The influence of accreditation on educational change in U.S. medical schools.

The authors examined the influence of accreditation on educational change and reform in U.S. medical schools in the past decade, by reviewing the survey databases and site visit reports of 90 schools that had comprehensive accreditation surveys by the Liaison Committee on Medical Education (LCME) between July 1992 and June 1997. In this study, substantive change was defined as centralizing the design and management of the curriculum, as well as one or more of the following reforms: integrating basic and clinical science instruction and/or conversion to interdisciplinary courses; implementing methods of active, small-group, independent, and hypothesis-based learning; and substantially increasing students' exposure to ambulatory and primary care. Accreditation reports were reviewed to determine the extent to which the LCME previously had admonished schools for shortcomings in their educational programs and advised curricular changes. Notice was taken of grant support by national foundations promoting educational reform, in relation both to the correction of accreditation deficiencies and to curricular reform undertaken by schools on their own initiative. The study also scrutinized the evolution of accreditation standards promoting educational reform, and the LCME's support of initiatives for shortening the period of medical education and promoting performance-based teaching and the assessment of clinical skills. On entering the 1990s, the LCME toughened the standards for design and management of the medical curriculum and for the evaluation of educational program effectiveness that schools must conduct. The greater assessment rigor identified educational shortcomings in 61 of 90 medical schools coming up for accreditation surveys during 1992-1997. On those occasions, 34 of the 61 schools had instituted reforms or were on the verge of doing so. Twenty-five of the schools carrying out reforms (73%) had received major foundation grants, compared with ten of the 27 schools (37%) that had accomplished little. Fifteen schools that had not been reproached earlier were found on the 1992-1997 surveys to have undertaken substantial innovation on their own initiative, five with the help of major foundation awards. The study also shows that a number of schools implemented parts of more sweeping reforms with the help of smaller foundation grants for more discrete purposes. In some instances, it has not been possible to differentiate the influence of the LCME as a force for educational reform from the incentives for change created by national foundations. Overall, the LCME, through its standards and assessment practices, and in synergy with schools and kindred agencies promoting change, is now on the leading edge of improved education and evaluation in the nation's medical schools.