Quality Assurance Tool Research Articles

Vermont Case Review Process Guide: Assessing and Delivering High Quality Services to Vocational Rehabilitation Customers

Contemporary quality assurance tools developed using participatory approaches are key to informing and influencing continuous improvement within the public vocational rehabilitation program. This project aimed to revise and validate a case review tool and accompanying staff guidance to align with and support the common performance measures requirements presented by the Workforce Innovation and Opportunity Act (WIOA) of 2014. The previous case review tool used by the state vocational rehabilitation program focused primarily on case compliance, whereas the new tool challenged the agency to shift focus and review cases for both compliance and quality throughout the vocational counseling process.

Multi-center analysis of machine-learning predicted dose parameters in brachytherapy for cervical cancer

Background and purposeImage-guided adaptive brachytherapy (IGABT) is a key component in the treatment of cervical cancer, but the nature of the clinical workflow makes it vulnerable to suboptimal plans, as the theoretical optimal plan depends heavily on organ configuration. Patient anatomy-based quality-assurance (QA) with overlap volume histograms (OVHs) is a promising tool to detect such suboptimal plans, and in this analysis its suitability as a multi-institutional clinical QA tool is investigated. Materials and methodsA total of 223 plans of 145 patients treated in accordance with the current state-of-the-art IGABT protocols from UMC Utrecht (UMCU) and Erasmus MC (EMC) were included. Machine-learning models were trained to predict dose D2cm3 to bladder, rectum, sigmoid and small bowel with the help of OVHs. For this strategy, points are sampled on the organs-at-risk (OARs), and the distances of the sampled points to the target are computed and combined in a histogram. Machine-learning models can then be trained to predict dose-volume histograms (DVHs) for unseen data. Single-center model robustness to needle use and applicator type and multi-center model translatability were investigated. Performance of models was assessed by the difference between planned (clinical) and predicted D2cm3 values. ResultsIntra-validation of UMCU data demonstrated OVH model robustness to needle use and applicator type. The model trained on UMCU data was found to be robust within the same protocol on EMC data, for all investigated OARs. Mean squared error between planned and predicted D2cm3 values of OARs ranged between 0.13 and 0.40 Gy within the same protocol, indicating model translatability. For the former protocol cohort of Erasmus MC large deviations were found between the planned and predicted D2cm3 values, indicating plan deviation from protocol. Mean squared error for this cohort ranged from 0.84 to 4.71 Gy. ConclusionOVH-based models can provide a solid basis for multi-institutional QA when trained on a sufficiently strict protocol. Further research will quantify the model’s impact as a QA tool.

Comparing the comparators: How should the quality of education offered by online universities be evaluated?

AbstractComparing universities and courses is of interest to a variety of stakeholders including potential students, policy makers, news and media organisations, ranking providers, and universities themselves. There are a range of existing university ranking schemes that provide comparisons (e.g. Academic Ranking of World Universities) but typically these are designed with face‐to‐face teaching and learning in mind. There is also a growing number of quality assurance tools and approaches aimed at ensuring the quality of online education This article reports on an analysis of a range of quality assurance systems for online higher education institutions and courses, together with variety of ranking systems targeting conventional universities—with the aim of establishing what they measure, and the metrics used to assess quality. The findings from this analytical study were compared with a meta‐analysis of the literature about how students choose their university in order to understand how these instruments influence current student opinion and can be used more proactively by universities themselves. The findings reveal: (1) current ranking systems are of limited value for most potential undergraduate students, particularly with reference to online education, (2) comparison systems that can be of value to students from a variety of different backgrounds are likely to be complex to set up and run, and (3) quality indicators that promote both formative and summative evaluation may be beneficial to both institutions and students.

Transgenic HepaRG cells expressing CYP2D6 as an improved model of primary human hepatocytes.

