Quality management of clinical-practical instruction for Practical Year medical students in Germany - proposal for a catalogue of criteria from the German Society of Medical Education.

OBJECTIVES: Amended in 2013, the current version of the German Medical Licensure Regulation contains structural specifications that are also required of non-university institutions involved in Practical Year clinical training. The criteria are worded in relatively general terms. Furthermore, not all of the structural specifications can be readily applied to every subject area. In order to ensure commensurability in Practical Year instruction in Germany, not least in light of recently introduced Practical Year mobility, it is necessary to define consistent quality criteria for Practical Year training. The authors therefore propose a catalogue of criteria for the quality management process in Practical Year instruction facilities.
METHODS: In January 2014, the board of directors of the German Society for Medical Education decided to establish a committee comprised of representatives from various German medical faculties. In a process similar to the Delphi methodology, the group developed criteria for structure, process and outcome quality in Practical Year training in Germany.
RESULTS: The criteria developed for structure, process and outcome quality apply to Practical Year training in academic teaching hospitals and university medical centres. Furthermore, modalities for review are proposed.
CONCLUSIONS: The present catalogue of criteria is intended to contribute to the formation of a basis for the most consistent quality standards possible for Practical Year instruction in Germany.

Introduction

Structured in 16-week trimesters, the Practical Year represents the final stage of medical studies in Germany. The medical faculties are responsible for the adequate clinical instruction of Practical Year students, regardless of whether the trimester is fulfilled in a university hospital or in an academic teaching hospital (ATH).

In Germany, the Medical Licensure Regulation (Ärztliche Approbationsordnung/ÄAppO) dictates the legal parameters (§3 and §4 ÄAppO 2013) in which the Practical Year must be conducted. To this end, §4 also comprises structural standards which are required of non-university facilities participating in the Practical Year instruction of their corresponding faculties of medicine. It is presumed that university hospitals adhere to said structural standards due to the greater size of departments required for the broad range of courses necessary in the implementation of the second segment of studies. The criteria named in the Medical Licensure Regulation (ÄAppO, Germany) are, however, relatively generally worded. Furthermore, not all of the structural standards can be extended to every field of expertise. The Medical Licensure Regulation stipulates, for example, that only departments with at least 60 inpatient beds with educationally appropriate patients are suitable for Practical Year instruction in internal medicine and surgery. The capacity requirements of other inpatient departments as well as the supervisory relationship between medical staff and Practical Year students remain undefined.

In order to ensure commensurability in Practical Year instruction in Germany, not least in light of recently introduced Practical Year mobility, it is necessary to define consistent quality criteria for Practical Year training in university hospitals and academic teaching hospitals. Well-known international forerunners in this field are, for example, the criteria of the Medical University of Vienna for quality management of the clinical practical year (Qualitätsmanagement des KPJ) [http://t3-org1.meduniwien.ac.at/fileadmin/kpj/kpj-beschluss-der-curriculumkommission-humanmedizin.pdf], and the WFME Global Standards for Quality Improvement in Basic Medical Education [1]. Dupuis et al. describe the situation of the clinical electives year (“Wahlstudienjahr”) in Switzerland [2].

The authors of the present work therefore propose a catalogue of criteria for Practical Year teaching facilities in Germany.

Methods

In January 2014, the board of directors of the German Society for Medical Education decided to establish a committee comprised of representatives from the Ludwig Maximilian University of Munich, the Technical University of Munich, the Albert Ludwig University of Freiburg, RWTH Aachen University, the Georg August University of Göttingen and the Ruprecht Karl University of Heidelberg. In multi-step approval processes, the group discussed defined and formulated criteria for structure, process and outcome quality in Practical Year instruction.

Results

The work herein presents a catalogue of criteria that can be used by medical faculties, university hospitals and academic teaching hospitals alike in the framework of the quality management process. The fulfilment of the criteria could be reviewed externally (as part of a certification process, for example) or internally by the medical faculty responsible for Practical Year instruction. The authors advocate a review of all Practical Year teaching facilities (i.e., academic teaching hospitals and university hospitals). Regardless of the type of review implemented, the contact between the medical faculty and the affiliated academic teaching hospital must be maintained and/or strengthened in order to cooperatively improve Practical Year instruction.

In addition, the committee recommends visits by the central Practical Year coordinating staff of the medical faculty to the respective academic teaching hospital. The objective is to engage in a cooperative dialogue on eye level with the academic teaching hospitals in order to collectively ensure a sustained high level of education for students.

