Accreditation Reports Research Articles

Guarding the gate politically and politely: How accreditation teams do facework while gatekeeping

AbstractAccreditation is a quality assurance mechanism which evaluates either the capability of an institution to offer an academic program or the quality of an academic program before its launch. Accredited institutions and programs are allowed to enroll students, both fee-paying and non-fee-paying. The outcome of an accreditation exercise will therefore have significant implications for an institution’s reputation and finance. Institutions are normally informed of the outcome through an accreditation report, a genre whose discourse is intrinsically interesting and important, and thus deserves fuller research attention, for two reasons: (1) the genre contains evaluations and comments which can be negative and face-threatening, and (2) the accreditation team, as we can safely assume, will do facework subsequent to the performance of face threats through the negative evaluations and comments. The present study seeks to gain a better understanding of the lexicogrammar of this genre in general, and the lexicogrammar used to textualize facework in particular by analyzing the discourse of 30 accreditation reports in an Australian context. This paper argues that the evaluative language used in this genre can serve to perform facework for both the institution being accredited and the accreditation team itself, and have important implications for both the workplace and classroom.

Cultural Awareness in Nursing is a Progressive Growth

During the past four decades, researchers have developed strategies used in nursing programs to promote cultural awareness. Minimal research has focused on the graduating associate degree-nursing students to determine if a relationship existed between the use of an integrated cultural curriculum and the nursing student’s level of cultural awareness. The associate degree-nursing program accreditation, statistical and benchmark reports mandated the integration of diversity content, local, national and worldwide perspectives in the curricula. Additionally societal and cultural patterns must be integrated across the entire nursing school curricula. In this study, a correlational approach was implemented to determine if relationships existed between the integrated cultural curriculum and level of cultural awareness in graduating associate degree nursing students in a large metropolitan area, such as in Los Angeles. In addition, the focus was to determine if differences existed in the level of cultural awareness among the graduating associate degree-nursing students based on demographic factors (gender, ethnicity and age). The Cultural Awareness Scale (CAS) was used during this study. Based on the results of the 51 participants surveyed in this study, the cultural awareness level may be attributed to several factors, including the integrated cultural curricula. The nursing student’s learning style, perception of faculty, personal experiences and cultural encounters may also contribute to the cultural awareness level.

The contribution of professional accreditation to quality assurance in higher education

This article examines the extent to which the professional accreditation of professional higher education programmes can complement other quality assurance endeavours being carried out. An analysis of a sample of professional accreditation reports for pharmacy education programmes in Ireland provides insight into the priorities of the regulatory professional body with regard to preparation for the profession. The results show that the reports address issues that are of relevance for the higher education institutions’ provision of quality programmes and for their quality assurance. The article also considers the extent to which the reports hold institutions accountable against the professional standards, while also acknowledging the professional responsibility of institution staff. Catering for both of these logics is necessary so that professional accreditation can contribute effectively as a mechanism for quality assurance, including enhancement, in the institution.

The Impact of Electronic Health Records on Risk Management of Information Systems in Australian Residential Aged Care Homes.

To obtain indications of the influence of electronic health records (EHR) in managing risks and meeting information system accreditation standard in Australian residential aged care (RAC) homes. The hypothesis to be tested is that the RAC homes using EHR have better performance in meeting information system standards in aged care accreditation than their counterparts only using paper records for information management. Content analysis of aged care accreditation reports from the Aged Care Standards and Accreditation Agency produced between April 2011 and December 2013. Items identified included types of information systems, compliance with accreditation standards, and indicators of failure to meet an expected outcome for information systems. The Chi-square test was used to identify difference between the RAC homes that used EHR systems and those that used paper records in not meeting aged care accreditation standards. 1,031 (37.4%) of 2,754 RAC homes had adopted EHR systems. Although the proportion of homes that met all accreditation standards was significantly higher for those with EHR than for homes with paper records, only 13 RAC homes did not meet one or more expected outcomes. 12 used paper records and nine of these failed the expected outcome for information systems. The overall contribution of EHR to meeting aged care accreditation standard in Australia was very small. Risk indicators for not meeting information system standard were no access to accurate and appropriate information, failure in monitoring mechanisms, not reporting clinical incidents, insufficient recording of residents' clinical changes, not providing accurate care plans, and communication processes failure. The study has provided indications that use of EHR provides small, yet significant advantages for RAC homes in Australia in managing risks for information management and in meeting accreditation requirements. The implication of the study for introducing technology innovation in RAC in Australia is discussed.

