Respiratory diseases place considerable burden on society and are among the leading causes of mortality worldwide. Within the European Union, these diseases account for 17% of male and 10% of female deaths . In monetary terms, the European Lung Foundation (ELF)/European Respiratory Society (ERS) estimates economic burden at approximately €102 billion or €118 per capita . It is concluded that failure to diagnose, treat or manage respiratory diseases, results not only in higher treatment costs, but also impacts upon quality of life and well-being for the patient. Subspecialty training and career development of the young respiratory specialist has been identified as a fundamental aspect of delivering quality care and strengthening respiratory medicine. Moreover, as adult respiratory specialists increasingly seek opportunities abroad, the harmonisation of standards to train specialists in respiratory medicine across Europe becomes crucial.
Working towards consistent criteria for respiratory medicine, ERS, since 1990, continues to produce consensus statements and clinical practice guidelines on issues related to this field of medicine. In 2005, as part of the mission to advance the practice of the specialty, the HERMES (Harmonised Education in Respiratory Medicine for European Specialists) project was born to provide a shared framework for the training and certification of adult respiratory specialists across countries. Justification for the project grew from results of a number of surveys carried out by ERS  confirming the stark differences of medical educational programmes and lack of homogeneity of syllabus, curriculum and exit criteria for training of adult respiratory specialists.
Within the HERMES model, a process of establishing consensus standards for training largely follows four key phases (fig. 1) with the goal of developing collective documentation and activities. To date, three of the phases have been published and delivered by the HERMES Task Force, and are available in the international public domain for use as a basis for training and assessment.
1. European syllabus
The HERMES syllabus for adult respiratory medicine was published by the Task Force in 2006  producing a consensus-based document outlining the core skills and competencies that a practicing specialist in the field should possess.
2. European curriculum
The syllabus document was further developed to create the HERMES Curriculum, published in 2008 , and essentially considered the educational processes required to ensure adequate teaching, learning and assessment of the listed syllabus knowledge items.
3. European examination
The knowledge-based HERMES Examination originates from the HERMES syllabus, covering 90 multiple-choice questions over 3 h. Individuals have the opportunity for three different options should they wish to sit the examination: a) in-training assessment for those currently within the speciality training period; b) self-assessment open to all medical practitioners who would like to benchmark themselves and; c) European Diploma for those who are nationally accredited adult respiratory specialists.
To support the HERMES initiative, a number of educational resources have been developed in conjunction with the HERMES standards and certification documents (fig. 2). The ERS Handbook of Respiratory Medicine  is the most recent, yielding great success. The textbook was launched at the ERS Annual Congress Barcelona 2010 and presents an overview of each of the modules listed within the HERMES syllabus. The HERMES website  and the ERS Handbook website further extend the pool of learning resources offering guidelines and CME-accredited questions, strengthening the HERMES initiative.
Today, the HERMES documents and examination are recognised as a mark of European excellence across national societies. The HERMES examination was afforded legal recognition as the official part I exit examination in adult respiratory medicine for Swiss trainees. The Netherlands participated in an annual in-training assessment for Dutch respiratory medicine trainees in October 8, 2010 with the possibility of adopting the exam either as a yearly in-training examination or exit examination. Spain encourage their trainees to sit the examination offering to sponsor anyone who wishes to take part, and Austria have also endorsed the HERMES exam as legally equivalent to their official national exit examination, a raising status which is allowing the HERMES initiative value, respect and legal recognition within Europe. In the concluding phase of the adult HERMES initiative, the ERS Criteria for Accreditation document represents the final efforts of the Adult HERMES Task Force to attain the overarching goal of harmonising training and ensure continued and sustained quality improvement of training for the subspecialty of adult respiratory medicine.