CYP2D6 and CYP3A4, which are members of the cytochrome P450 superfamily of metabolic enzymes, play major roles in the metabolism of commonly available drugs. CYP3A4 is involved in the metabolism of 50% of drugs on the market, whereas CYP2D6 is involved in the metabolism of 25% of them. CYP2D6 exhibits a high degree of polymorphic nature in the human population, causing individual differences in CYP2D6 expression and enzymatic activity. Therefore, accurate prediction of drug metabolism and toxicity require a human adult hepatocyte cell model that mimics individual responses in the average population. HepaRG cells, a human hepatocellular carcinoma cell line, is the only cell line that can differentiate into hepatocyte‐like cells with high expression of CYP3A4 but poor expression of CYP2D6. To solve this problem, we developed transgenic HepaRG cell clones expressing either full‐length or spliced CYP2D6 at various levels with an easy monitoring system for CYP2D6 expression in living cells under a fluorescent microscope. As CYP2D6 mRNA, protein, and fluorescence intensity were closely correlated among transgenic HepaRG clones, fluorescence levels will provide a simple tool for quality assurance of CYP2D6‐expressing HepaRG cells. Thus, the package of transgenic HepaRG cell clones expressing CYP2D6 at various levels will provide an improved hepatocyte model that reflects the average or individual reactions in the human population for in vitro studies of drug metabolism and toxicity involving CYP2D6 and CYP3A4.

Technical Standards for Cancer Surgery: Improving Patient Care through Synoptic Operative Reporting.

The Operative Standards for Cancer Surgery manuals define critical elements of optimal cancer surgery based on data and expert opinion. These key aspects of commonly performed cancer operations define technical standards that can be used as a quality assurance tool for practicing surgical oncologists and as an educational tool for trainees. This article provides background on these operative standards and their subsequent integration into synoptic operative report templates. With the goal of codifying the most important aspects of surgical oncology care to elevate and harmonize cancer care, the American College of Surgeons Cancer Programs has developed comprehensive synoptic operative reports. Synoptic operative reports are structured so that key data elements are recorded in a standardized format with prespecified terminology. In contrast to the narrative or structured operative reports frequently used by surgeons, these synoptic operative reports improve semantic clarity, provide uniform fields for abstraction, and facilitate passive data collection and real-time analytics while delivering key information for downstream multidisciplinary patient care. In this way, the synoptic operative report is a key component of a comprehensive effort to elevate the quality of cancer care nationally.

Toward MR-only proton therapy planning for pediatric brain tumors: Synthesis of relative proton stopping power images with multiple sequence MRI and development of an online quality assurance tool.

To generate synthetic relative proton stopping power (sRPSP) images from magnetic resonance imaging (MRI) sequence(s) and develop an online quality assurance (QA) tool for sRPSP to facilitate safe integration of magnetic resonance (MR)-only proton planning into clinical practice. Planning computed tomography (CT) and MR images of 195 pediatric brain tumor patients were utilized (training: 150, testing: 45). Seventeen consistent-cycle generative adversarial network (ccGAN) models were trained separately using paired CT-converted RPSP and MRI datasets to transform a subject's MRI into sRPSP. T1-weighted (T1W), T2-weighted (T2W), and FLAIR MRI were permutated to form 17 combinations, with or without preprocessing, for determining the optimal training sequence(s). For evaluation, sRPSP images were converted to synthetic CT (sCT) and compared to the real CT in terms of mean absolute error (MAE) in Hounsfield units (HU). For QA, sCT was deformed and compared to a reference template built from training dataset to produce a flag map, highlighting pixels that deviate by >100HU and fall outside the mean±standard deviation reference intensity. The gamma intensity analysis (10%/3mm) of the deformed sCT against the QA template on the intensity difference was investigated as a surrogate of sCT accuracy. The sRPSP images generated from a single T1W or T2W sequence outperformed that generated from multi-MRI sequences in terms of MAE (all p<0.05). Preprocessing with N4 bias and histogram matching reduced MAE of T2W MRI-based sCT (54±21HU vs. 42±13HU, p=0.002). The gamma intensity analysis of sCT against the QA template was highly correlated with the MAE of sCT against the real CT in the testing cohort (r=-0.89 for T1W sCT; r=-0.93 for T2W sCT). Accurate sRPSP images can be generated from T1W/T2W MRI for proton planning. A QA tool highlights regions of inaccuracy, flagging problematic cases unsuitable for clinical use.

A transit portal dosimetry method for respiratory gating quality assurance with a dynamic 3D printed tumor phantom.