Learning to manage: development experiences of hospital frontline managers

In high performing human resource management (HRM) systems, much responsibility for managing employees and associated processes is typically devolved to frontline managers (FLMs). Research indicates that undeveloped FLM HRM ability can impact performance, particularly in health‐care organisations. We present the incidence and characteristics of HRM‐oriented learning and development programs for FLMs in hospitals with high performing systems of HRM, and experiences of FLMs directly participating in them. We combine data from 50 Australian hospital accreditation reports with interviews from eight ‘high performance HRM’ cases. We find: almost all high performers develop FLM HRM ability; development programs are extremely diverse between hospitals and succession planning is deficient. While primarily focused on understanding ability, the study contributes to the ability, motivation, opportunity framework, proposing a model and new interrelationships between these variables in the FLM context.

The Relationship between Using Electronic Health Records and Meeting Accreditation Standards for Client Safety in Residential Aged Care Homes.

This study aims to identify the benefits of using electronic health records (EHR) for client safety in residential aged care (RAC) homes. The aged care accreditation reports published between 27 April 2011 and 3 December 2013 were downloaded and analysed. It could be seen from these reports that only 1,031(37.45%) RAC homes in Australia had adopted an EHR system by 2013. 13 RAC homes failed one or more accreditation standards. Only one of these was using an EHR system and this one met the accreditation standards on information systems. Our study provides empirical evidence to suggest that adopting and using EHR can be one of the effective organisational mechanisms to meeting accreditation standards in RAC homes.

Professional field in the accreditation process: examining information technology programmes at Dutch Universities of Applied Sciences

In this paper, we analyse 53 Dutch accreditation reports in the field of information technology to assess the mechanisms of the reported involvement of the professional field in the undergraduate programmes of universities of applied sciences. The results of qualitative content analysis reveal a coupling effect in reporting on mechanisms of interaction. Although the involvement of the professional field is tightly coupled with the undergraduate programmes at universities of applied sciences at the strategic level, there is an under-representation of university-industry interaction on an operational level, which suggests the need to explore the actual interaction taking place between the professional field and the programmes. Simultaneously, our results indicate that accreditation reports are not able to provide a holistic picture of professional field engagement in the curriculum of undergraduate programmes at the operational level, which questions their role in acknowledging the role of industry in shaping and achieving intended learning outcomes. Perhaps policymakers should consider introducing other tools or standards for addressing the outcome of the engagement and the responsiveness of the programmes at universities of applied sciences to the professional field.

SAT0576 Creating New Rheumatologists: the Canadian Experience

BackgroundMany countries face a critical shortage of rheumatologists. Based on an accepted benchmark of 1 specialist per 50,000 people as the number needed for effective patient care,1 recent figures show...

Evaluating trauma center structural performance: The experience of a Canadian provincial trauma system

Background:Indicators of structure, process, and outcome are required to evaluate the performance of trauma centers to improve the quality and efficiency of care. While periodic external accreditation visits are part of most trauma systems, a quantitative indicator of structural performance has yet to be proposed. The objective of this study was to develop and validate a trauma center structural performance indicator using accreditation report data.Materials and Methods:Analyses were based on accreditation reports completed during on-site visits in the Quebec trauma system (1994-2005). Qualitative report data was retrospectively transposed onto an evaluation grid and the weighted average of grid items was used to quantify performance. The indicator of structural performance was evaluated in terms of test-retest reliability (kappa statistic), discrimination between centers (coefficient of variation), content validity (correlation with accreditation decision, designation level, and patient volume) and forecasting (correlation between visits performed in 1994-1999 and 1998-2005).Results:Kappa statistics were >0.8 for 66 of the 73 (90%) grid items. Mean structural performance score over 59 trauma centers was 47.4 (95% CI: 43.6-51.1). Two centers were flagged as outliers and the coefficient of variation was 31.2% (95% CI: 25.5% to 37.6%), showing good discrimination. Correlation coefficients of associations with accreditation decision, designation level, and volume were all statistically significant (r = 0.61, -0.40, and 0.24, respectively). No correlation was observed over time (r = 0.03).Conclusion:This study demonstrates the feasibility of quantifying trauma center structural performance using accreditation reports. The proposed performance indicator shows good test-retest reliability, between-center discrimination, and construct validity. The observed variability in structural performance across centers and over-time underlines the importance of evaluating structural performance in trauma systems at regular intervals to drive quality improvement efforts.

