Developing Social Accountability Indicators at Medical Schools

© 2015 The Authors. This is an Open Access article distributed under the terms of the Creative Commons Attribution (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, as long as the original authors and source are cited. No permission is required from the authors or the publishers. Article History: Received: 28 Jan 2015 Accepted: 2 June 2015 ePublished: 4 July 2015


Introduction
Medical education is discussed frequently by experts and is a concern of society due to its close relationship with the public health from the perspectives of relevance, appropriateness and responsiveness to community needs.These challenges have passed a rigorous process since Flexner's report and some approaches and strategies for its improvement have been suggested, some of which are community-oriented medical education, education in society and social accountability.Accountability is a set of social relations by which a person has sense of commitment to explain and justify behavior with others.In other words, an individual insists on explaining and justifying his relationships with other people.Accountability is one of the ways of creating public trust and indeed, it is a kind of report. 1 The World Health Organization has defined the social accountability of medical schools as "the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a authorization to perform". 2The main challenge in the 21 st century for the education of health professions, a century after Flexner's report on medical education in North America, resides in the demonstration by educational institutions of their greater assisstance to improving health systems performance and people's health status.In October 2010, sixty five delegates from medical education and accrediting bodies around the world met in London, South Africa to finalize the Global Consensus on Social Accountability of Medical Schools (GCSA).Before this meeting, there was the culmination of an International Reference Group (IRG) of 135 organizations by a steering committee (SC) of 20 international experts, the IRG members participated in a three-stage Delphi process over eight months leading up to the GCSA. 3 Educational institutions were originally derived from community facilities and are created in order to respond to community needs in education, research and training the required human force.So, naturally, they should be responsive to community expectations regarding the optimal use of national resources.In the Global Consensus on Social Accountability (2010), comprehensive studies conducted on social accountability during three phases and the following ten areas have been provided for.The purpose of this study was to determine the parameters that could be used to evaluate the social accountability of medical schools.Long-term use of these indicators can improve the quality of medical education.

Materials and Methods
A qualitative study was conducted to obtain the opinions of experts using the Delphi technique.In the first stage, we conducted a deep review of the global consensus on social accountability in medical education .After reviewing several papers and using the opinions of experts, we conducted the tables related areas, criteria and indicators.Based on the complete and final report after a multistage Delphi study by the World Federation for Medical Education in 2010, it became clear that since many researchers in the field of medical education from different countries participated in preparing this report, the content provided by the International Federation was comprehensive enough to be the basic framework of our study.However, ultimately, we used additional experts' articles and opinions as well.In the second stage, during the first round of the Delphi, the tables draft was sent to twenty experts selected using purposive sampling who studied medical education or did some studies about social accountability and were active in community-based medicine in Tabriz University of Medical Sciences or other Medical Sciences universities in the country.Then, comments were collected and classified in the first meeting of the focus group discussions and necessary changes were implemented in the tables.In the third stage and second round of Delphi, the set of reforms were sent to the same selected instructors.The suggested reforms were applied after collecting the instructors' comments in the second focus group discussions.

Ethical considerations
Participant ,s names were kept confidential.

Results
The final indicators (Social Accountability) in higher education institutions after the second round of Delphi and the second focus group discussions were as follows:

AREA 3. Training and Providing Efficient Human Resources Based on the Competencies and Roles Required by the Community and Health System
Criterion A. 2) Suitable training programs and regulations for graduates, 3) A system of continuous professional development for graduates, 4) Level of faculty members interaction and departments in continuous professional development (CPD), 5) Revision and development of continuing education programs based on the needs of graduates and the health system, 6) A continuous professional development system for faculty members in the field of education and research, 7) An orientation and supportive program to acquaint students with the opportunities and the future job environment.

AREA 5. Accountable and Effective Management (Governance of the Medical School)
Criterion A.5.: Medical school uses all its facilities, staff and students in order to assess the needs and challenges of community health (five indicators): 1) The activities of departments and various wards of the medical school based on documentation, 2) Planning, monitoring and assessment of medical school, 3) An appropriate mechanism for having transparency and accountability are critical management, 4) Selecting and assessing the managers, 5) Creating the areas of criticism and participation of stakeholders in the assessment.Criterion B.5.: Financial management and resources (three indicators): 1) Fair distribution of funds, manpower and, education, research, health and treatment facilities, 2) Efficient use of distributed resources, 3) Transparent and scientific management and accountability.Criterion C.5.: The medical school ensures that avaibleresources are appropriately allocated and efficiently ran and that new resources are looked for to enable it to actas a socially accountable institution (three indicators): 1) Continuous and active cooperation of the medical school and the relevant units in primary healthcare, 2) Continuous and active cooperation of the faculty in specialized areas, 3) Continuous studies and assessment to promote effective cooperation with other organizations.