BackgroundsRespiratory gating is one of the motion management techniques that is used to deliver radiation dose to a tumor at a specific position under free breathing. However, due to the dynamic feedback process of this approach, regular equipment quality assurance (QA) and patient‐specific QA checks need to be performed. This work proposes a new QA methodology using electronic portal imaging detector (EPID) to determine the target localization accuracy of phase gating.MethodsQA tools comprising 3D printed spherical tumor phantoms, programmable stages, and an EPID detector are characterized and assembled. Algorithms for predicting portal dose (PD) through moving phantoms are developed and verified using gamma analysis for two spherical tumor phantoms (2 cm and 4 cm), two different 6 MV volumetric modulated arc therapy plans, and two different gating windows (30%–70% and 40%–60%). Comparison between the two gating windows is then performed using the Wilcoxon signed‐rank test. An optimizer routine, which is used to determine the optimal window, based on maximal gamma passing rate (GPR), was applied to an actual breathing curve and breathing plan. This was done to ascertain if our method yielded a similar result with the actual gating window.ResultsHigh GPRs of more than 97% and 91% were observed when comparing the predicted PD with the measured PD in moving phantom at 2 mm/2% and 1 mm/1% levels, respectively. Analysis of gamma heatmaps shows an excellent agreement with the tumor phantom.The GPR of 40%–60% PD was significantly lower than that of the 30%–70% PD at the 1 mm/1% level (p = 0.0064). At the 2 mm/2% level, no significant differences were observed. The optimizer routine could accurately predict the center of the gating window to within a 10% range.ConclusionWe have successfully performed and verified a new method for QA with the use of a moving phantom with EPID for phase gating with real‐time position management.

Novel diagnostic model for bone metastases in renal cell carcinoma patients based on bone scintigraphy analyzed by computer-aided diagnosis software and bone turnover markers

BackgroundComputer-assisted diagnosis (CAD) systems for bone scans have been introduced as clinical quality assurance tools, but few studies have reported on its utility for renal cell carcinoma (RCC) patients. The aim of this study was to assess the diagnostic validity of the CAD system for bone scans and to construct a novel diagnostic system for bone metastases in RCC patients.MethodsWe evaluated bone scan images of 300 RCC patients. Artificial neural network (ANN) values, which represent the probability of abnormality, were calculated by BONENAVI, the CAD software for bone scans. By analyzing ANN values, we assessed the diagnostic validity of BONENAVI. Next, we selected 108 patients who underwent measurements of bone turnover markers and assessed the combined diagnostic validity of BONENAVI and bone turnover markers.ResultsForty-three out of 300 RCC patients had bone metastases. The AUC of ANN values was 0.764 and the optimum sensitivity and specificity were 83.7 and 62.7%. By logistic analysis of 108 cases, we found that ICTP, a bone resorption marker, could be a diagnostic marker. The AUC of ICTP was 0.776 and the optimum sensitivity and specificity were 57.1 and 86.8%. Subsequently, we developed a novel diagnostic model based on ANN values and ICTP. Using this model, the AUC was 0.849 and the optimum sensitivity and specificity were 76.2 and 80.7%.ConclusionBy combining the high sensitivity provided by BONENAVI and the high specificity provided by ICTP, we constructed a novel, high-accuracy diagnostic model for bone metastases in RCC patients.

Clinical guidelines - a tool for quality assurance of care for patients with low back pain

A serious problem in clinical medicine today is the impossibility of applying all available knowledge to a particular patient in the conditions of a continuously growing flow of information. Hence, a qualitative transition from the banal accumulation of information to the search for specific tools that make it possible to single out only constructive solutions is natural. On the one hand, many often fundamentally new methods of diagnosing and treating various diseases are constantly appearing. On the other hand, their usefulness in correct scientific analysis is not always obvious. In this regard, it is sometimes difficult for a doctor to form a single diagnostic and therapeutic concept. The basis for resolving these contradictions is the so-called evidence-based medicine, which takes into account and promotes the dissemination of only those treatment methods whose effectiveness has been proven by strictly scientific, standardized and unified statistical methods. A tool that helps the practitioner in making a clinical decision and the relevant principles of evidence-based medicine are the "Clinical guidelines" (in the English literature "Clinical guidelines"). This is a document that is compiled by a team of authors, which, as a rule, includes several dozen leading specialists in a particular field of medicine from different countries.

Going viral: A scoping review of the current state and impact of online research dissemination in emergency medicine.