Accreditation and Power: A Discourse Analysis of a New Regime of Governance in Higher Education

This article studies discourses within the accreditation of Norwegian higher education conducted by the Norwegian Agency for Quality Assurance in Education (NOKUT), using one concrete case (the accreditation of bachelor programs in nursing). Analysis of policy documents and accreditation reports are influenced by two of Foucault's concepts of power; governmentality and panopticon. The analysis provides insights into firstly, how the two forms of power are woven into the schemes used for quality control by redefining quality to be a quantifiable concept; secondly, how the supervision of quality gives privilege to specific types of knowledge; thirdly, how supervisory power is reformulated to require self-control mechanisms within higher education in terms of constant quality development and realization of unexploited potentials; and fourthly, how this power legitimates itself by making all parties guardians of quality control, deconstructing the difference between evaluator and evaluated.

Director of Clinical Education Performance Assessment Surveys: A 360-Degree Assessment of the Unique Roles and Responsibilities of This Position in Physical Therapy Education

Background and Purpose. Academic coordinators/directors of clinical education (DCEs) serve unique roles in physical therapist education programs with responsibilities that extend beyond those of teaching, service, and scholarship. Traditional faculty evaluation tools frequently fail to capture the diverse leadership, administrative, managerial, and experiential teaching responsibilities of these faculty members. The purpose of this project was to develop a set of assessment surveys for the DCE to use to solicit comprehensive performance feedback. Method/Model Description and Evaluation. A comprehensive literature review, analysis of professional documents and existing institutional tools, and feedback solicited from evaluator groups informed the development of the DCE Performance Assessment Surveys (Surveys). Fifty-six accredited physical therapist (PT) and physical therapist assistant (PTA) programs self-identified as the sample of convenience to pilot test the Surveys. Outcomes. The majority of program directors (88%) indicated they would consider using the Surveys. Clinical education faculty (88.6%) and academic faculty (84%) respondents stated they would be willing to complete a Survey for the evaluation of a DCE. A range of 85.0%-93.3% of respondents stated they could adequately evaluate the DCE using the Survey unique to their rater group and reported a range of 13.0-15.9 minutes to complete the Survey. Discussion and Conclusion. This project used a systematic process to develop a comprehensive set of Surveys for use in physical therapy academic programs. The Surveys solicit 360-degree performance feedback on the role of the DCE from the program director, DCE, clinical education faculty (clinical instructors, center coordinators of clinical education), academic faculty, and students. Data obtained may be useful to DCEs in professional and program development, workload allocation, promotion and tenure applications, and accreditation reports.

Using accreditation reports to measure performance: from expectations to reality

The American College of Surgeons has published criteria for trauma centre accreditation since the 1970s. Following their initial designation as trauma centres in 1993-95, 59 hospitals in the province of...

Development of a standardised evaluation grid for trauma center accreditation process

Regionalised and integrated trauma systems are effective in reducing mortality. Following initial designation of 59 trauma centres in the province of Quebec, Canada, each centre was evaluated in situ twice...

Does accreditation stimulate change? A study of the impact of the accreditation process on Canadian healthcare organizations.