Accreditation is typically defined as a voluntary process whereby a professional association or society assesses the healthcare organisation to establish if predetermined criteria (or standards) have been met . The process of accreditation is to ensure continuous assurance of healthcare for patients and implementation of recommended minimum standards. Historically, accreditation concentrated on safe and effective care within the familiar focus of the structure of the hospital and determining standards for the physical make-up and equipment for example. Since the birth of the Joint Commission in 1910, the accreditation process has evolved to include a variety of initiatives from “medication management and use” to “information management” and to include processes and outcomes in accreditation practices .
In 1993, the European Union of Medical Specialists (UEMS) published the Charter on Training of Medical Specialists in the European Community, directive 93/16/EEC of 5 April 1993 [10, 11], to mutually recognise basic and specialist medical qualifications across European countries in an effort to open the European job market for specialists practising their speciality. The intended purpose of this initiative has failed to echo the reality that movement across international boundaries continues to be difficult for practicing specialists .
Within the scope of the HERMES initiative, employing standards for education and training of the trainee is essential to practice high-quality adult respiratory medicine and improve mobility across countries. In order to lead HERMES towards this end goal, each phase intends to cover key criteria to standardise training and educational activities. The Task Force recognised that in order to ensure all facets of the educational continuum are covered, a published document incorporating quality measures is necessary. This document should facilitate assessment and confirm that those carrying out training do so with appropriate knowledge and authority. Consequently, the Task Force presents the document on ERS Criteria for Accreditation, representing the consensus-based standards and measurable criteria required to accredit training centre networks within Europe.
Utilising a number of specific and individual processes, in June 2009, the Task Force began the assignment of developing the ERS Criteria for Accreditation document. Accreditation is dependent upon a robust structure for assessment and success demands a simple, easy-to-observe regime to allow for implementation. The first process challenged the Task Force to find a straightforward model which could be adapted to incorporate European consensus-based standards. A skeleton structure, utilising a number of reference documents [13–17], was presented to the Task Force in June 2009, and development of the document began.
In line with stipulations of the project, the Task Force recognised a need to include indicative numbers of procedures which the training centre has to perform yearly to ensure the trainees’ adequate exposure. The growth of the ERS Criteria for Accreditation document was thus dependent upon the wider expertise of respiratory medicine practitioners including trainees, and sought feedback from those working within educational and clinical supervisory roles, as well as appealing to national delegates across Europe. The second process employed an online survey tool to reach this wider audience and collect expert opinions on the indicative number of procedures to be performed by the training centre annually to ensure trainees’ adequate exposure. Although the aspirations of the Task Force to retrieve usable results were immersed in doubt, (due to inconclusive results collated in a preliminary survey of the same nature) a clear trend in responses emerged from this particular survey. In December 2010, the survey was distributed and findings from the survey were deliberated among the Task Force for each procedure and successfully employed and included within the document during the March 2010 Task Force meeting.
Between September 2009 and March 2010, the Task Force discussed and considered criteria to be included in each of the eight sections of the document (fig. 3) utilising a number of reference documents [4, 5, 13–23]. In March 2010, the remaining sections were finalised and the ERS Criteria for Accreditation document was created.
With the intention of providing criteria for training institutions to follow, the ERS Criteria for Accreditation document was composed and structured in eight specific sections (fig. 4). Each of the developed sections constitute the minimum recommended criteria that training centre networks should aim to incorporate for the medical training of adult respiratory specialists. The objective of this phase sought to generate an inclusive, flexible and simple model to ensure participation and allow enough flexibility to adopt criteria at national levels. For each meeting, the Task Force concentrated on addressing each section with care and consideration, utilising specifications within the HERMES syllabus and curriculum. In March 2010, a comprehensive document including the guidelines and criteria for European accreditation of training centre networks was completed.
If we consider the successful deployment of standardised processes within the sphere of medical training, the process of accreditation is most certainly one of the most challenging to implement. Success of this phase is dependent on a rigorous structure applicable to hospital training centres. The Task Force were met with a number of challenges in developing a simple, effective and appropriate document for accreditation.