The use of free open-access medical education (FOAM) and other online knowledge dissemination methods has increased over the past decade. However, the role and impact of these tools in the knowledge translation continuum are poorly understood, potentially limiting the ability of knowledge generators to fully harness and exploit their potential. Here, we aim to comprehensively map and synthesize the literature describing the use of online tools for the dissemination of emergency medicine research. Using scoping review methodology, we searched the traditional literature via PubMed, CINAHL, EMBASE, ERIC, SCOPUS, and the gray literature for publications exploring online methods to disseminate new research findings. We synthesized the results and constructed a conceptual model of current research dissemination methods. We included 79 out of 655 unique abstracts and articles identified in our search, 62 of which were from the traditional literature. We describe six primary domains: integration with traditional literature, measurement of dissemination, online organizations and communities of practice, professional development, quality assurance tools and techniques, and advantages and disadvantages of FOAM. For each domain we present an exemplar article and prevailing gaps in knowledge. Finally, we propose a current conceptual framework for dissemination of new research findings that describes both traditional and novel methods of dissemination. This comprehensive review of the literature and current dissemination framework will empower researchers, research networks, and granting organizations to maximize their use of FOAM and other online methods to disseminate new knowledge as well as provide clinicians a better understanding of the tools and methods by which to access and implement new research findings.

Application of 3D Gel Dosimetry as a Quality Assurance Tool in Functional Leksell Gamma Knife Radiosurgery.

Highly precise dose delivery to the target (tumor or cancerous tissue) is a key point when brain diseases are treated applying recent stereotactic techniques: intensity-modulated, image-guided radiotherapy, volumetric modulated arc therapy, Gamma knife radiosurgery. The doses in one single shot may vary between tens and hundreds of Gy and cause significant cell/tissue/organ damages. This indicates the need for implementation of quality assurance (QA) measures which are realized performing treatment dose verification with more than one calibrated quality assurance method or tool, especially when functional radiosurgery with a high dose (up to 40 Gy in our case) shall be delivered to the target using small 4 mm collimator. Application of two dosimetry methods: radiochromic film dosimetry using RTQA2 and EBT3 films and dose gel dosimetry using modified nPAG polymer gels for quality assurance purposes in stereotactic radiosurgery treatments using Leksell Gamma Knife© Icon™ facility is discussed in this paper. It is shown that due to their polymerization ability upon irradiation nPAG gels might be potentially used as a quality assurance tool in Gamma knife radiosurgery: they indicate well pronounced linear dose response in hypo-fractionated (up to 10 Gy) dose range and are sensitive enough to irradiation dose changes with a high (at least 0.2 mm) spatial resolution. Dose assessment sensitivity of gels depends on parameters of a dose evaluation method (optical or magnetic resonance imaging), however, is similar to this estimated using film dosimetry, which is set as a standard dosimetry method for dose verification in radiotherapy.

Assessing the quality of patient handovers between ambulance services and emergency department \u2013 development and validation of the emergency department human factors in handover tool

BackgroundPatient handover between prehospital care and the emergency department plays a key role in patient safety. Therefore, we aimed to create a validated tool for measuring quality of communication and interprofessional relations during handover in this specific setting.MethodsBased on a theoretical framework a comprehensive item pool on information transfer and human factors in emergency department handovers was created and refined in a modified Delphi survey involving clinical experts. Based on a pre-test, items were again revised. The resulting Emergency Department Human Factors in Handover tool (ED-HFH) was validated in a field test at the emergency department of a German university hospital from July to December 2017. The ED-HFH was completed by emergency department and ambulance service staff participating in handovers and by an external observer. Description of item characteristics, exploratory factor analysis, analyses on internal consistency and interrater reliability by intraclass-correlation. Construct validity was analysed by correlation with an overall rating on quality of the handover.ResultsThe draft of the ED-HFH contained 24 items, 90 of 102 eligible staff members participated in the field test completing 133 questionnaires on 38 observed handovers. Four items were deleted after analysis of item characteristics. Factor analysis supported a single factor explaining 39% of variance in the items. Therefore, a sum-score was calculated with a possible range between 14 and 70. The median value of the sum-score in the sample was 61.5, Cronbach’s α was 0.83, intraclass-correlation was 0.52, the correlation with the overall rating of hand-over quality was ρ = 0.83 (p ≤ 0.001).ConclusionsThe ED-HFH showed its feasibility, reliability and validity as a measure of quality of information transfer and human factors in handovers between ambulance services and the emergency department. It promises to be a useful tool for quality assurance and staff training.