BackgroundOne way to improve quality and safety in healthcare organizations (HCOs) is through accreditation. Accreditation is a rigorous external evaluation process that comprises self-assessment against a given set of standards, an on-site survey followed by a report with or without recommendations, and the award or refusal of accreditation status. This study evaluates how the accreditation process helps introduce organizational changes that enhance the quality and safety of care.MethodsWe used an embedded multiple case study design to explore organizational characteristics and identify changes linked to the accreditation process. We employed a theoretical framework to analyze various elements and for each case, we interviewed top managers, conducted focus groups with staff directly involved in the accreditation process, and analyzed self-assessment reports, accreditation reports and other case-related documents.ResultsThe context in which accreditation took place, including the organizational context, influenced the type of change dynamics that occurred in HCOs. Furthermore, while accreditation itself was not necessarily the element that initiated change, the accreditation process was a highly effective tool for (i) accelerating integration and stimulating a spirit of cooperation in newly merged HCOs; (ii) helping to introduce continuous quality improvement programs to newly accredited or not-yet-accredited organizations; (iii) creating new leadership for quality improvement initiatives; (iv) increasing social capital by giving staff the opportunity to develop relationships; and (v) fostering links between HCOs and other stakeholders. The study also found that HCOs' motivation to introduce accreditation-related changes dwindled over time.ConclusionsWe conclude that the accreditation process is an effective leitmotiv for the introduction of change but is nonetheless subject to a learning cycle and a learning curve. Institutions invest greatly to conform to the first accreditation visit and reap the greatest benefits in the next three accreditation cycles (3 to 10 years after initial accreditation). After 10 years, however, institutions begin to find accreditation less challenging. To maximize the benefits of the accreditation process, HCOs and accrediting bodies must seek ways to take full advantage of each stage of the accreditation process over time.

Are accreditation surveys reliable?

The purpose of this article is to test whether healthcare accreditation survey processes are reliable. The study uses multiple methods to document stakeholder experiences and views on accreditation survey reliability. There were 29 research activities, comprising 25 focus groups, three interviews and a survey questionnaire. In total, 193 stakeholders participated; 134 in face-to-face activities and 56 via questionnaire. All were voluntary participants. Using open-ended questioning, stakeholders were asked to reflect upon accreditation survey reliability. Stakeholders perceived healthcare accreditation surveys to be a reliable activity. They identified six interrelated factors that simultaneously promoted and challenged reliability: the accreditation program, including organisational documentation and surveyor accreditation reports; members' relationship to the accrediting agency and survey team; accreditation agency personnel; surveyor workforce renewal; surveyor workforce management; and survey team conduct including coordinator role. The six factors realised shared expectations and conduct by accreditation stakeholders; that is, they enabled accreditation stakeholder self-governance. Knowledge gained can be used to improve accreditation program reliability, credibility and ongoing self-governance. The paper is a unique examination of healthcare accreditation surveys the reliability. The findings have potential application to reliability in other healthcare areas.

Faculty Achievement Tracking Tool

Faculty development and scholarship is an expectation of nurse educators. Accrediting institutions, such as the Commission on Collegiate Nursing Education, the National League for Nursing Accrediting Commission, and the Higher Learning Commission, all have criteria regarding faculty achievement. A faculty achievement tracking tool (FATT) was developed to facilitate documentation of accreditation criteria attainment. Based on criteria from accrediting organizations, the roles that are addressed include scholarship, service, and practice. Definitions and benchmarks for the faculty as an aggregate are included. Undergoing reviews from different accrediting organizations, the FATT has been used once for accreditation of the undergraduate program and once for accreditation of the graduate program. The FATT is easy to use and has become an excellent adjunct for the preparation for accreditation reports. In addition, the FATT may be used for yearly evaluations, advancement, and merit.

