carries the responsibility of accreditation for over 150 medical and dental colleges in the country. The country requires a robust accreditation system to cater the needs of such a large number of medical and dental colleges. Few important features of the system include developing and updating accreditation standards that are contextual to the needs of the country, developing policies and procedures for accreditation in consultation with key stakeholders, and ensuring that faculty and other staff are welltrained to prepare the colleges for accreditation. Research on medical accreditation is limited in Pakistan. WFME standards provide a good start to develop a robust accreditation system in the country. In 2019, Wajid et al. conducted a study to assess the relevance of WFME standards to the Pakistani context. 8 Later on, Khan and colleagues identified the likely challenges faced by Pakistani colleges in implementing WFME standards in Pakistan. 9 No study has been conducted in Pakistan on the experiences of key stakeholders (faculty and administration of medical colleges) about the accreditation challenges faced during the accreditation process. This study provides evidence from the first-hand experiences of key persons involved in the accreditation process, challenges faced by them while preparing the institution for accreditation and strategies adopted by them for overcoming these challenges.  10 All the four components of CIPP were used to analyze accreditation inspection. The context and input evaluation describe the challenges faced during the preparatory phase of inspection. The process evaluation describes challenges faced during the actual inspection and product evaluation is about various coping strategies and future suggestions. Completion of the accreditation process was taken as the end product. A questionnaire, based on the CIPP model was developed comprising of eight open-ended questions, covering all the components of CIPP.

This
Data was collected through focus group discussions (FGDs). Two FGDs were conducted face to face in medical colleges and another two, through Zoom meetings because of the Covid-19 pandemic. Each FGD lasted for 45-60 minutes. Each focus group comprised of Dean, DME director of each medical college and medical director (MD) or medical superintendent (MS) of their affiliated hospital. Proceedings of FGD were recorded and notes were taken for important points. Data Analysis: Audio recording of FGDs was transcribed manually and was counter-checked by an independent observer. The data was analyzed through three cycles of coding and thematic analysis was done to generate themes from these codes. The results were analyzed and compiled based on the CIPP model.

RESULTS
Among the 12 FGD participants, 3 (25%) were females and 9 (75%) males aged from 40-50 years. The main challenges identified were grouped into three themes & nine subthemes. Theme one included administrative challenges with subthemes of rules and regulation challenges, documentation and record challenges and DMErelated challenges (Table-I).
The second theme was accreditation challenges with sub-themes of accreditation process-related challenges, accreditation standards-related challenges and curriculum-related challenges ( Table-II). The third theme was resource challenges with sub-themes of infrastructurerelated challenges, human resources and financial challenges ( Table-III).

DISCUSSION
Challenges faced by medical colleges during PMC accreditation inspection 2019 were grouped under three themes: administrative, accreditation and resource challenges.
The study identified several administrative challenges at the level of PMC, medical colleges, and hospital administration during the accreditation process. These challenges mainly stem from the lack of planning, lack of coordination among different stakeholders and poor staff training for preparing and conducting accreditation. The PMC, since its inception struggled in developing and implementing its rules, regulation and policies. 11 Administrative Challenges in the implementation of accreditation standards in Pakistan Process "In hybrid composition, the coordination and goals among different stack is produced with difficulty" (MD-1) Product "Discussions with higher authorities of health department and medical university to come up with demands of PMC". (DME Director-1)

Documentation & record related challenges
Context "It was not an inspection but going through the record"(Principal-2)

Input "it was not accreditation rather audit of medical college"(Principal-4)
Process

"If I am given the opportunity to speak the whole truth, we adopted deceptive fake and ostensible temporary measures to fill the gaps like installation of defective equipment and provision of filtered information to the PMC inspection team"(MD-2)
Product "Record was retrieved on recall basis, from old registers, purchase slips and computer data basis" (MD-2) DME-related challenges Context "The DME was made mandatory for recognition since 2008 but was started just before visit" (DME director-1) Input "The additional responsibility of DME was given to already over-occupied faculty" (DME director-4) Process "PMC inspector was judging our faculty rather than standards. The PMC team came with the mind set to make us fail" (DME director-2)