To effectively achieve success in this project, phase specific development areas were considered necessary: 1) documented minimum criteria; 2) requirements for the accreditation process; and 3) supporting documentation to determine if prerequisites are met, including questionnaires for example. The Criteria for Accreditation document marks the completion of this first step. The next issue for address is to determine a structure for the accreditation process. In fact, the accreditation process was considered during the development of the ERS Criteria for Accreditation document, as the final section of the document. Five specific criteria will need to be addressed within this section, including the accrediting body, self-reporting, the visitation programme, certification of accreditation and costs. This section was produced on the well-established accreditation practice of site visitation [14, 23, 24]. Within this section, the whole process of accreditation was considered utilising methods, including questionnaires, log-books and interviews. Visitation of the training centre would be granted pertaining to criteria set out within the questionnaires. It is intended that this section will be published on the ERS website  as soon as it is finalised.
The difficulties surrounding implementation of a voluntary process of accreditation were further researched by the Educational Activities department of ERS, whereby a benchmark analysis was conducted to assess the resources required to support such a structure. The results of the analysis only served to confirm impending complexities especially highlighting the costs required and potential exclusion of those training centres unable to afford ERS accreditation. A decision was taken by the Task Force that initiatives, including potential collaboration with national and European societies as well as the possibility of offering financial support, would be further investigated.
Customs surrounding the medical ‘teaching hospital’ and indeed the practices of medicine in more generic terms is a discipline deeply rooted in tradition, culture and boundaries created by a long-standing history of social practices. To adopt uniform standards and new expectations of educational procedures is more than just a change in routine practice; rather, it is the realisation of required changes of attitudes and behaviours within that institution . The reality today resonates a current disconnect in training of adult respiratory specialists across Europe. Consequently, teaching institutions taking part in ERS accreditation will not all encounter the same challenges. While some educational training programmes of respiratory medicine will have little or no modifications to reach European certification, others will need to consider a framework for educational redesign.
With the great intention of the HERMES Task Force to open accreditation to all training centre networks of adult respiratory medicine, irrespective of geographical location, emphasis of certification focuses on development, education and quality assurance. Sustained quality improvement of training in adult respiratory medicine is the end goal.
Education is undoubtedly one of the primary mechanisms to ensure a better future for the practice of specialist medicine and, more specifically, the practice of adult respiratory medicine. At the centre of this focus, the adult HERMES initiative attempts to establish coherence between national standards and broader European aspirations of harmonisation. It is intended that training centres in adult respiratory medicine use the ERS Criteria for Accreditation document as a blueprint for best practice for structure and training, and recognise that the potential gains in terms of patient care are real and significant. Building on the success afforded to the activities and documents developed within the first three project phases, with great confidence, the Task Force moves one step closer towards their intended mission: to Harmonise Education and training in Respiratory Medicine for European Specialists!
The following experts participated as national respondents: Altraja. A (Estonia), Chovan.L (Slovakia), Costello. R (Ireland), Danila. E (Lithuania), Delaunois. L (Belgium), Gaga. M (Greece), Hansson. L (Sweden), Hesse. P (Austria), Ivanov. Y (Bulgaria), Joos. L (Switzerland), Keser. D (Bosnia-Herzegovina), Kinnula. V (Finland), Kocabas. A (Turkey), Kosnik. M (Slovenia), Kozielski. J (Poland), Krams. A (Latvia), Laursen. L (Denmark), Lorenz. J (Germany), Mihaltan. F (Romania), Petrovic. V (Serbia & Montenegro), Rakusic. N (Croatia), Rodriguez De Castro. F (Spain), Rosin. R (Sweden), Smeenk. F (Netherlands), Sotto-Mayor De Azevedo e Castro. R (Portugal), Tamm. M (Switzerland), Tollali. T (Norway), Zatloukal. P (Czech Republic).
For further detailed information on accreditation of centres, see the PDF version of this article.
- ©ERS 2010