AREA 6. Scope of Standards
Medical school develops and applies appropriate standards to maintain and promote programs quality and its performance in social accountability.Criterion A.6.: Standards of academic excellence to best respond to the needs and challenges of community health (three indicators): 1) Developing and implementing social accountability standards, 2) Standards of academic excellence, 3) Consistency of school activities with the approved standards.Criterion B.6 .: Revision of existing educational standards in all areas of input, process and outcome (two indicators): 1) An appropriate mechanism for reviewing and developing social accountability standards, 2) Updating the standards.Criterion C.6.: Outcomes (graduates) of education programs standards (two indicators): 1) Developing the standards for recruitment and employment of graduates,2) Developing the standards for the graduates' competencies.Criterion D.6.: Excelent standards relating to governance of a medical school cover (four indicators): 1) Accountable leadership, 2) Professionalism of faculty members, 3) Ability to create and sustain strong partnerships, 4) Innovation and dynamic management.

AREA 9. Global Principles with Context Specificity
Criterion A.9.: Interaction with other domestic and international institutions and organizations to establish of local quality assurance and improvement systems (two indicators): 1) The faculty takes the advantage of the other institutions experiences and cooperation, 2) Improving the awareness and participation of community and stakeholders in terms of quality improvement.

Discussion
In our study, the global consensus on social accountability principles include the same principles and each principle was designated as an area.However, the criteria and indicators were determined based on the provided areas in the mentioned understanding and considering the conducted studies and papers.We continued the discussion with focus on the important areas.

AREA 1. Anticipation of Society's Needs
Considering the importance of social accountability values and standards, as well as a comprehensive and continuous needs assessment to identify and anticipate the community needs, it is essential to look at the institution's mission and identify other influential factors the affect community health.Identifying factors that affect the community health in order to develop accountable training programs (and other provided indicators in the area) are essential, and have, despite their importance, been neglected in our country.This area includes three criteria and twelve indicators.Values such as relevance, equity, quality and cost-effectiveness have been emphasized in many articles.Based on the academic members' opinions, community participation and professionalism are considered necessary values due to their great importance.Suggested values from Flinders University include: equity, quality, relevance, cost effectiveness, social justice, community engagement and partnership, professionalism, cultural sensitivity, mutual transformation, access to education, altruism, responsiveness and student-oriented programs.Medical schools must be committed to promoting equity in health.For example, a commitment to improve health equity must be confirmed by measures such as selecting students from minority groups and taking up learning strategies with equity issues at their core. 4

AREA 2. Partnerships with the Health System and Stakeholders
Cooperation and interaction with the health system are cases in which if non-governmental organizations are engaged in educational areas, effective benefits can be followed.The role of other governmental and non-governmental organizations in the health areas is impressive in the healthcare system, so that most organizations have created an organization to provide health care treatment.The coordination of these institutions with medical school and mutual external relationship provide a better and dynamic background for health services.And, here, the role of the faculty members in using the vast capabilities of the health system for greater efficiency, continuous communication and using their work fields for education and getting the learners to know how the services are provided by these institutions is very evident.Indeed, the field of education in society and the presence of the learners in the field will lead to better education and learning.

AREA 3. Training and Providing Efficient Human Resources Based on the Capabilities and Roles Required by the Community and Health System
The efficient and experienced workforce is one of the components of the service providing system.The inefficient training of students who are supposed to be employed after graduating in areas needed causes problems in the community.As the lack of needed workforces damages service delivery, so do the trained additional forces, they wander in society and the charge for their employment is uncertain.Estimating courses, levels and training course admission rates in each one based on the current and future needs of the community are the cases in which universities usually do not play a role.A periodic need assessment on the development of education courses and levels is not based on the needs of the health system and the labor market which results in a waste of national wealth and the accumulation of excess labor.