Accreditation outcomes, quality of and access to university education in Nigeria

PurposeIn response to the challenges of enhancing quality, the agency of government which is responsible for coordinating university education in Nigeria, the National Universities Commission, evolved a system of academic programme accreditation in 1991 to ensure conformity with minimum standards and to promote quality. The purpose of this paper is to examine the outcomes of some of those accreditation exercises and how they have influenced the quality of and access to university education.Design/methodology/approachThe paper analyses secondary source data from accreditation reports of 1999, mop up exercises and accreditation re‐visitation of 2000‐2005 and that of November 2005.FindingsThe mean percentage of programmes with full accreditation status was found to have increased from 12.6 in 1999 to 48.5 in 2005, that of programmes which got interim accreditation decreased from 72.66 in 1999 to 48.30 in 2005, while the one for programmes which were denied accreditation decreased from 17.9 in 1999 to 9.5 in 2005. Federal universities had more programmes with full accreditation and less programmes with denied accreditation status. State universities had less number of programmes with full accreditation and higher number with denied accreditation status. Generally, the results showed that accreditation status of most academic programmes improved in subsequent accreditation exercises, meaning that the deficiencies noticed were remedied. The programmes that were denied accreditation caused a reduction in the number of vacancies for student admission.Research limitations/implicationsThe paper focuses on federal and state universities only. Private universities are excluded.Practical implicationsThe paper suggests that the universities in Nigeria should be closely monitored for their academic programmes to scale the accreditation hurdle.Originality/valueThe paper shows that accreditation of academic programmes helps to improve the quality of university education.

Analysis on the Performance and Tasks of Accreditation System for Medical Colleges

The present study investigates the performance and tasks of the accreditation performed by Korean Institute of Medical Education and Evaluation. The study analyzes survey data for 309 professors and 41 accreditation reports published during the first accreditation cycle (2000~ 2004). The finding shows that 32 medical colleges were accredited and 9 medical colleges were accredited on probation. Up to 98.5% of must standards’ and 85.3% of ‘should standards’ were satisfied in this accreditation. The areas of accreditation standards, such as students, and facilities were satisfied relatively lower than the curriculum and administration/finances areas. However, 70.2% of the faculties replied that the accreditation achieved its purpose, and 80.7% of them pointed out the necessity of accreditation system. All these things make it clear that the accreditation system has made a significant contribution to the quality of medical education and the accountability of medical colleges. In addition, there are some issues which need more consideration, such as the government recognition of accreditation system, evaluation experts training, and practical application of accreditation results.

Accreditation of Dental Programs in Australia: A Thematic Analysis of Recommendations, 1996–2004

For dental education to continue to grow in Australia, there is a need to understand the effect of new innovations and to reflect on the way the profession as a whole has adapted to the highly innovative environment that is modern dental education. The Australian Dental Council's (ADC) accreditation activities for undergraduate dental programs is one constant over the last ten years that can be used to provide some insight into the reactions of schools to threats and opportunistic solutions brought about by change. In this study, accreditation reports were analyzed to provide trends in the themes of accreditation findings over the last ten years. The hypothesis was that the themes emanating from the findings of accreditation will reflect changes over time as schools have adapted to the changing higher education environment. A total of 820 recommendations were collated from twenty-one reports. From the recommendations collated, a series of themes were identified; predominant themes included staff, external relationships, funding, structure, documentation, curriculum, and communications. No clear trends in terms of recommendations were noted over the study period, and themes remained fairly consistent over the years. The outcome of the study did not support the hypothesis that changing trends in accreditation recommendations over the last ten years would reflect changes in the environment in which education providers are operating.

Leadership Lessons from Curricular Change at the University of California, San Francisco, School of Medicine

After successive Liaison Committee on Medical Education accreditation reports that criticized the University of California, San Francisco, School of Medicine for lack of instructional innovation and curriculum oversight, the dean issued a mandate for curriculum reform in 1997. Could a medical school that prided itself on innovation in research and health care do the same in education? The authors describe their five-phase curriculum change process and correlate this to an eight-step leadership model. The first phase of curricular change is to establish a compelling need for change; it requires leaders to create a sense of urgency and build a guiding coalition to achieve action. The second phase of curriculum reform is to envision a bold new curriculum; leaders must develop such a vision and communicate it broadly. The third phase is to design curriculum and obtain the necessary approvals; this requires leaders to empower broad-based action and generate short-term wins. In the fourth phase, specific courses are developed for the new curriculum, and leaders continue to empower broad-based action, generate short-term wins, consolidate gains, and produce more change. During the fifth phase of implementation and evaluation, leaders need to further consolidate gains, produce more change, and anchor new approaches in the institution. Arising from this experience and the correlation of curricular change phases with leadership steps, the authors identify 27 specific leadership strategies they employed in their curricular reform process.