Sigma metrics in quality control- An innovative tool

The clinical laboratory in today’s world is a rapidly evolving field which faces a constant pressure to produce quick and reliable results. Sigma metric is a new tool which helps to reduce process variability, quantitate the approximate number of analytical errors, and evaluate and guide for better quality control (QC) practices.To analyze sigma metrics of 16 biochemistry analytes using ERBA XL 200 Biochemistry analyzer, interpret parameter performance, compare analyzer performance with other Middle East studies and modify existing QC practices.This study was undertaken at a clinical laboratory for a period of 12 months from January to December 2020 for the following analytes: albumin (ALB), alanine amino transferase (SGPT), aspartate amino transferase (SGOT), alkaline phosphatase (ALKP), bilirubin total (BIL T), bilirubin direct (BIL D), calcium (CAL), cholesterol (CHOL), creatinine (CREAT), gamma glutamyl transferase (GGT), glucose (GLUC), high density lipoprotein (HDL), triglyceride (TG), total protein (PROT), uric acid (UA) and urea. The Coefficient of variance (CV%) and Bias % were calculated from internal quality control (IQC) and external quality assurance scheme (EQAS) records respectively. Total allowable error (TEa) was obtained using guidelines Clinical Laboratories Improvement Act guidelines (CLIA). Sigma metrics was calculated using CV%, Bias% and TEa for the above parameters. It was found that 5 analytes in level 1 and 8 analytes in level 2 had greater than 6 sigma performance indicating world class quality. Cholesterol, glucose (level 1 and 2) and creatinine level 1 showed &amp;#62;4 sigma performance i.e acceptable performance. Urea (both levels) and GGT (level 1) showed &amp;#60;3 sigma and were therefore identified as the problem analytes. Sigma metrics helps to assess analytic methodologies and can serve as an important self assessment tool for quality assurance in the clinical laboratory. Sigma metric evaluation in this study helped to evaluate the quality of several analytes and also categorize them from high performing to problematic analytes, indicating the utility of this tool. In conclusion, parameters showing lesser than 3 sigma need strict monitoring and modification of quality control procedure with change in method if necessary.

Pro-Active Detection of Potentially Wrong Diagnoses Due to Substantial Changes of Laboratory Measurements.

For guiding decisions on medical diagnoses and diagnoses, it is crucial to receive valid laboratory test results. However, such results can be implausible for the physician, even if the measurements are within the range of known reference values. There are technical sources of implausible results that are related to the laboratory environment, which are frequently not detected through usual measures for ensuring technical validity. Here, we describe the development of a quality assurance tool that tackles this problem and replaces the current manual statistical analyses at the Center for Laboratory Medicine in St Gallen (ZLM). Further analysis of the factors responsible for shifts in laboratory test results requires to collect and analyze data related to reagents as well as calibration or reference probes. Due to a lack of standard operating procedures in many laboratories with respect to these processes, this remains one of the big challenges.

Quality assurance for on-table adaptive magnetic resonance guided radiation therapy: A software tool to complement secondary dose calculation and failure modes discovered in clinical routine.

Online adaption of treatment plans on a magnetic resonance (MR)‐Linac enables the daily creation of new (adapted) treatment plans using current anatomical information of the patient as seen on MR images. Plan quality assurance (QA) relies on a secondary dose calculation (SDC) that is required because a pretreatment measurement is impossible during the adaptive workflow. However, failure mode and effect analysis of the adaptive planning process shows a large number of error sources, and not all of them are covered by SDC. As the complex multidisciplinary adaption process takes place under time pressure, additional software solutions for pretreatment per‐fraction QA need to be used. It is essential to double‐check SDC input to ensure a safe treatment delivery. Here, we present an automated treatment plan check tool for adaptive radiotherapy (APART) at a 0.35 T MR‐Linac. It is designed to complement the manufacturer‐provided adaptive QA tool comprising SDC. Checks performed by APART include contour analysis, electron density map examinations, and fluence modulation complexity controls. For nine of 362 adapted fractions (2.5%), irregularities regarding missing slices in target volumes and organs at risks as well as in margin expansion of target volumes have been found. This demonstrates that mistakes occur and can be detected by additional QA measures, especially contour analysis. Therefore, it is recommended to implement further QA tools additional to what the manufacturer provides to facilitate an informed decision about the quality of the treatment plan.

8 - Quality Assurance Self-assessment: A Catalyst at Aga Khan University

This article describes the establishment of the Aga Khan University’s Network of Quality Assurance and Improvement in promoting the principles of quality in its programmes. As an international university, the experiences and lessons learned have the potential to inform quality assurance and improvement in similar contexts. The authors reflect on past attempts to improve the quality of educational offerings, which were primarily traditional quality assurance audits. With the advent of the Inter-University Council for East Africa self-assessment process, the next generation of quality assurance and improvement was launched for the Aga Khan University programmes. They found the self-assessment process effective in changing attitudes towards quality enhancement and implementation of improvement plans, because it created ownership in the process. Practically, self-assessment is an important tool for academic quality assurance providing critical feedback, and catalysing action. The article will be useful for those establishing quality teaching and learning units across multi-site, multi-campus universities, especially in resource challenged environments.