AREA 4. Outcome-Based Education
Determining outcomes consistent with community needs in developing goals; objectives of the curriculum; adopting strategies and educational methods fitting with outcomes; learning areas and professional duties of graduates; the assessment of students' capabilities and performance using tools and methods to suit their future roles and community needs; and using comprehensive methods of assessment and quality improvement of curriculums considering social responsibility indicators are the four major criteria in this area.And using the appropriate programs and successful global experience in training and applying appropriate educational strategies for promoting social accountability are the elements of educational quality improvement.The area includes four criteria and sixteen indicators.

AREA 5. Accountable and effective management
Participation of medical school and interaction with the health system, research in various areas of health, development of governance structures, familiarizing students with the challenges of health system, identifying professional and government structures and collaborating with them and identifying promotion processes (five indicators): 1) Medical school management pursues the departments activities based on the conducted needs assessment, 2) Medical school engages in planning, monitoring and evaluation, 3) Medical school develops transparent, accountable and critical management, 4) Medical school selects and evaluates managers based on accountable management criteria, 5) Medical school provides criticisim and participation areas of stakeholder in the evaluation and promotion of accountable management.

AREA 6. Scope of Standards
The role of standards is impressive in all evaluation systems.The departments' activities in various areas can be compared and their position can be measured based on the standards.In evaluation, appropriate standards should be always prepared by the relevant organizations and then they must be announced to subordinate organizations to run.Sometimes these standards, such as standards of excellence are provided by faculties to improve further educational activities.For example, the faculty do not suffice upper standards alone in social accountability, but develop and carries standards of excellence.Standards of academic excellence provide capacities in education, research and service delivery to meet the challenges and community needs.

AREA 7. Quality Improvement
Given the missions of the medical school, it must try to move towards excellence and improvement of the education process, research and service delivery.It cannot be achieved without considering quality improvement.Quality improvement in medical education and standards assessment for the introduction of social accountability should be reviewed and mechanisms for national validation must be done on that basis. 5

AREA 8. Mandated Mechanism for Accreditation
Accreditation is administered by the Ministry of Health and Medical Education.This organization is responsible for the licensing of educational qualification for the universities.Board delegations from various universities in the country as accreditation teams are sent to universities by the aforementioned ministry and review the relevant processes.Academic members are involved in developing accreditation indicators indirectly.If social responsibility played a role in this process, a major step would be taken towards achieving the goals of social accountability.World accreditation is one of the main objectives for a number of medical schools for the time being, and social accountability is one of the most important aspects of accreditation in medical curriculum. 6n our study, medical schools were recognized as a globally accrediting mechanism in change and improvement of schools, and carry out this process based on national and international principles and guidelines and approved standards.Accreditation and recognition medical education should be done based on accepting transparent standards.International standards have been accepted in World Federation for Medical Education and this provides a accreditation tool for supporting quality improvement.

AREA 1 :
Anticipation of Society's Health NeedsCriterion A.1.: The inclusion values, baseline criteria of accountability ,mission and goals in the institution's strategic plan (six indicators), such as equity, quality, relevance, cost effectiveness-community participation and professionalism.Criterion B.1.: Studies on prediction of community needs (two indicators): 1) Continuous comprehensive need assessment of social needs, 2) Identifying factors that affect community health Criterion C.1.: Considering the needs and indicators of community health in education and research programs (four indicators): 1) Curriculum planning, 2) Developing Education Programs and Courses, 3) Considering the community needs, 4) Supervision of research projects and theses based on the needs.AREA 2. Partnerships with the Health System and Stakeholders Criterion A.2.: Developing the effective methods and mechanisms of cooperation in the health sector (public/ private/non-governmental organizations with medical school (two indicators): 1) Mechanisms for management, 2) Cooperation with health systems and other organizations.Criterion B.2.: Providing grounds for community and nongovernmental organizations' participation in the planning and management of education and health services (three indicators): 1)The use of voluntary contributions of nongovernmental organizations, 2) The participation of the true representatives of the community and NGOs in policymaking, monitoring and management of educational centers, 3) Cooperation of other institutions and relevant sections.Criterion C.2.: Evolving roles of departments and education professionals in policy making and studies of the health and other sectors (two indicators): 1) Taking advantage of the consultation and participation of faculty members by health system, 2) Participation of faculty members in the needs assessment, studies and evaluations.

