LCME Element 1.4 – Affiliation Agreements
In the relationship between a medical school and its clinical affiliates, the educational program for all medical students remains under the control of the medical school’s faculty, as specified in written affiliation agreements that define the responsibilities of each party related to the medical education program. Written agreements are necessary with clinical affiliates that are used regularly for required clinical experiences; such agreements may also be warranted with other clinical facilities that have a significant role in the clinical education program. Such agreements provide for, at a minimum the following:
- The assurance of medical student and faculty access to appropriate resources for medical student education.
- The primacy of the medical education program’s authority over academic affairs and the education/assessment of medical students.
- The role of the medical school in the appointment and assignment of faculty members with responsibility for medical student teaching.
- Specification of the responsibility for treatment and follow-up when a medical student is exposed to an infectious or environmental hazard or other occupational injury.
- The shared responsibility of the clinical affiliate and the medical school for creating and maintaining an appropriate learning environment.
Hidden Curriculum
Maintaining and growing clinical capacity for students is a universal challenge for medical schools, and many have sought partnerships with other healthcare systems to ensure the delivery of core clinical curricula. Element 1.4 recognizes the need for medical schools to expand beyond its home health system while ensuring that student learning, support, and safety are not compromised. The core of this element is to execute legal documentation that preserves a medical school’s central authority and management when it partners with a health system/clinical site. An affiliation agreement or memorandum of understanding (MOU) codifies that a medical school retains control over the curriculum, grants faculty appointments, reserves the right to remove students if the learning environment is not optimal, and bears ultimate responsibility for safety protocols.
The LCME has always required affiliation agreements with each clinical site where students complete required in-patient experiences. More recently, it also requires an affiliation agreement with each hospital within the university’s own health system, as well as MOUs with ambulatory sites where students complete a significant portion of the core clinical curriculum. While the LCME does not require an affiliation agreement for every site where students complete selectives/electives, doing so may represent a best practice from a legal perspective.
We are all aware of the interconnectedness of the elements. In fact, Element 1.4 is a reflection of other elements, such as Elements 3.5 (learning environment), 3.6 (student mistreatment), 4.3 (faculty appointments), 5.6 (clinical instructional facilities/information resources), 5.11 (study/lounge/storage space/call rooms), 8.1 (curricular management), 9.3 (clinical supervision), and 12.8 (student exposure). As such, administrators must remain vigilant of these interdependencies to ensure full alignment. For example, the LCME now recommends that faculty appointment letters mirror language found in affiliation agreements regarding a school’s primacy of the medical education program.
Best Practices
Affiliation agreements and MOUs must explicitly spell out the five bulleted points listed in the element. The AAMC offers a template, which the LCME endorses, that captures these bulleted items. A school should strongly consider using the template and ensure that legal teams do not amend it in a way that changes the intention of these aforementioned key points. However, it is important to carefully review the template as changes in LCME standards may not be immediately reflected in the template.
The DCI requires schools to submit each and every affiliation agreement for clinical teaching sites where students complete the inpatient portions of required clerkships as well as the MOU template used for ambulatory sites. As such, medical school must maintain a well-organized, central repository of these documents that affords access to a team of appropriate administrators. There is nothing more frustrating than being unable to locate an affiliation agreement that already required organizational resources to complete.
Do not wait until the last minute to complete affiliation agreements as these documents must make multiple stops within the medical school and partner health system for legal reviews and signatures. If your school has distributed campuses, then a tripartite affiliation agreement between the medical school, branch campus, and health system may be necessary; and this process demands even more time.
Continuous Quality Improvement
Administrators must pay extra attention to any changes in the elements that could affect the language and accuracy of an affiliation agreement or MOU. While it is not practical to renew affiliation agreements every year, and many agreements are “evergreen,” the reality is that the duration of the agreements should be sufficiently short to require a full review to capture changes or issues. We strongly suggest you renew at least every 5 years. In addition, as part of the CQI process, coursesF and clerkship should be required to submit the names of all sites being used for clinical experiences in order to verify affiliation agreements and MOUs are in place. It is tempting to reduce Element 1.4 to a bureaucratic hurdle or check box. However, a school must develop a plan to communicate the intent of the agreement to participating faculty and staff who may never lay eyes on the document or be aware of its existence.
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