6 - Student Evaluation of Teaching: Bringing Principles into Practice

Student evaluation of the teaching process is an important quality assurance tool with the potential to give data that can be used to inform the development of courses and guidance of instructors. They have become increasingly important in western countries over the last forty years or so as their results are also used for ‘high stakes’ purposes. This paper examines the background of student evaluations, including reasons – sometimes conflicting – for undertaking them, choice of question items, administration, and analysis and use of results. The design of the Student Evaluation of Teaching used at the Aga Khan University is described; it looks to capture the student voice in a meaningful, helpful and proportionate manner. Data from the pilot stage, which assessed the efficacy of student evaluation of teaching, are given along with pointers for future good practices.

Pay-for-performance and tools for quality assurance in health care

Pay-for-performance and tools for quality assurance in health care

Evaluation of silicon strip detectors in transmission mode for online beam monitoring in microbeam radiation therapy at the Australian Synchrotron.

Successful transition of synchrotron-based microbeam radiation therapy (MRT) from pre-clinical animal studies to human trials is dependent upon ensuring that there are sufficient and adequate measures in place for quality assurance purposes. Transmission detectors provide researchers and clinicians with a real-time quality assurance and beam-monitoring instrument to ensure safe and accurate dose delivery. In this work, the effect of transmission detectors of different thicknesses (10 and 375 µm) upon the photon energy spectra and dose deposition of spatially fractionated synchrotron radiation is quantified experimentally and by means of a dedicated Geant4 simulation study. The simulation and experimental results confirm that the presence of the 375 µm thick transmission detector results in an approximately 1-6% decrease in broad-beam and microbeam peak dose. The capability to account for the reduction in dose and change to the peak-to-valley dose ratio justifies the use of transmission detectors as thick as 375 µm in MRT provided that treatment planning systems are able to account for their presence. The simulation and experimental results confirm that the presence of the 10 µm thick transmission detector shows a negligible impact (<0.5%) on the photon energy spectra, dose delivery and microbeam structure for both broad-beam and microbeam cases. Whilst the use of 375 µm thick detectors would certainly be appropriate, based upon the idea of best practice the authors recommend that 10 µm thick transmission detectors of this sort be utilized as a real-time quality assurance and beam-monitoring tool during MRT.

Assessing Higher Education Exit Exam in Ethiopia: Practices, Challenges and Prospects

Ensuring quality and relevant education in Higher Education institutions is one of the challenges that remained to be solved. In a pursuit to rise educational outcomes in terms of quality and relevance, many countries currently aim to improve accountability in the school system. Many school systems provide educational outcome information. However, the Exit exam provides outcome information to be comparable across schools on an external standard. Exit exams have been argued to improve the signaling of educational achievement on the labor market and to increase labor-market productivity through increased human capital. The exit exam is intended to ensure all graduates from HEIs have developed adequate mastery of the core competencies articulated in the respective curricula thereby satisfying the requirements of the labor market and employability through the nationwide implementation of curriculum-based external exit examination. The purpose of this study, therefore, is to examine the current practices, and challenges on the implementation of exit exams and put forward way for its enhanced implementation. Thus, desk review of different articles, documents, policies, manuals, and guidelines was made from global and local pieces of literature. Moreover, key informants from concerned institutions including National Examination and Assessment Agency, Health Professionals Competency Assessment Licensure Directorate, Higher Education Strategy Center, and Federal Justice and Legal Research and Training Institute) were interviewed to substantiate the desk review result. Results have shown that although institutions across nations or states in a nation call exit exam in different names, the purpose in one way or another is the same, improving students' achievement, enhancing graduates performance, improve quality of education and improve graduates' competence in their respective fields of study. It has been identified that exit exam has many strength including helping to ensure common standard knowledge and practical competencies, improving public trust, improving reliability and validity of assessment tools, a tool for quality assurance to benchmark any potential problem, and helping the faculty to perform an ongoing global assessment. Moreover, several concerns regarding the scheme of exit exam including efforts and costs to maintain the process, opposing arguments, exposing potential weakness in the education system, fear of impeding flexibility within curriculum, quality and trustworthiness of the employee, ownership, exam administration, and management and cheating were indicated. Consequently, establishing independent exit exam organization, online exam administration, awareness creation before full implementation of exit exam and cost-sharing are some of the recommendations forwarded.