3 .:
Estimating courses, levels, training courses and admission rate in each one based on the current and future needs of the community (six indicators): 1) Periodic needs assessment of course development and educational level, 2) The use of periodic comprehensive need assessments to determine student admission, 3) Determining the number of the student admission, 4) Respecting justice and neutrality in student admission, 5) Students admission based on community need, 6) Admitting students based on professional competence required.Criterion B.3.: Considering the roles and Competencies required in community for education programs such as teamwork) (three indicators): 1) Formulation of learning objectives (outcomes), 2) Developing content and curriculum, 3) Evaluation based on roles and duties.Criterion C.3.: Prediction of appropriate mechanisms for continuous professional development of graduates and faculty members in order to better meet the evolving needs of community and health system (seven indicators): 1) Active participation of departments in continuing education and job training for graduates in different fields.
Criterion A.4.: Determining outcomes in accordance with community needs to develop goals and objectives of the curriculum (three indicators): 1) Developing learning outcomes based on the needs of the community, 2) Developing training courses based on professional and social tasks and needs, 3) Taking advantage of the appropriate programs and successful global experience in the curriculum.Criterion B.4.: Adopting strategies and teaching methods appropriate to outcomes, areas of learning and professional duties of the graduates (three indicators): 1) Applying appropriate educational strategies for social accountability development, such as SPICES, 2) Education in community and health system (Community-Based Education), 3) Relevancy of methods and learning opportunities with domains and outcomes.Criterion C.4.: The assessment of students' Competencies and performance using tools and methods appropriate to their future roles and society needs (four indicators): 1) Relevancy of the assessment methods and tools of student learning, 2) Student assessment in a real professional environment, 3) Being fair in assessing student learning, 4) Assessment of students' learning.4.4.Using comprehensive assessment methods and the quality of educational programs considering social accountability indicators (six indicators): 1) Comprehensive and continuous assessment of programs, 2) Considering criteria and indicators of social accountability in curriculum assessment, 3) Program review and improvement, 4) Metaevaluation of projects, 5) Determining the effectiveness of the graduates, 6) Establishing appropriate legal and administrative requirements.

AREA 7 .
Quality Improvement Criterion A.7.: The medical school engages in a periodic process of internal evaluation and quality improvement, guided by defined standards across social accountability (three indicators): 1) Developing social accountability indicators in internal evaluation, 2) Proper use of social accountability indicators in external evaluation, 3) The consistency of assessment indicators with accountability standards.Criterion B.7.: Medical school evaluates educational improvement in order to meet the needs of society and educational challenges, with the participation of all stakeholders based on accreditation indicators.(two indicators): 1) Proper use of indicators and continuous measures (quantitative and qualitative) for making progress towards social accountability, 2) Participation of service recipients, students and other stakeholders in assessing and accreditation.Criterion C.7.: The medical school completely supports the use of measurement tools and uses them roundly and successively for evaluation and institutional improvement.The process is explicit, clear, constructive and open to other stakeholders.(twoindicators): 1) Developing program and doing evaluation process and quality, 2) Availability of evaluation results, 3) Appropriate and timely feedback of evaluation results.Criterion D.7.: The medical school recognizes that a conducive governance structure, responsible leadership, and setting of professional standards are key determinants for quality improvement and progress towards becoming a socially accountable medical school.(Two indicators): 1) School management based on leadership principles and social accountability, 2) The amount of medical school efforts to achieve a more accountable system AREA 8. Mandated Mechanism for Accreditation Criterion A.8.: Medical school considers accreditation as a powerful leverage for institutional change and improvement, and this process is based on national and international principles and guidelines and approved standards (four indicators): 1) Active participation of the faculty in the developing, approving or revising of indicators and standards, 2) Preparing and facilitating the accreditation process, 3) The use of accountability indicators in accreditation, 4) Participation of experts and stakeholders in accreditation.
Criterion A.10.: A balance to be struck between the preservation of institutional autonomy and the role of stakeholder (two indicators): 1) Presence of a desirable number of stakeholders to monitor and assess social accountability development, 2) Continuous and mutual cooperation among the organization and local stakeholders, 3) Commitment of local representatives to values and principles of social accountability, 4) Maintaining the autonomy and sovereignty of medical school.Criterion B.10.: Doing field studies and giving feedback to stakeholders (two indicators): 1) Conducting comprehensive and periodic field studies, 2) Proper analysis and reporting.
7Using social accountability indicators for evaluation and accreditation of medical education institutions can help faculty members and other responsible bodies to be familiar with areas and domains of social accountability, result in educational quality improvement and better response to community needs.