The ASPIRE-To-Excellence Program: a Global Effort to Improve The

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Invited Commentary Invited of an excellent medical of an excellent components for excellence in each component. in each excellence for excellence, determine “To One might ask, use a country’s not simply why and the outcomes standards accreditation the of from the reports that derive was That approach visits?” accreditation over States in the United attempted periodan eight-year when the two those disciplines were incorporated into into incorporated those disciplines were in 2014. panels and board ASPIRE the has 24 board ASPIRE the present, At 16 countries. from members establish goal the was to Initially, an for ofthese standards excellence medical program. education entire to that goal was soon seen However, ambitious because ofbe overly the ofnumber up an variables that make including program, education excellent both high- and low- criteria covering and the need environments resourced It in cultural factor differences. to might that a school was also accepted aspects in some excellence demonstrate of not in program its education but define to a decision This led to others. the that had been Once program. education the around experts from accomplished, criteria develop impaneled to were world continuing global interaction for quality quality for interaction global continuing optimism prevails. improvement, the 88 schools submitting evidence, evidence, submitting schools 88 the their for recognized been have 38 topic ASPIRE the of one in excellence representatives of number the As areas. awarded are that schools the from increase to continues recognition ASPIRE ways new find individuals those and this for high are hopes contribute, to to how in remain Challenges program. low-resources in excellence define better on, take to areas new what settings, costs infrastructure keep to how and of example an as However, down. Strong Strong 1,2 director for education at the the at education for director 3

excellence in medical education. medical in excellence for a fee, may submit evidence that they they that evidence submit may fee, a for one in excellence for criteria the met have international The areas. five the of more or submitted evidence the judge then panels an whether determine and school the by excellence is merited. of award from learned lessons share authors The Of experience. program of years five do we grants, of research lists available of benchmarks objective any provide not accountability, student engagement, engagement, student accountability, development, faculty assessment, student criteria publish to plan they simulation; and development and design curriculum on use to encouraged are Schools 2018. in and, themselves challenge to criteria ASPIRE Leaders in dentistryLeaders and veterinary and involvement, medicine requested That is, until now. That is, for Association the 2012, August In (AMEE) in Europe Education Medical A entitled an initiative introduced International for Programme Schools in Education ofRecognition Excellence a board Through awards. (ASPIRE) of in medical leaders international and panelseducation of this experts, ASPIRE- sometimes called the initiative, began establish to program, to-Excellence standards peer-based internationally in medical education. of excellence Organisation for Economic Co-operation Co-operation Economic for Organisation current the that stated Development, and than harm more do rankings university key a ignore largely they because good on goes what ofquality—namely, measure theaters. lecture and rooms seminar the in research programs, the number of Nobel of Nobel number the programs, research of amounts dollar the and winners, Prize as taken mistakenly are grants external of the quality of the evidence sufficient Barbara Dr. Indeed, program. educational Ischinger,

n the United States and throughout throughout and States United the n Academic Medicine, Vol. 93, No. 8 / August 2018 93, No. 8 / August Academic Medicine, Vol. Acad Med. 2018;93:1117–1119. Acad Med. First published online December 19, 2017 doi: 10.1097/ACM.0000000000002099 Copyright © 2017 by the Association of American Medical Colleges NYU Long Island School of Medicine, 222 Station Suite 510, Office of Academic Affairs, Plaza Dr., e-mail: [email protected]. Mineola, NY; Please see the end of this article for information about the authors. to Dan Hunt, should be addressed Correspondence I panels of international experts in in experts international of panels have education medical of areas specific peer-based internationally developed social in excellence benchmark to criteria entitled A Schools Programme for for Programme Schools A entitled Excellence of Recognition International ASPIRE awards. (ASPIRE) Education in data. To address the vacuum of evidence evidence of vacuum the address To data. 2012 in quality, education medical for in Education Medical for Association the initiative an introduced (AMEE) Europe medical schools rely heavily on schools’ schools’ on heavily rely schools medical data grant-success and research-oriented available publicly the are those because Abstract ranking organizations and Publications Ronald M. Harden, MD, FRCP(Glas), FRCS(ED), FRCPC, MD, FRCP(Glas), FRCS(ED), Harden, Ronald M. and Farzand Ali, MBA Effort to Improve the Quality of Medical Medical of Quality the Improve to Effort Education MD, MHPE, MD, MBA, Debra Klamen, Dan Hunt, The ASPIRE-to-Excellence Program: A Global Global A Program: ASPIRE-to-Excellence The ourselves, because the publishers are are publishers the because ourselves, the with can they that best the doing publicly Unlike them. to available data of education another program,school’s wanting by influenced be may they as Yet, higher. rank to school own their but blame to one no have we educators, both subjective and vulnerable to conflicts conflicts to vulnerable and subjective both provide faculty surveyed the As ofinterest. quality of the evaluations personal their for grants. Althoughfor grants. the publishers of in factor to effort an make rankings these the quality of program, the educational are faculty school of medical surveys their part because of the heavy reliance on how how on reliance heavy of the because part and research emphasizes school a much competing in is school a successful how the world, the annual published reports reports published annual the world, the schools of medical quality the ranking in controversial been have universities and Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.