The quality criteria developed for structure, process and outcome quality along with the proposed review modalities can be seen in tables 1 to 3. The colours used indicate the facility to which the criteria are to be applied (see legend) (Tab. 1), (Tab. 2), (Tab. 3).

Table 1

Definition and proposal of procedures for review of structural quality criteria (green = Criteria for use with ATHs and university hospitals; yellow = Criteria for use with ATHs; blue = Criteria for use with university hospital/medical faculties)

Table 2

Definition of and proposal for the mode of review of the criteria for process quality (green = Criteria for use with ATHs and university hospitals; yellow = Criteria for use with ATHs; blue = Criteria for use with university hospital/medical faculties)

Table 3

Definition of and proposal for the mode of review of the criteria for outcome quality (green = Criteria for use with ATHs and university hospitals; blue = Criteria for use with university hospital/medical faculties)

Discussion

In the opinion of the authors, the establishment of the quality criteria defined in tables 1 to 3 (Tab. 1), (Tab. 2), (Tab. 3) represents a necessary, practice-oriented supplement to the structural specifications of the German Medical Licensure Regulation (§4). In view of the significant differences in the organisation of the Practical Year, faculty-specific adaptations of the details are presumably necessary. For example, not every medical faculty provides for logbook evaluation. The evaluation has, however, proved to be a sensible measure in order to draw conclusions about Practical Year training [3].

Within the quality criterion for capacity, a difference must be made between inpatient and non-inpatient departments. Hence, two criteria were formulated in table 1 (2.1 and 2.2) (Tab. 1). For non-inpatient departments, only the proposed “consultant ratio” (0.5 Practical Year students per 100% consultant position) should be used; both criteria should be used with inpatient departments. If the two calculated capacity figures differ, as the more solid of the two, the “consultant ratio” is recommended.

Because of the lack of related specification in the German Medical Licensure Regulation, the authors of the present work abstain from detailing concrete study time or study days for Practical Year students, although it is recommended that at least 10% of the required weekly working time be considered for structured advanced learning. This time should not, however, be accumulated for “work weeks” or the like. Additionally, the licensure regulations prescribe that Practical Year students should, as a rule, be present in the hospital full-time – i.e., preferably learning at a single location. Verification procedures concerning this should take place in a manner defined in the Practical Year regulations - student case reports in the scope of cardinal symptom oriented seminars [4], [5] and presentations on current subjects, for example.

The third phase of medical examination (M3) at the end of medical studies differs in its organisation depending on the individual faculty of medicine. Some faculties hold examinations exclusively at the university, while other faculties allow testing on-site at the teaching hospital, stipulating, however, that the panel of examiners includes a university lecturer. In the opinion of the authors, it is important that lecturers from the teaching hospitals participate in the university-held M3 examination process. Specifically, it is suggested (5.1 in table 2 (Tab. 2)) that teaching hospitals participate in the process with at least one M3 examiner per specialty and at least one M3 examination per year. In order to obtain better standardisation in oral state examination testing [6], participation in an M3 training course or workshop is recommended as well.

Although the German Medical Licensure Regulation does not prescribe any formative testing in the Practical Year, academic research revealed that testing during the different phases of the Practical Year can increase the learning effect [7], [8]. Therefore, this quality criterion (1.6 in table 2 (Tab. 2)) should be introduced or maintained, at least as an optional offer for Practical Year students, for example in the form of a mock examination. Additionally, students must present certification of “proper” completion of the trimester to the examination office at trimester’s end. Regulated testing at trimester’s end could provide an objective basis for this certification. Currently in development, the German National Competence-based Learning Objectives Catalogue (Nationaler Kompetenzbasierter Lernzielkatalog Medizin – NKLM) [9], [10] could be used in the future as a point of orientation for creating Practical Year test content.

The quality of the academic teaching practices for the elective subject “general medicine” was fundamentally addressed by the primary care committee of the GMA [11]. A specialised catalogue of criteria for accreditation of academic teaching practices for the Practical Year is in the planning stage.

In summary, the present proposal is meant to serve medical faculties in Germany as a set of guidelines for establishing quality standards of the highest possible consistency. The practical implementation of the standards will uncover further aspects that will lead, in turn, to the modification and/or expansion of the criteria.

Note

The position paper was accepted by the GMA executive board at 09-24-2014.

Compoeting interests

The authors declare that they have no competing interests.