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Accreditation in Medical Education: Concepts and Practice Mohamed Elhassan Abdalla

2012


Accreditation in Medical Education: Concepts and Practice

Mohamed Elhassan Abdalla, MB.BS, MHPE,PhD Medical Education Specialist, Medical Education Unit, Faculty of Medicine, Jazan University, KSA Former Medical Education Specialist, Education Development and Research Center, Faculty of Medicine, University of Gezira, Sudan Chairman of Group on Social Accountability (GOSA), Association of Medical Education in Eastern Mediterranean (AMEEMR)

Forward by: Prof. Mohamed Awadalla Salih Head Medical Education Unit, Faculty of MedicineJazan University, KSA.

Accreditation in Medical Education: Concepts and Practice by Mohamed Elhassan Abdalla is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

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Table of Contents Topic 1- Dedication

Page 3

2- Acknowledgments

4

3- Executive Summary

5

4- Forward

6

5- Accreditation: History, Definition, Rationale and Criteria

7

5-1 Historical Background 5-2 Definitions of Concept 5-3 Purpose/Rationale of Accreditation 5-4 Criteria of Good Accreditation System 6- Standards in Accreditation

8 9 10 12 13

6-1 Accreditation Standards

14

6-2 New Aspects for Accreditation Standards

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6-3 Effectiveness of Accreditation Standards

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7- Accreditation Process

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8- References

28

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Dedication

To My Parents: Who

gave

me

To my family: the

Rasha, Ahmed &Rudaina

means to learn.

who helped me to relax during the preparation of this work

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Acknowledgement I would like to express my sincere thanks and appreciation to all the people who helped me finish this book. My special thanks and appreciation go to Dr. Charles Boelen, Prof. Bashir Hamad and Prof. Osman Khalafalla, who provided their valuable time, experience and resources.

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Executive Summary The aim of this book is to spread basic knowledge about accreditation among medical school’s staff. The first section of the book summarises the history of accreditation since 1787 in post-secondary education and in medical education. The first section will cover multiple definitions of accreditation and the rationale for accreditation. The final part of the first section mentions the criteria for a good accreditation system. The second section includes a description of developments in the current accreditation standards in the field of medical education. The final section describes the process of accreditation with more emphasis on the self-evaluation step.

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Forward The concepts and practices of accreditation in medical education emerged with the realization of the community that medical schools should meet the health needs of the community and should be accountable for the quality of their graduates. The impetuous to the adoption of medical schools accreditation followed Abraham Flexner report in 1910. In his lucid and clear style, Dr. Mohamed Elhassan takes you from the interesting history to the concepts, the practice and the standards of accreditation in medical education today. In his concise book, he admirably succeeded in his goal to disseminate basic knowledge on accreditation among medical school’s staff for whom the book is primarily written. As such it is a must read for them to study before embarking on implementing or supporting accreditation activities.

Prof. Mohamed Awadalla Salih, DGO, MHPE Head Medical Education Unit, Faculty of Medicine- Jazan University, KSA. October 2012

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Accreditation: History, Definition, Rationale and Criteria

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Historical Background: Accreditation is one of the processes of quality assurance in education. Historically, the first attempts of accreditation in post-secondary education began in the USA in 1787. The University of the State of New York was assigned to visit each college in the state to review its work, register its curriculum and report to the legislature. Other states adopted similar processes. In 1847, the American Medical Association started to look into the curricula of medical schools in the USA, where many poor medical degrees existed (Harcleroad 1980). Between 1876 and 1903, representatives of medical colleges in the USA developed a register for medical colleges that met certain agreed upon standards (El-Khawas 2001). In 1905, the American Medical Association established its council on medical education, which produced a ten category system for rating medical schools. The first list of medical schools accepted by the association was published in 1907 (El-Khawas 2001). Throughout the nineteenth century, the accreditation movement developed through regional and professional associations in the USA until the process of accreditation in medical schools was assigned to the Liaison Committee of Medical Education (LCME) (Harcleroad 1980). Among these landmarks of accreditation, the most well-known milestone in seeking quality assurance and compliance with medical education standards was the work completed by Abraham Flexner for the Carnegie Foundation for the Advancement in Teaching. His work led to the production of Flexner's Report in 1910, which is considered a major turning point in medical education. The report described a need for

