Self-Review And Its Relation To Regulation And Accreditation In Medical Education

MED501 Introduction to Medical Education

What is self-review and how does it relate to regulation and accreditation?

1. What is self-review and how does it relate to regulation and accreditation?

Self-review can be defined as a systematic, objective,  and unbiased, as well as value based expert self assessment, which determines an action to be followed, as per certain criteria (Evans et al. 2002). Its main role is to achieve uninterrupted quality improvement of the medical education, by updating the data for any subsequent self evaluation, thereby minimizing the chances of negative accreditation decisions of the accrediting agencies (Clinch & Violato 2016).

Where does self-review fit into the accreditation process?

	Step	Purpose Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper
1.	Self-Assessment Study (SAS)- Gathering the information	The first stage in the accreditation process is the gathering of Information by a medical institution, as per the authorized national accrediting agency’s norms.  It is implemented  by the college accreditation committees of SAS and Data Collection, nominated by the College Council   (NCAMC 2016).
2.	Self-Assessment Study (SAS)-Preparation of self-review	The self-evaluation will highlight the areas of strength, while displaying the areas wanting improvements.  It enables the medical institution to document their strengths, achievements, and weaknesses, in the form of a self-evaluation report. The self-review report  reflects the institution’s mission and efficiency in maintaining program quality (NCAMC 2016).
3.	Peer review visit	The College may organize peer review visits to verify all the information contained in its self-review and to exchange their experiences and viewpoints that conform to the authorized accrediting agency (NCAMC 2016). Their report contains a review of the institution’s accomplishments and resource allocation, students, faculty, and other infrastructure (El-Khawas 2001).
4.	Submission of application	The College will submit the accreditation application, together with all documents, including the self-review report to the government authorized accrediting agency (NCAMC 2016).
5.	Accreditation committee’s field visit	After evaluating the application and the self assessment report, the accreditation agency may deploy a committee to carry out a field visit at the college, in order to assist the college authorities in addressing any existing problems, prior to the site-visit (NCAMC 2016).
6.	Site-visit for evaluation	The site –visit team, consisting of academic staff and experts,  will check and verify all the information contained in the self-review report submitted by the college. They may collect documents and conduct individual and group interviews, and also make direct observations. On the basis of these data, they will prepare the site evaluation report (NCAMC 2016).
7.	Submission of the site-visit team’s report	After preparing the report as per the guidelines, the visiting team will submit the same to the authorized accrediting agency (NCAMC 2016).
8.	The accrediting agency reviews the report of the visiting team	The accreditation agency will review the report submitted by the team that visited the site and initiate actions, accordingly (NCAMC 2016).
9.	The final decision on accreditation	Immediately after the lapse of the allowed time for submitting any objections about the decision of the team that visited the site, an accreditation decision will be formulated by the accreditation council. The decision may either be granted accreditation, or conditional accreditation, or denied accreditation (NCAMC 2016).
10.	Raising objection	The College can object the decision of the Council, if there is a conflict of interest. On receiving the appeal of the College, the Council can accept or reject the appeal after reviewing it (NCAMC 2016).

 

2. What are the common reasons for undertaking a self-review within an institution?

The self-assessment in a medical institution starts when it receives the accrediting agency’s instructions relating to the evaluation criteria of accreditation. The guidelines for self-assessment capacitate the institutions to present their problems and solutions logically and feasibly, while giving an insight on the value of their institutional culture and diversities. In the process of self evaluation, they can assess their strengths or weaknesses, as well as originating innovative ideas towards self-improvement. Self-review provides regular quality improvement in every activity of the institutions, and can envision future improvements. Such accomplishments cannot be achieved through a general submission of filled up checklists (HAC 2008).

An institution that has fulfilled a recent accreditation cycle will serve as  a model for other medical institutions, resulting in a quality improvement culture.  Since the self-assessment process is conducted by the faculty committees, their analysis and recommendations can contribute more to the efficacy of institutional effectiveness. The self-reviews can promote professional excellence of the individuals in the research environment, as well as the integrity of the institutional behaviors. The research trainees can learn science more effectively, through experience and mentoring processes. Another significant reason for self review is the need for change, without harming the institutional autonomy (IMNRC 2002).

Self-review helps policy making, innovating strategies, and procedures for quality assurance. It can enhance the systematic launching, efficient monitoring, and periodic internal review of the various study programs. A self-review within a medical education institution can display the overall student progress and their achievements, while improving the quality assurance of the teaching faculty. With a self-review, the learning resources and student services can be augmented.  Moreover, it will promote the performance of the internal information system, through  efficient coordination of data and publicity (HAC 2008).

