A guide for accreditation reviews aimed at quality assurance in South African undergraduate medical education and training
Bezuidenhout, Maria Johanna
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Quality assurance is not something new to higher education, but recent years have seen an increase in the interest in the quality of education, mainly due to demands for accountability. This study was conducted to investigate the phenomenon of quality assurance in higher education with special reference to accreditation as quality assurance measure in undergraduate medical education, and to develop a guide for accreditation reviews. Quality assurance as it manifests in a number of higher education systems in different countries was studied. It was found that social and economic demands, an increase in and a changed student population have contributed to a renewed emphasis on quality, that is, effectiveness and efficiency, in higher education. Medical education could not escape the demands for quality assurance. Recent publications on medical education stress the necessity for change and innovation in medical education, and a concomitant need for measures to ensure that the education and training students receive are of a high standard.In many higher education systems accreditation is used as a quality assurance mechanism. Accreditation is defined as a process of external quality review used to scrutinise institutions and their programmes to ensure quality in the offerings and to encourage quality improvement. The process of accreditation usually entails a selfassessment by the institution (internal evaluation), followed by an external review conducted by a panel of peers with a view to verifying the findings of the internal assessment. Accreditation usually also has a dual goal, namely to ensure quality and to promote quality. In South Africa the Health Professions Council through the Sub-committee for Undergraduate Education and Training (UET) of the Medical and Dental Professions Board is the professional body responsible for quality assurance in medical education and this is brought into effect through a process of accreditation of medical education programmes. The first accreditation reviews took place in 2001, and by the end of 2004 all medical faculties/schools had been subjected to at least one accreditation review visit. The process was based on sound studies and apparently served its purpose well. As different panels comprise different members, however, there is no comparability in the accreditation reviews. Each member, it is perceived, approaches the process from his/her own frame of reference, as no fixed set of standards exists to ground the evaluations. Although panel members are experienced and experts in their disciplines, they are not necessarily experts in the field of modern medical education, and may hold disparate views on what quality in education entails. Therefore, specific standards in terms of which a quality appraisal can be done are required in an accreditation process.Involvement of the researcher in the accreditation process of the UET led to the research problem being identified, namely a lack of a review guide that might be used in the appraisal of medical education programmes and the institutions that offer them. In this study it was assumed that a guide for accreditation reviews, containing standards with rubrics and criteria to use as a measurement tool, would serve well to render the accreditation process more objective and structured, thereby contributing to ensuring quality in medical education in South Africa. Such a guide, it was presumed, would also be useful in the planning processes of medical schools/faculties, especially with a view to quality improvement as well as in the internal self-evaluation, and would contribute to better preparation for the external accreditation review. As background to the study an extensive literature review was conducted to investigate the phenomenon of quality assurance. Quality assurance in higher education perse and in medical education specifically was studied; accreditation as quality assurance mechanism and the role standards have to play in quality assurance mechanisms were attended to, and tools used in quality assurance processes were put to scrutiny. The standards that apply in various quality assurance systems in higher and medical education received special attention during this phase of the study, as these were used as point of departure when the draft guide for accreditation reviews was compiled. The accreditation process of the MDPB of the HPCSA, as implemented by the UET was studied in detail to gain a complete picture of the process as it manifests in South Africa. A qualitative research design was employed and a phenomenological descriptive and exploratory approach was followed. The methods employed for data collection included participant observation, individual interviews and a focus group interview, while a literature study provided the required grounding and background. As the researcher has been involved in the quality assurance process since its inception, participant observation and emanating field notes played an important part in the study. This was amplified with information collected from literature. A draft guide for accreditation reviews in undergraduate medical education in South Africa was compiled based on the information collected. In this guide it is proposed that medical schools/faculties in South Africa should compile a portfolio to serve as evidence of the quality of their teaching and training. The portfolio, it is recommended, should be a (mainly) computer-based document with links to appropriate sites, and should comprise two parts: (i) an overview of and background information on the school/faculty, and (ii) an indication of the extent to which the school/faculty satisfies the standards in the Standards for accreditation part of the guide, supplemented by a list of materials (links) to substantiate the response. The proposed use of the guide by medical schools/faculties and the accreditation review panels is described, and the remainder of the document consists of a set of standards for undergraduate medical education with rubrics and rating scales for use by the medical school/faculty and the accreditation panel. The rubrics are set out in three levels, namely a minimum level, higher level and highest level, requiring the evaluator to indicate for each standard the level at which the school/faculty is in compliance with the standard. It is recommended that each school/faculty in the self-evaluation rates itself in terms of the rubrics. This rating together with the completed portfolio and evidence cited is then submitted to the accreditation review panel, and each panel member rates the school/faculty/ programme individually. The individual ratings and that of the institution are used to structure the subsequent on-site visit. During the visit the panel then verifies the self-evaluation response, and brings out a joint rating of compliance with the standards, together with a report containing recommendations and comments. The draft Guide for accreditation reviews was used as research instrument in the empirical study. Individual interviews were conducted with six deans/heads of medical schools or their representatives and four former members of accreditation review panels to gauge their views and opinions on the draft guide and to gain their perspectives of the phenomenon under study. Following the individual interviews a focus group interview was conducted with seven members of the UET to collect their opinions and perspectives. The interviews were conducted in a positive spirit and the interviewees were enthusiastic about the possibility of using the proposed guide for accreditation reviews. The data collected during the interviews were analysed in terms of a data analysis spiral for use in qualitative studies. The data provided the researcher with a clear view of the respondents’ perspective of the phenomenon and their opinions on the draft guide. Based on the findings, the draft guide was adapted to incorporate recommendations made by the respondents. The findings were compared to the findings of the literature review in a literature control. In the final analysis it was found that the participants regarded the current accreditation process as unstructured and rather subjective, and supported the idea of the use of the proposed guide for accreditation reviews, as well as for planning and quality enhancement purposes in medical schools/faculties. The assumption thus could be accepted on the basis of the opinions of the participants in the study, namely that a guide for accreditation reviews would address the research problem, that is, a lack of a tool or mechanism to use in accreditation review evaluations. The use of this guide, it was found, has the potential to render accreditation reviews more structured and more objective, as panel members would no longer conduct evaluations based on their individual frames of reference or background, but on a common set of standards and criteria as set out in the rubrics. This will bring comparability to the accreditation process. The guide will also satisfy the second goal of accreditation, namely improvement of quality, as schools/faculties will be encouraged to strive for higher levels in the evaluations. It is hoped that this proposed Guide for accreditation reviews will receive attention from medical educators, planners and the accreditation body, that the information and perspectives on quality assurance and accreditation presented in the study will contribute to a better understanding of the phenomenon of quality assurance in education, and that the information and newly constructed knowledge in the study will be applied to the benefit of quality assurance in medical education in South Africa. As final outcome of the study a Guide for accreditation reviews is presented, with the recommendation that it be brought to the attention of the accreditation body for South African undergraduate medical education and training, with a view to implementation as part of the accreditation process. It is also recommended that it be considered for use as planning guideline for medical education programmes, as it has the potential to enhance innovation and improvement in medical education and to be used as benchmarking instrument.