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improvement of the education systems in medical schools and a method to assess the quality of these institutions (Flexner 1910; Boelen 2002). Flexner visited the 155 medical schools that existed at that time in the USA and Canada and examined their standards. Among his suggestions, he claimed that medical schools should be a part of universities. He stated that the teaching of basic science is important to the study of medicine, and appropriate resources should be made available for teaching and learning. This report led to the reduction in the number of medical schools from 155 to 31 (Flexner 1910). In the last two decades, the need for accreditation in medical education rose in response to changes in medical practice and health care delivery systems. Other justifications for establishing standards must also be highlighted, including globalisation and the cross-border movement of the health profession (Schwarz 2000; Lilley and Harden 2003; Karle 2006; Karle 2007; vanZanten, Norcini et al. 2008). Today, the accreditation process has been implemented in many countries throughout the world (Davis and Ringsted 2006). Ninety-two countries are registered with the Foundation for Advancement of International Medical Education and Research (FAIMER) Directory of Organizations that Recognize/Accredit Medical Schools (DORA) (FAIMER 2009).

Definitions of Concept The word accreditation originates from the Latin word credo, which means trust (list 2007).In the Oxford Advanced Learner's Dictionary; accreditation is the official approval that is given by an organisation stating that a subject or thing has achieved a

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required standard. In medical education terminology, accreditation has numerous definitions. The World Health Organization (WHO) defines accreditation as "a voluntary peer-review process designed to test the educational quality of new and established medical programmes"(WHO 2005). The International Institute of Medical Education defines accreditation as "a selfregulatory process by which governmental, non-governmental, voluntary associations or other statutory bodies grant formal recognition to educational programs or institutions that meet stated criteria of educational quality. Educational programs or institutions are measured against certain standards by a review of written information, self-studies, site visits to the educational program, and thoughtful consideration of the findings by a review committee “(Wojtczak 2002). In a publication of the (LCME), accreditation is defined as "a process of quality assurance in postsecondary education that determines whether an institution or program meets established standards for function, structure, and performance. The accreditation process also fosters institutional and program improvement" (LCME 2008).All of these definitions indicate that accreditation is a process that aims to ensure quality in medical education.

Purpose/Rationale of Accreditation The ultimate goal of accreditation is to improve the health status of communities, and it is one way to improve the outcomes of medical schools. The process of either voluntary or mandatory accreditation aims to ensure the compliance of medical schools with preestablished standards in order to satisfy the consumers of the educational process. This

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process aims to achieve this compliance by producing competent graduates to ensure a high level of institutional function and to improve public confidence in medical schools (Ezekiel and Linda 1996; George 1999; van Niekerk 1999;WHO2005; Cueto, Burch et al. 2006; vanZanten, Norcini et al. 2008; FAIMER 2009). Accreditation aims to adjust medical education programmes to the changing conditions in the health care delivery systems and to produce doctors who can serve societies in accordance to their health needs and expectations. Thus, it is expected that accreditation standards will foster the medical programmes that prepare graduates to deal with new knowledge and become lifelong learners(WHO 2005).By achieving the above aims, the accreditation process plays an important role in serving the interest of the public by increasing trust in educational institutions and the doctors they graduate. Accreditation is not an end in itself; rather, it must be considered a risk reduction strategy that attempts to diagnose problems and improve the educational system. The long-term purpose of accreditation is to improve the health status of the population (WHO 2005). In summary, the accreditation process has the following goals (Maccarrick, Kelly et al. 2010; van Zanten, McKinley et al. 2012): 

Ensure quality of the educational programmes

Encourage institutional improvements

Increase public and stakeholder's trust in medical schools

Foster international recognition of medical schools

Provide a basis for comparison between programmes and graduates 11


Facilitate the movement and mobility of doctors across the boarders

Criteria of good accreditation system For the accreditation system to remain effective and work as a safeguard for the society and the profession, the following criteria should be ensured (WHO 2005; Karle 2006; CHEA 2007; Lindgren and Karle 2011): 