Product
The importance of DME was realized and faculty registered itself in various medical education certificate and masters programs (Principal-4) PMC: Pakistan Medical Commission; MD: Medical Director; DME: Department of Medical Education.
challenges of insufficient technical capacity, political influence and ad-hoc members in the accrediting body, and problems with rules and regulation have already been highlighted in other national and international studies. 12, 13 Rafi and Anwar highlighted the accreditation challenges in low and middle-income countries in a recent scoping review. These include the poor technical capacity of the accrediting body, lack of autonomy, undue political pressure, bureaucratic interference in decision making, ad-hoc members in the council and committees, bias in the selection of inspectors, incompetent inspectors, inappropriate inspection time and lack of coordination. 14 The medical colleges and hospital administration faced various executive challenges due to variations in the administrative and financial rules and regulations of the institutions working under the Medical Teaching Institution (MTI) act and the non-MTI act. In 2015, KP Government granted financial and administrative autonomy to various medical colleges and affiliated teaching hospitals through the MTI act to improve the quality of health services and delegated administrative powers and responsibilities to an independent policy board. 15 The health and finance departments were neither involved in developing standards nor taken on board during accreditation inspection. All medical colleges and affiliated hospitals were assessed with the same yardstick, although they were being governed under different rules. This 'one-sizefits-all' approach led to several administrative and financial challenges.  Context "The accreditation process was as stressful as like thesis defence ("DME director-2) Input "Many developments in pipeline could not be implemented because of short preparation time" (MD-4) Process "It is very hectic for college as well as for PMC team to inspect college in one day on such elaborated proforma" (DME director-1) Product "Single uniform policy will increase liaison between accreditation body, health and finance departments."(Principal-4) Accreditation standardsrelated challenges Context " They just sent us the standards but how to prepare on these standards, there was no awareness" (Principal-3) Input "The PMC should follow realistic approach according to our local conditions and such strict criteria for evaluation is very difficult to fulfil" (MD-3)

Process "The evaluation of different categories of hospitals and medical colleges on the same standards led to biased results"(Principal-4)
Product "PMC standards should be modified according to hospitals categories and for medical colleges should be adjusted according to its location/funding and facilities being given" (Principal-1) Curriculum-related challenges Context "All of a sudden the modular system was implemented in all medical colleges. We implemented it for inspection purpose without any know-how of this system" (DME director-4) Input "We invited medical educationist from various universities as guest speakers to give orientation & training to our faculty members" (Principal-4) Process "Fake timetables were made. Seeing timetable only is a deceivable method." (DME director-1) Product "The importance of DME & integrated modular curriculum was realized." (DME director-4) DME: Department of Medical Education; MD: Medical Director. expenditure challenges in low-and middleincome countries as the main obstacle to successful and sustainable accreditation. 16 Accreditation is a collective process with a distinct role played by key stakeholders in achieving the desired results. All stakeholders must be taken in confidence and play an effective role in making accreditation successful from its planning to final execution. Failure to effectively involve stakeholders in accreditation planning and execution may threaten the effectiveness of accreditation. It may become merely a tick box exercise.
Though the department of medical education (DME) was declared the accreditation of institutions in 2008, the accrediting body did not provide the regulations and policy guidelines for establishing DMEs. 17 The role of DME remained ambiguous and inactive in medical colleges due to the lack of guidelines, absence of full-time DME directors, inadequate infrastructure and human and financial resources for DME. 18 Along with inadequate infrastructure for DME departments, the lack of training of DME staff poses a major threat to the efficient and effective functioning of the departments. Although health professions education programmes have taken their roots in Pakistan over the past one decade, effective training of DME staff, especially for planning and conducting accreditation at institutional level still remains questionable.  One of the biggest challenges faced by almost every medical college was a poor documentation system. Short preparatory time, variation in rules and regulations and non-familiarity with new standards resulted in an increased workload on faculty and hospital administration. Similar accreditation challenges of increased workload, faculty resistance and too many standards were reported in a study from Iran. 19 Participants of our study mentioned several coping strategies to get through the accreditation process successfully. Most strategies were mere box-ticking exercises to maximize accreditation scores, rather than addressing the gaps in the quality of education in a more transformative and sustainable manner. Few strategies included establishing DME (albeit on papers), manipulation of records and creating new documents on an emergency basis.

