Background
The number of chiropractic education programs has increased considerably over the past decades. Some are run as private initiatives, some are included in university structures, sometimes even within a medical school setting. Concomitantly, perhaps both as a result and a driver, evidence-based practice approaches have become important and the traditional chiropractic vitalistic approaches downgraded, at least ‘officially’.
Accreditation standards and inspection procedures have been established worldwide by Councils on Chiropractic Education (CCEs) to safeguard standards and to ensure harmonisation between schools and geographical regions. CCEs are variously mandated and exist for the purposes of assuring educational quality and institutional integrity to governments, regulatory bodies, chiropractic programs, professional organizations, students and the public at large. Members of the CCEs may be elected or appointed. Medical education has adopted science and evidence-based practice as a basis for training [
1]. This is not always the case for chiropractic education. Some CCE accredited chiropractic programs have aligned with an evidence-based mainstream healthcare approach and declared that since there is no evidence for vitalist or subluxation beliefs it has no place in chiropractic training, except from as a historical context [
2]. Other CCE accredited colleges have continued to hold to a
vitalist philosophy. Some even openly advertise vitalistic statements such as the New Zealand College of Chiropractic
“To offer well-resourced, integrated, relevant, evidence based curriculum with the correction of vertebral subluxation as the primary chiropractic aim” [
3] and
“The purpose of chiropractic is to help people reach and maintain excellent health and wellbeing through the care of the spine and nerve system” [
4]
.
This has implications for patient safety and quality of care. Vitalist or subluxation trained chiropractors have been characterised by excessive X-ray usage, anti-vaccination beliefs, and poor levels of inter-professional / disciplinary communication [
5,
6].
This raises the two questions,
i.
How can these vitalistic educational practices occur?
ii.
Why are these issues not discovered and dealt with during the CCE inspections?
In our opinion, this suggests two possibilities; chiropractic accreditation standards are not addressing such issues adequately or there is inadequate monitoring and site inspection processes. Site inspection teams, appointed by the accrediting agency, is the mechanism by which program performance is assessed against prescribed standards. Such teams compile a report with the intention of identifying deficiencies and making recommendations for their rectification and continued improvement.
We have previously conducted a systematic review of these accreditation standards, and made a series of recommendations with the intention of improving their uniformity and quality [
7]. The intent of this study was to conduct a similar systematic review of the site inspection standards and processes to the same end.
Medical education is frequently ‘overseen’ by accreditation agencies, whether governmental or private. This activity rests on (among other things) the relevance of inspection, the skills and knowledge of the inspection teams, and the subsequent use made of any recommendations for improvement [
8]. Obviously, accreditation and re-accreditation surveys depend on the expertise of the people involved and are therefore at risk of becoming subjective and even invalid. Historically the reliability of inspection team surveys has been unknown and difficult to study [
9]. Nonetheless it is recognised as an important area for further attention as it is under-investigated [
10‐
12].
Research to date has identified several factors that are thought to increase the likelihood of improved outcomes of this process. These include having the processes for inspection surveys clearly outlined, standardized and consistently applied to the accreditation standards [
9], strong communication skills within an experienced team and team members should be temporary or replaceable so that it promotes allegiance to the accrediting organisation [
11]. Also the teams should undergo detailed training and mentoring [
13]. Yet another paper suggested that team members should have extensive experience in the profession, with a minimum of experience in high managerial positions (ranging from 2 to 5 years), and profession-specific certification [
8].
Intrinsic to the accreditation process of chiropractic, as performed by the various CCEs, is the site inspection team appointment, training, co-ordination, quality control and review, and implementation of the survey team’s final report. However, we could not find any previous work on the monitoring aspect of the tasks of the CCEs, nor with respect to site visitations for accreditation or re-accreditation purposes of chiropractic programs in PubMed, Scopus or Chirolndex databases.
Clearly, regardless of how good the accreditation standards are, unless the monitoring process is relevant, consistent and effective, they will not be reinforced in teaching institutions that, prefer to deviate in other directions.
In view of these problems, we wanted to see if there is an appropriate and comprehensive approach to inspecting chiropractic programs for re-accreditation by site inspection / surveys by CCEs.
Aim
The aim of this systematic audit was to investigate similarities and differences between the various CCEs inspection site team documentation and processes and compare these to known quality standards and the available evidence.
Objectives
The objectives were to:
1.
Review and compare the available site team inspection documentation from each CCE to look for similarities and differences.
2.
Review and compare a sample of CCEs site inspection team surveys / reports for commonly identified recommendations and quality improvements and determine if they are described in their respective accreditation standards.
3.
Make recommendations that would create a high-quality set of site inspection team standards and processes that is consistent with known best standards and evidence.
Results
Responses were received from 3 of the 4 CCE organisations.
The CCE-USA referred us to their website and declined to forward any further material. Information on their website related to site inspection standards and processes but did not include training or recruitment data. This CCE also declined to provide site inspection team reports, as they deemed these reports to be disclosed at the discretion of the chiropractic program (CP) only. It was also claimed that this was to protect the confidentiality of CCE members, CCE office staff and CPs, and to comply with the overarching bodies’ policy of not making accreditation activities open to the public for release.
The CCE-Canada did not respond to our request despite further correspondence.
The CCE-Australasia informed us that this material was confidential in nature and could not be reproduced or commented on in any public domain or format. Also, this CCE took the view that site inspection reports were confidential and released only at the discretion of the CP. Further that this related to the integrity of the accreditation process as it depends, in part, on the Council and the Committee maintaining confidentiality with all aspects of the process other than the reporting of procedure and decisions. We recontacted this CCE and asked them to reconsider their decision on the grounds that their overarching government organisation had a policy on research and this area of investigation was identified as a high priority. Also that this study would meet all the confidentiality and privacy requirements and was redacted and not being released to the public but to researchers. The CCE-Australasia responded “The CCE has considered your response and we re-confirm our original position as advised previously”.
The ECCE readily complied and forwarded all site inspection documentation, including their training information. This also included site inspection team reports that were, in fact, also available on their website.
This resulted in a complete and usable set of desired documents from only 1 of the 4 CCEs.
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