Base the process on pre-determined standards

Possess the legal status and instruments to implement decisions

Engage the institution’s leadership

Remain independent and transparent

Represent all stakeholders: such as the public, governments, licensing bodies, teaching staff

Gain acceptance from stakeholders: such as the public, governments, licensing bodies, teaching staff

Have a clear agreed upon process based on the self-evaluation and the site visit

Fair selection and good training of the evaluation teams

Adequate human and financial resources

Periodic evaluations and reviews

Publication of the results to the public and stakeholders

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Standards in Accreditation

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Accreditation Standards Standards are referred to as the criteria, or yardstick, by which decisions and judgments can be made (Schwarz 2000). The use of standards in accreditation has developed overtime. In the early 1900s, the accreditation agencies were using a limited number of standards, generally relied on the available information and were mainly quantitative. In the1920s, the main standards used were concerned with the resources available to deliver the educational programme (El-Khawas 2001).Since that time, the construction of standards improved to include other aspects of institutional functions, such as research and service, in addition to addressing the students and the institution outcomes. Today, many national and international initiatives check for quality assurance in medical education by developing and applying standards (WFME 2007). The functions of the standards are to direct the design of educational programmes, lead programme evaluations, assess consistency among programmes and help students understand what is required of them(Schwarz 2000; Leinster 2003). The standards are also set to ensure that academic institutions have adequate resources to support their educational programmes (El-Khawas 2001).Standards may serve as the only way to bring all stakeholders of an individual medical school together by creating an understanding of the values on which the education programme is based, the curriculum content, the strategies of teaching and learning, and the selection of students (Lilley and Harden 2003). Recent advances in the establishment of standards for the accreditation of medical schools include the work led by the World Federation for Medical Education (WFME) in collaboration with the WHO, which aims to provide a general quality assurance

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instrument for medical education to be used worldwide on a voluntary basis (WHO 2001). This work resulted in the publication of the document "Basic Medical Education WFME Global Standards for Quality Improvement" in 2003(WFME 2003). These global standards are intended to be used primarily as a tool for the development of medical programmes and to facilitate the accreditation and recognition of medical schools on an international level (Karle 2008) while maintaining a focus on the issue of addressing national problems and challenges (Karle 2007). The WFME standards do not call for unifying all medical education programmes; rather, these standards recommend respect and consideration for the variation in medical education among countries due to cultural factors, socio-economic factors, health disease spectrums, and health care delivery systems (WFME 2000). The WFME standards for basic medical education include nine areas with a total of 36 sub-areas (Lilley and Harden 2003; WFME 2003). The sub-areas are defined as specific aspects of an area that correspond to performance indicators, and each sub-area has two levels. The basic standards are expressed by "must", which indicates that the standards must be met by every medical school. In contrast, the quality development standards use the word "should" and thus reflect desired standards that will vary according to the stage of development of each medical school. The WFME asks countries and regions to adopt the standards in accordance with their own circumstances and systems. Accordingly, many regions and countries have adopted the areas suggested by the WFME in their accreditation systems, with some modifications in the sub-areas (vanZanten, Norcini et al. 2008).The WHO Regions for the Western Pacific (WHO 2001), the Gulf Countries Council, Central Asian

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Republics(Hamdy), Sudan(Abdalla 2008; Sukkar 2008), Egypt, Iran(WHO 2005), China, Korea, the Philippines, Vietnam and Malaysia(Lilley and Harden 2003; Lim 2008; vanZanten, Norcini et al. 2008) are among the regions and countries that have adopted the WFME standards. The Thematic Network on Medical Education in Europe has adapted the WFME standards to Europe by incorporating some European specifications into the standards. The standards in Europe were also revised to ensure that new quality assurance measures were included and implemented as basic procedures (WFME 2007). Many other countries have developed their own standards and processes for accreditation. For example, the Liaison Committee on Medical Education (LCME), established in 1942, is the body responsible for the accreditation of medical schools in the United States (WHO 2005). LCME has issued the standards for the accreditation of medical education programmes and has led to improvements in the MD degree. These standards are published in a document titled "Functions and Structure of a Medical School"(LCME 2008; vanZanten, Norcini et al. 2008).The standards of the LCME are also expressed using the words "must" and "should" to reflect the same meanings as the WFME standards. Five areas and 17 sub-areas are considered in the LCME standards. In the Caribbean, the LCME standards were combined with the General Medical Council-United Kingdom (GMC) standards in addition to other local standards to produce the "Standards for the Accreditation of Medical Schools in the CARICOM Community" in 2007 (CAAM 2007). The accrediting body in the Caribbean is called the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP), and has established the same six areas of accreditation as in the