3. How should a self-review be conducted? 

Step	Purpose
1.	Assemble the Self-Study Committee	The purpose of the Program evaluation committee is to look after the educational activity planning and evaluation, curriculum review, noncompliance assessment, and the Annual Program Evaluation. It also focuses on educational outcomes that coordinates the sub specialty programs.
2.	Data aggregation and analysis	The Self-Study conducts program assessment of all past annual evaluations, and adds the current year’s Annual Program Evaluation to it.  This is to highlight strength and weakness, and to identify the areas for improvement. The committee may also probe into other information gathered by the sponsoring institutions.
3.	Engage leaders in program discussions	This is to add context for improving the programs by generating responses to the various dimensions of educating, including future roles, practice settings, extended objectives, health policy, population health, and the like.
4.	Identify program strengths and areas for improvement	Annual Program Evaluations’ longitudinal data provide the Strengths and Areas for Improvement. It addresses all dimensions of program evaluation, put forward by the Common Program Requirements.
5.	Examine program opportunities and program threat	Self review focuses on opportunities and threats. Here, the opportunities are the elements that can contribute to the success, while threats are the negative effects. Recognizing the potential threats will support the development of contingency plans to overcome them.
6.	Aggregate the Self-Study findings	The next step is the consolidation of the collected data, that are examined in the Self-Study process. The consolidation ensures the maintaining of the program, and prioritizing the areas for improvement, showing a way how to track success. The program discussion will allow the leadership to take advantage of the opportunities to overcome the threats.
7.	Discuss with program leadership to set improvement priorities	The discussion with the stakeholders  over the findings, will enable the leadership to elicit their reflections on program improvement and prevailing challenges (Philibert & Lieh-Lai, 2014).

 

4. What special advice would you give for institutions with limited resources who wish to conduct a self-review?

In order to get accreditation, a medical education institution must have a specific vision, mission, and objectives. The institution should focus on curriculum design and evaluation, as well as manage student admission, support services, personnel, physical resources, and research, to maintain the constant quality enhancement and governance.  The first step towards achieving them is preparing a self review, by increasing awareness, evidence-campaign, effective administration, and quality education, through SWOT analysis, and keeping standards as per WFME  (NCAMC 2016).

The self- review needs to be done by the organization’s in-house people, who have expertise in coordinating the process, through engaging their colleagues in, managing interviews, scrutinizing standard and criterion, and taking decisions on the policies that require promotion.  The self assessment can be fulfilled by including the feedback from clients, management, and staff, as well as workshops and meetings within the institution (NCAMC 2016).

Include assessing evidence for all standards to demonstrate the documents, learning, awareness, evaluation, and monitoring. One can find the examples of evidence in the  Department of Human Services Standards evidence guide, for understanding whether the relevant criteria and category of evidence are met (NCAMC 2016).

This is required by the institution for examining the evidence categories in relation to the standards that identify the strengths and weakness areas. In order to process  them, it is possible to develop a rating for self-assessment, according to the criteria.  Improvements should be made applicable, as per the self-assessment rating, and the same be documented as a part of the quality improvement plan (NCAMC 2016).

A quality improvement plan (QIP) needs to be conceived, if the institution does not meet any particular criteria. Likewise, a QIP shall be generated to identify the areas for improvement to prioritize them. Additionally, on completing the self-review,  an assessment matrix needs to be prepared for giving a rating to reflect the self assessment findings (NCAMC 2016).

Reference List

Clinch, C. R., & Violato, C., 2016, Continuous Review of Accreditation Standards and Quality Improvement in a Medical Education Program – Practical Recommendations for Implementing a Program, viewed 15 April 2017, https://www.mededpublish.org/manuscripts/518/v1

Evans, A. W., McKenna, C., & Oliver, M., 2002, Self-assessment in medical practice. Journal of the Royal Society of Medicine, 95(10), 511–513, viewed 15 April 2017,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279183/

Hungarian Accreditation Committee (HAC), 2008, Self evaluation report, Hungarian Accreditation Committee External Evaluation,  viewed 15 April 2017,

https://www.mab.hu/web/doc/hac/publications/SERfinal_80306.pdf

Institute of Medicine and National Research Council (IMNRC), 2002, Chapter 6, Evaluation By Self-Assessment. Integrity in Scientific Research: Creating an Environment That Promotes Responsible Conduct, Washington, DC: The National Academies Press, viewed 15 April 2017,

https://www.nap.edu/read/10430/chapter/8#113

NCAMC, 2016, A Guide for Accreditation of Medical Colleges, IRAQ  Iraqi National Standards for Accreditation of Medical Colleges,  viewed 15 April 2017,

https://asse.edu.iq/share/guidelin%20for%20accreditation.pdf

Philibert, I., & Lieh-Lai, M. (2014). A Practical Guide to the ACGME Self- Study, Journal of Graduate Medical Education, 6(3), 612–614,  viewed 15 April 2017,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535243/