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Table 1 Overview of specific recommendations provided by the different stakeholders

From: The strategic role of competency based medical education in health care reform: a case report from a small scale, resource limited, Caribbean setting

1. Professional standards 2. Distribution of responsibilities 3. Accountability 4. Quality assurance and improvement
Medical specialists and the hospital institutions should both fulfill the requirements expected from good care providers. They should act in accordance with the responsibilities as defined by their respective professional standards. The medical specialist is to be held primarily accountable for the specialist care he/she provides. He/she is also accountable for the care providers who work under his responsibility. The medical specialist systematically gives account of the quality of the care he has provided in the manner agreed upon between the executive members of the medical staff and the Board of Directors. The medical specialists and the hospitals collaborate in assuring quality and improving the care provided in the hospital and also in those activities considered to be in the best interest of the patient, the hospital and/or the medical specialist.
The medical specialist is expected to provide good health care services that meet acceptable standards i.e. are safe, effective, patient centered, delivered timely and commensurate with the patient’s real needs. The medical specialist shares the responsibility for care with other care providers involved in the health care process. It is possible to set up partnerships/departments and to formulate desired professional responsibilities in regulations or contracts for employment purposes. The board of the medical staff periodically informs the Supervisory Board about the quality and safety of care via the board of directors (medical director). The medical specialist participates regularly in formal meetings (such as meetings of the group practice or department) not only within his medical specialty (such as patient hand over, difficult cases, necrology, complications), but also between medical specialties (such as patient handover, necrology, clinical pathology, x-ray, intensive care, trauma and complications).
The medical specialist abides by the professional guidelines/protocols that apply to him, and may deviate from these, if and when necessary, and documenting the reason(s) for this in the medical file. Should a specialist need to deviate from a professional guideline/protocol then the documentation should be in a (predefined) uniform format. The medical staff and the hospitals board of Directors are jointly responsible for the development of professional standards for medical specialists. The board of the medical staff and the Board of Directors receive the conclusions and recommendations from internal and external quality assurance audits from partners, department or group practice, and they receive reports of educational audits from the hospital’s central committee for educational activities In order to ensure the quality of care and education, use must be made of indicators measuring both internal and external parameters.
The medical specialist keeps her knowledge and skills up to date, for instance by attending accredited continuing professional development activities required for re-registration in the register of medical specialists of the Medical Specialist Registration Commission (MSRC) or an equivalent body in Curaçao. In accordance with the National Legislation on Health Care Institutions, the Board of Directors has the final responsibility for the integral quality of care within the health care institution and must also create the conditions to facilitate the delivery of good care. The medical specialist takes part in the periodical and systematic evaluations of his personal functioning within the hospital. External Measurement of Quality Assurance - Characterized by periodic visitations/accreditation. If such a procedure is not established in accordance with an integral “quality of care” system, it often results in expensive and bureaucratic processes with low return and relatively small improvements. In general, such a procedure only promotes compliance with minimal standards aimed at obtaining and maintaining the status of an accredited top clinical institution (for example the NIAZ accreditation) or training hospital (such as CCMS or MSRC recognition) .
The medical specialist keeps a medical file of every patient treated or examined by him in the outpatient clinic, in the hospital ward or in the short-stay clinic in a manner customary to the hospital and keeps a medical file (in a standardized manner ), that provides a good overview of the history of the disease, the diagnosis or diagnoses, the treatment plan and the current situation. The medical specialist must be aware of the limitations of his/her own capabilities and expertise, and must refer patients timely to other specialists or care providers if and when necessary. The medical specialist must report incidents in accordance with the procedures of the organization in which he/she works and provides all factual information that is considered to be necessary and in the best interest of the patient and the hospital. Internal Measurement of Quality Assurance - Characterized by continuous and reliable collection of information that can be used for feedback and improvement of quality. If well designed and organized, such a process is not expensive and yields more results for improvement.
Also, the standardization of medical records/patient files offers benefits for internal and external visitations to monitor the quality of care and the training of medical doctors and medical specialists. The medical specialist calls to account his colleagues and members of the partnership, department or group practice in cases of undesired behavior and takes steps to rectify any undesirable situation. If necessary, the medical specialist informs the board of the medical staff and/or the Board of Directors. The medical specialist immediately informs the board of the medical staff and the Board of Directors of any calamities as well as circumstances that could possibly lead to a calamity.  
Reliable registration procedures are also needed from a public health care perspective. Should there be a suspicion of possible dysfunctional behavior, then this shall be dealt with in accordance with the Dutch document on the professional code regarding potential dysfunctional medical specialists [2] or an equivalent regulation in Curaçao. Incidents, calamities, complications, errors, near misses and complaints are regularly discussed within departments, group practice or medical staff, and steps for improvement are formulated, implemented and evaluated periodically  
  At all times, it should be clear to the patient: Openness about medical errors or incidents is a priority within the hospital as well as between medical specialists and in relation to the patient.  
i. Who they or their guardians can contact;
ii. Who is responsible for the care provided to them;
iii. Who is responsible for the coordination of (their) care.
  The medical specialist who together with a colleague or colleagues and/or other care providers provides care to a patient, makes clear arrangements with those colleague(s) and/or care provider(s) about the distribution of tasks and responsibilities concerning the care for the patient. These agreements are documented in writing in the patient’s medical and/or in the nursing file, so that it is clear at all times whom the point of contact is for that patient. The patient has a right to honest and timely information about the nature and full facts of any incidents that have noticeable consequences for him/her.  
The medical specialist who, together with other care providers delivers care to a patient, makes sure that he has the relevant data available for those medical specialist(s) or care provider(s) and informs them about any details and findings that they need to be able to provide good care.
The medical specialist makes sure that the rights of patients are well protected.
The medical specialist must report about the nature and full facts of incidents that have noticeable consequences for the patient and record this in the patient’s medical file. The medical specialist must immediately report to the board of the medical staff and the Board of Directors if or when civil, criminal or disciplinary actions related to care provided has been taken against him/her.