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LCME standards. The Australian Medical Council (AMC) is responsible for the accreditation of medical schools in both Australia and New Zealand (AMC 2002; vanZanten, Norcini et al. 2008).The AMC standards are divided into eight areas that are divided into sub-areas with standards under each sub-area. In a document titled "Tomorrow's doctor"(GMC 2003), the General Medical Council (GMC) in the United Kingdom presented the standards that must be met by medical schools in the UK when designing curricula and assessment schemes. The GMC verifies compliance with these standards by conducting formal visits to schools. The GMC has initiated another programme that is known as Quality Assurance of Basic Medical Education (QABME) with the following goals (BJ 2004; GMC 2008) : 

Ensure that medical schools meet the outcomes in Tomorrow's Doctors

Identify examples of innovation and good practice

Identify concerns and assist in resolving them

Identify changes that schools may need to make in order to comply with doctors and create a timetable for their implementation

Promote equality and diversity in medical education

Similar to other countries, in Taiwan (as an example from Asia), the accreditation of medical schools is the responsibility of the Taiwan Medical Accreditation Council (TMAC 2009).The Council establishes criteria for medical schools to encourage the graduation of competent doctors who are life-long learners and to assist medical schools in establishing development focuses according to the standards.

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The various accreditation processes and standards throughout the world share many common areas and standards that aim to improve the quality of medical education. The following table compares the areas in the above-mentioned accreditation standards.

Table (1): Areas of accreditation standards WFME Standards Mission Objectives

and

Educational Programme Assessment Students

LCME Standards Institutional Settings Medical Students

of

Students

Educational Programme Faculty

Academic Staff/Faculty

Educational Resources

Educational Resources

Internship

Programme Evaluation Governance and Administration Continuous Renewal

AMC Standards

Tomorrow's Doctor

The Context of the Medical School

Curricular Outcomes

The Outcomes of the Medical Course The Medical Curriculum The Curriculum: Teaching and Learning The Curriculum: Assessment of Student Learning The Curriculum: Monitoring and Evaluation

Curricular Content, Structure and Delivery Assessing Student Performance and Competence Student Health and Conduct

Taiwan Medical Council Administration Branch Schools The Teaching Process Design and Implementation of the curriculum Contents Curriculum

of

the

Evaluation of Student Academic Performance Student Recruitment and Academic Counselling Utilisation of Teaching Resources Funding

Implementing the Curriculum: Students

General Facilities

Implementing the Curriculum: Educational Resources

The Library

Teaching Faculty

Resources education

for

clinical

New Aspects for Accreditation Standards As medical doctors exist for the good of others and the welfare of the society, as stated by Lindgren and Karle (Lindgren and Karle 2011), coupled with the notion of the movements of Outcome Based Education and The Social Accountability, a need for 18


change in the accreditation standards is very important, the focus on the process standards (standards which concentrate on the makeup of the programme) partially contradicts these movements which concentrates on the outcome of the education process and not on the process itself (Boelen and Heck 1995; Albanese, Mejicano et al. 2008). Concentration on the process standards puts too much emphasis on fragments of information that may be meaningless to the outcome expected from the programme; for example, the presence of adequate classrooms or an extensive library with access to thousands of journals does not guarantee that graduates will be of high quality. Another drawback is that the use of such standards does not allow for obvious differences between medical schools' missions, objectives, strategies and expected outcomes (El-Khawas 2001). The accreditation system can be a powerful tool for change (Boelen and Woollard 2009) and can lead schools to consider the impact of their educational programmes on the societies they serve rather than the process of delivering these programmes (Boelen 1999). Thus, it is recommended that social accountability of medical schools be addressed in all accreditation standards and processes (Lindgren and Karle 2011). To achieve the above movements the accreditation standards should encourage medical schools to: 

Build an alignment between the school's mandate and its commitment to addressing the community’s high-priority health concerns (Boelen and Boyer 2001).