Challenges in the implementation of accreditation standards in Pakistan
Some of the challenges faced during the inspection were solely related to the accreditation body and the planning and process of accreditation. Proficient and skillful inspectors are vital to conducting the accreditation survey effectively. Inspectors must be trained well on the nature and measurement of standards, and their role during the accreditation process. Unfortunately, the PMC overlooked both the selection and training of its inspectors, which resulted in an inconsistent inspection process. One participant reported that the inspectors finished the whole inspection process in a college in single day only (typically eight hours). Such threat to the validity of the accreditation process has been reported in other studies from Pakistan and Iran. 9,12 In one of the colleges, the inspection was carried out during the month of July, without considering summer vacations and hot weather. Vali (2020) also reported similar incompatibility in scheduling accreditation in Iran. 19 The successful implementation of accreditation standards can be ensured when the standards are contextualized to each country's needs and accepted by health professionals. 20 Accreditation can serve as a strong driving force to upgrade educational programs, including the curriculum. 21 The quality of medical education in Pakistan is compromised due to a lack of curricula based on international standards. 9,11 Non-alignment of educational and medical accreditation policies results in the wastage of resources and the purpose of accreditation cannot be achieved. 22 The independent nature of accreditation department, availability of highly trained staff, well developed standards of education that are thoroughly understood and implemented by the institutions and a major shift in the perception of accreditation as a 'policing exercise' to a 'quality improvement' strategy is likely to help the institutions reap the real rewards of accreditation.
Coping strategies included calling emergency staff meetings to distribute responsibilities to prepare the college for accreditation, staff orientation on accreditation standards and identifying the major deficiencies that could drastically pull the score down. It was evident that there was no concerted quality improvement effort behind the accreditation process. The curricular issues were addressed by medical colleges through the capacity building of faculty members. Developing new teaching strategies, incorporation of study guides, adjustment of subject hours in timetable, improved internal assessment and relevant documentation were the main reforms in the curriculum.
Medical colleges and hospital administration faced various resource challenges: human resources, infrastructure, and financial difficulties. PMC has set standards for human resources in medical colleges and affiliated hospitals. These resources include a range of faculty, office personnel and other support staff. Medical colleges generally faced the challenges of fulfilling human resource requirements as per PMC standards. Studies conducted in Pakistan 11 and Bangladesh 23 highlighted similar human resource shortage challenges. Participants mentioned that the buildings of medical colleges and their affiliated hospitals, especially in the periphery were not purpose-built. Studies from Bangladesh 23 and India 24 pointed out similar challenges of inadequate infrastructure, insufficient staff, and weak logistics management in accreditation implementation. Implementing a national accreditation program requires considerable financial resources. 25 Participants complained that the inspection was carried out in urgency, ignoring the financial constraints of medical colleges and their affiliated hospitals. The release of finances to fulfil financial commitments required coordination between Finance and Health Departments, which was simply missing. This led to the lack of financial availability to comply with PMC accreditation standards. Institutions had to hire staff on an emergency basis to fill staff deficiencies. The finance department was requested to release funds in an emergency to buy necessary equipment on urgent basis to fulfil standards requirements. At times, accreditation of an institution might be a time consuming and resource intensive exercise. A robust accreditation system is still far from taking its roots in Pakistan. Communication gaps and the lack of coordination among stakeholders could pose serious threats to the successful implementation of the system. These gaps must be addressed by the leadership.
Participants gave several suggestions to improve the accreditation process. These related to the composition of the accreditation team, inspection schedule, inspectors training, liaison between health and finance departments, better coordination between the colleges and PMC and post-inspection analysis. The inspection of an institution for accreditation purposes is a resource intensive process. PMC may consider introducing a pre-inspection process to guide the institutions conduct their self-assessment for readiness for inspection. Effective staff training at all levels is the key to successful accreditation.

Limitations:
This study was conducted in just four medical colleges of KP province, so it cannot be generalized to all medical colleges of Pakistan because of different administrative and financial rules and regulations in other provinces. The accreditation challenges could be explored more holistically by interviewing the heads of the inspection committees and conveners of the accreditation team. Medical colleges in the public and private sectors may also need to be explored further as the challenges may be different for the two sectors.

CONCLUSION
The main challenges faced by medical colleges during accreditation inspection were related to administration, accreditation body and resources. The main administrative challenges faced were related to records and documentation followed by highly variable regulations among public and private sector medical colleges and hospitals. The significant resource-related challenges were meeting human resource requirements, poor infrastructure and financial constraints. Untrained inspectors, poor inspection scheduling and lack of uniform inspection standards were the accrediting body related challenges.

RECOMMENDATIONS
The study provides evidence not only about the challenges during the accreditation process but also shows how institutions view accreditation as a policing and audit process. Quality assurance is the essence of any accreditation process. PMC needs to develop a robust accreditation system in consultation with the stakeholders. An accreditation department at PMC that is equipped with technically qualified staff and leadership support to develop and implement an accreditation system in over 150 medical and dental colleges of the country is perhaps the biggest challenge faced by the Commission and the colleges. Effective stakeholder coordination and staff training at all levels may significantly improve the accreditation system in Pakistan.