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co-secretaries (one being the first author mentioned above; these criteria can serve excellence in medical education can be of this Commentary) of the Liaison as benchmarks for a school’s own quality assessed using these criteria, and that Committee on Medical Education tried management. schools find the process of applying the three different approaches to using criteria useful when they review their the extensive information from an One must not underestimate the enormity education programs. Patterns have accreditation visit to devise a reliable of the challenge in bringing 15 to 20 emerged as a result of this review process. and valid approach to ascertaining content experts from around the world For example, with the criterion of student excellence—but failed to do so. The together on a volunteer basis and asking engagement, it has become clear that underlying cause of this failure is that them to develop criteria for excellence. The schools not only must show evidence that accreditation standards are designed to ASPIRE website4 presents the five criteria their students have voting privileges on ensure minimum levels of quality and established so far. For a fee of £2,500 (U.S. the curriculum management committee do not address levels of excellence. In $3,230 at the time of this writing), a school but must also show that change has the process, they also found that listing can submit evidence of excellence for come about based on student input. As strengths in these accreditation reports these criteria and be judged by a panel of well, the students’ evaluations of faculty was so inconsistent across schools that international experts in the corresponding teaching must be systematically used for this practice was eliminated in 2015. content area(s). If successful, an ASPIRE faculty promotion and not just for annual prize is awarded during the annual AMEE teaching awards. conference. If unsuccessful, targeted Five Years of the ASPIRE Program feedback to the school is provided to A surprise for all is the relatively low The ASPIRE program initially formulated identify the areas that can be improved, submission and success rate for the criteria for social accountability, student and a reduced fee for reapplication is student assessment award; as of 2017, assessment, and student engagement, available. In an informative essay, Cianciolo there have been 15 student engagement and these were followed in years 3 and 4 et al5 offer an interesting perspective in awards but only 4 for student assessment, by faculty development and simulation. their description of the challenges and as shown in Table 1. It appears that a Curriculum development and design benefits of one school’s experience with common shortcoming is not having a are undergoing pilot review during 2018 their ASPIRE application. As evidence for variety of reliable and valid assessment and should be available for schools to the rigor of the criteria, as noted in Table 1, tools in place that are aligned across examine late in that year. While as of this across all of the categories, only 38 (43%) the continuum of the educational writing, 88 schools (see Table 1) have of the 88 submissions were awarded the experience. taken the time to apply for recognition designation of excellence. of excellence in one or more of these Schools failing to achieve an ASPIRE five criteria, perhaps the most significant Lessons learned award with their submission for social contribution of the ASPIRE initiative is We have demonstrated that it is possible accountability appear to fall short in that there are now criteria that recognize to develop criteria for best practices in one main way: their ability to provide best practices in each of the five areas several areas of medical education, that evidence that their graduates are in fact

Table 1 ASPIRE Applications and Awards, by Topic Areas of Criteria of Educational Excellence, 2013–2017a

Topic area of a criterion of excellence Student Student Social Faculty assessment engagement accountability development Simulation Total Total No. of No. of No. of No. of No. of No. of No. of No. of No. of No. of no. of no. of schools schools schools schools schools schools schools schools schools schools schools schools that granted that granted that granted that granted that granted that granted Year applied awards applied awards applied awards applied awards applied awards applied awards 2013 7 2 12 6 10 3 29 11 2014 3 1 6 1 5 2 14 4 2015 2 0 7 6 7 0 16 6 2016 1 0 2 1 4 4 5 2 12 7 2017 2 1 2 1 3 1 3 2 7 5 17 10 Total 15 4 29 15 29 10 8 4 7 5 88 38

Abbreviations: ASPIRE indicates A Schools Programme for International Recognition of Excellence in Education awards initiative; AMEE, Association for Medical Education in Europe. a To address the vacuum of evidence for medical education quality, in 2012 AMEE introduced the ASPIRE awards initiative. Panels of international experts developed peer-based criteria of excellence in the ﬁve educational topic areas shown in the table. Schools from any country may submit evidence that they have met the criteria for excellence in one or more of the areas. The panels then judge the evidence submitted by the school and determine whether an award of excellence is merited.