Necessitate institutionalised relations among the health system, the community and the other stakeholders. 19


Address the process, the content and the outcomes of the curriculum with appropriate weight.

Consider the relevance of the programme to the community’s health needs as well as the quality, equity and cost-effectiveness of the programme (Gastel 1999; GCSA 2010). Overall, the standards aim to generate a socially accountable programme that can produce a practitioner who can deliver high-quality, relevant, and cost-effective services with equity to the community (Boelen, Jaques et al. 1992; Boelen and Heck 1995; Aretz 2011).

Provide and use the available educational resources effectively.

Draw a clear student selection and recruitment policy with a rule for selecting students from underserved areas (GCSA 2010).

Ensure adoption of assessment systems and policies to regularly monitor the students’ performance (GCSA 2010). This system must produce professional graduates who are aware of their moral obligation to society and are able to translate the social mission and objectives of the school into reality(Canada 2001).

Hire qualified staff members who are able to deliver high-quality instruction, who are recruited according to the schools’ plans, and who help to achieve the schools’ missions and objectives. The standards should encourage the creation of recruitment policies and a promotion system for the staff that demonstrate their commitment to and support for the social mission of the medical school (Woollard 2006).

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Periodically monitor institution effectiveness and develop a process to increase institution effectiveness (GCSA 2010). The quality should balance the outcomes, content and process of the programme (Lindgren and Karle 2011).

Actively provide health services in accordance with the community’s health needs, as indicated by the WHO definition of the social accountability of medical schools (Boelen and Heck 1995). This area should emphasise that the creativity of medical education can address the other functions of medical schools instead of concentrating only on the curriculum (Boelen 1999; Boelen and Woollard 2009).

Promote research that is relevant to the community’s health needs (Boelen and Heck 1995; Rourke 2006).

Set their graduate profiles according to their missions. Follow up on their graduates’ progress and obtain feedback about the graduates’ performance and the needs of the employers and the community.

Continue renewal and development by considering the community’s changing health needs. Effectiveness of the Accreditation Standards The accreditation standards should be simple, clear and obvious, use common

language and have only one meaning. The desirable outcome of each standard should be clear and measurable (Kassebaum, Cutler et al. 1998). The use of the annotations and clarifications when setting standards for accreditation, and giving guidelines for data collection for each standard, will unify understanding and hence help increase the usability and validity of the standards. The guidelines and annotations are found in almost 21


all of the accreditation standards around the world, but no study in the available literature has yet supported or contradicted the above assumption. An assessment rubric is needed although they are not used widely in the accrediting process of medical schools. A rubric would be used by the different accreditation visiting teams to generate consistent judgments regarding the compliance of the medical schools with the standards. The rubric will lead to a common and uniform interpretation of a school’s performance with respect to the standards, as a rubric presents a continuum of performance levels (Bezuidenhout 2005)that differ depending on the degree to which the standards are satisfied. One of the benefits of using a rubric is that it could lead medical schools and accrediting bodies to track a school’s progress in developing higher degree of compliance with the standards (Simmon and ForgetteGiroux 2001).

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Accreditation Process

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The application of accreditation differs from country to country; it is voluntary in some countries and mandatory in others. Whether voluntary or mandatory, the established accreditation process is composed of the following three stages (AMC 2002; Cueto, Burch et al. 2006; LCME 2008); Self-Evaluation, Site Visit and Accreditation decision. Below is a description of each stage. The self-evaluation is performed by a school itself, and the purpose of this evaluation is to analyse the school situation in relation to the pre-determined standards of accreditation. The self-evaluation is the most important step in the process; it aims to conduct self-analysis of the current situation in the medical school against the accreditation standards and against its mission and objectives to elicit the areas of strength and the areas which need improvement, before the accreditation visit. The first use of the self-study in accreditation was in the 1950s (El-Khawas 2001). This stage is designed to assist schools in recognising their strengths and weaknesses prior to accreditation visits. These evaluations are typically performed using a pre-designed format with either questions to be answered or statements that require responses. This stage concludes with the production of the self-evaluation report, which emphasises the strengths and weaknesses in a school and should be supported by as much evidence as possible. After the school reaches agreement on the report, it is sent to the accreditation committee which will discuss the report and may request further clarifications and more information, as the report will be the basis for the site visit.

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The self-evaluation should have the full support and engagement of the medical school leadership (CHEA 2007) together with all staff and students in the school (Maccarrick, Kelly et al. 2010). The medical school's leader should advocate for the process of self-evaluation and ideally play an active role in one or more of the steps in the evaluation. This will ensure other’s participation as well (CHEA 2007).Preparation for the selfevaluation is important, as it is a demanding process. Extra effort is needed from the staff that will require access to appropriate equipment. Self-evaluation should be considered as a step for development and, more importantly, viewed as a partnership between the medical schools and the accrediting body (CHEA 2007). The common practice in conducting the self-evaluation is to create multiple working groups under the supervision of a team of experts from within the school who complete the evaluation. Each group works on one standard, but a high level of communication and coordination to share the data and evidence between the groups is needed to eliminate any unwanted duplication of work. This coordination is the responsibility of the higher team of supervision. An effective way to facilitate the self-evaluation is to make use of the existing committees in the school when assigning groups. For example, if there is a student assessment committee, it can take the responsibility of the assessment standard, and a community service committee can work on the standard related to the school’s role in the community.

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The use of a newsletter or a website to disseminate information to the staff and students about the self-evaluation will ensure a high level of involvement and increase the sense of ownership (Maccarrick, Kelly et al. 2010). The outcome of the self-evaluation process is the report on which the rest of the accreditation process will be based. The purpose of the report is to provide written documentation of the school’s strengths, achievements and weaknesses reflecting the programme quality institutional effectiveness (ACCJC/WASC 2011). The report should not be just descriptive, rather it should be analytical and forward-looking, and one of the characteristics of this report is that it should contain a quality improvement plan. The report must refer to the mission and objectives of the medical school and cite the evidence of achievements beside suggestions for improvements when describing the quality process within the school, as this will be convincing to the evaluation team (ACCJC/WASC 2011). The format of the report may differ from one accrediting body to another, but generally it has a description of the medical school, a description of the selfevaluation process, an analysis of the school’s current situation and a recommendation section. The site visit by the accreditation team verifies the information in the selfevaluation document. A site visit report includes a review of the school's fulfilment of the standards and the allocation of school resources, students, faculty, physical facilities, and other aspects of the school (El-Khawas 2001). The visit report is sent to the school, which may offer additional comments. The visit

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may take 2 to 5 days depending on the status of a school. A team is typically composed of experts in medical education from other medical schools who represent multiple disciplines in the field of medicine. A medical school should initially agree on the composition of the team to ensure maximum transparency and to avoid any conflict of interest. A team's report usually describes the actual situation in a medical school and the degree of compliance with the standards and may contain suggestions for improvement for any unsatisfactory levels of compliance with the standards. A medical school should agree on the report before its submission to the accreditation committee for a final decision. To have successful site visit, the medical school should plan and be prepared for this visit by preparing all the documents that may be needed by the visiting team. The team should be met by staff that are well informed about the self-evaluation and its results (CHEA 2007; Maccarrick, Kelly et al. 2010). The decision of whether an institution obtains accreditation is made according to the results of the visit. There are three possible outcomes: full accreditation is granted when a school demonstrates a satisfactory level of compliance with the standards, conditional accreditation is granted when some minor changes are needed, and accreditation is withdrawn when a school demonstrates poor compliance with the standards. Accreditation is usually valid for 5 to 10 years.

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