practicing in the targeted communities had only 25% success. How to judge take on, and how to keep infrastructure consistent with the school’s social the evidence provided by schools from costs down. However, as an example of accountability mission statement. regions with fewer resources is a central continuing global interaction for quality theme in discussions of the ASPIRE improvement, optimism prevails. It is too early to identify trends in faculty board and the panels. development and simulation. Funding/Support: None reported. As ASPIRE passes through its fifth year, Other disclosures: None reported. ASPIRE Academy: An unanticipated discussions at the board level have benefit returned to the original question of Ethical approval: Reported as not applicable. Although not initially anticipated, it soon how to identify schools with overall Previous presentations: Portions of this became apparent that the representatives excellence in medical education. With information were presented at the 2016 AAMC from the successful schools wanted more an ASPIRE award for curriculum Learn Serve Lead meeting held in Seattle, than just a designation of excellence. development and design coming on Washington, on November 13, 2016. They organized a group of former award board in 2018, could a school with winners to help other schools learn from awards in all, or a certain number of, D. Hunt is associate dean for curriculum innovation, these areas be recognized as having an NYU Long Island School of Medicine, Mineola, New them. The ASPIRE Academy was formally York, and former co-secretary, Liaison Committee on recognized by the ASPIRE board in 2015. excellent medical education program Medical Education, Washington, DC. He is chair of This group of educators from around the overall? What about other areas, such as the board of ASPIRE. world now provides a resource to other interprofessional education? How would D. Klamen is senior associate dean for education schools, both in individual coaching and one constitute panels from around the and curriculum, as well as professor and chair, faculty development sessions. To date, 3 world and from multiple professions Department of Medical Education, Southern Illinois University School of Medicine, Springfield, Illinois. webinars and 19 workshops or symposia to write criteria and judge excellence in She is co-chair, ASPIRE Academy. have been provided by the ASPIRE these other areas? What about schools that have unique areas of excellence, R.M. Harden is general secretary and treasurer, Academy. These faculty development Association for Medical Education in Europe, editor, offerings are careful not to explain how such as the school that requires all Medical Teacher, and professor (emeritus), University to apply for an award but, instead, to of its teachers to have training in of Dundee, Dundee, Scotland. He is a board member provide guidance and examples of the education and then goes the extra mile and cofounder, ASPIRE. different ways a school can be excellent in in providing support and protected time F. Ali is international business development the five ASPIRE areas. for the teachers to pursue the additional manager, Association of Medical Education in qualifications involved? What about Europe, Dundee, Scotland. He is administrator for ASPIRE. schools that support their students Future Challenges to learn about education and become References In some ways, two of the limitations of teachers themselves? the ASPIRE effort are intertwined. The 1 Harden RM, Roberts TE. ASPIRE: International recognition of excellence in absence of a visit to a school by peers to Moving Forward medical education. Lancet. 2015;385:230. validate the school’s data is a concern. 2 Harden RM, Wilkinson D. Excellence in However, the cost of a visit to each In a relatively short period of time, teaching and learning in medical schools. applicant school would be prohibitive, the ASPIRE criteria and awards have Med Teach. 2011;33:95–96. as the existing fee, although already emerged as a systematic way to provide 3 Ischinger B. Preface. In: Assessment of Higher Education Learning Outcomes supplemented by AMEE, is often reported objective and peer-based benchmarks of (AHELO). Paris, France: Organisation for as a barrier to application. The cost to excellence in medical education. Bringing Economic Co-operation and Development; the school is not only the fee but also international experts together to create 2009. https://paginas.fe.up.pt/~sfeyo/ the time and effort it takes to complete these criteria is a significant contribution Docs_SFA_Bologna/660_Brochure_2009%20 an application. Another pattern that in and of itself. As the number of %5bOECD%20AHELO%20Initiative%5d. pdf. Accessed November 25, 2017. has recently emerged and is creating representatives from the schools that are 4 ASPIRE—International recognition of intense discussion among the ASPIRE awarded ASPIRE recognition continues excellence in education. http://www.aspire-to- board members is that schools from to increase and those individuals find excellence.org/. Accessed November 12, 2017. Australia, New Zealand, Europe, and new ways to contribute, the hopes are 5 Cianciolo AT, Klamen DL, Beason AM, Neumeister EL. ASPIRE-ing to excellence at North America (with 61 submissions) high for this program. Challenges remain SIUSOM. AMEE MedEdPublish. May 5, 2017. enjoyed a 51% success rate, whereas the in how to better define excellence in https://doi.org/10.15694/mep.2017.000082. 28 submissions from the rest of the world low-resource settings, what new areas to Accessed November 9, 2017.