ACCM Accreditation Procedures

Effective 1st May 2022:

Contents

Introduction

The Accreditation Commission on Colleges of Medicine (ACCM/The Commission) is an independent, not for profit organisation based in the Republic of Ireland. ACCM is invited by Governments of countries that may not have a national medical accreditation body, to act on their behalf in relation to the accreditation of specified medical schools (See Footnote 1) within their jurisdiction. In the majority of medical schools currently under accreditation by ACCM, the student body is drawn predominantly from North America where the Liaison Committee on Medical Education (LCME) is the recognised authority for the accreditation of medical education programmes leading to the degree of M.D. ACCM’s standards are therefore closely aligned with those of the LCME.

The US Department of Education’s National Committee on Foreign Medical Education and Accreditation (NCFMEA) recognizes ACCM as using accrediting standards comparable to those of the LCME. In addition, ACCM has been granted recognition by the World Federation for Medical Education (WFME) for a period of ten years until 31 December 2026 and is fully compliant with the Educational Commission on Foreign Medical Graduates (ECFMG) requirements for an internationally recognised medical accrediting agency.

ACCM evaluates schools of medicine for accreditation based on the ACCM Standards of Accreditation for Schools of Medicine. By judging the compliance of medical education programmes with internationally accepted standards of educational quality, the ACCM serves the interests of the general public and of the medical students enrolled in those programmes. To achieve and maintain accreditation, a medical education programme leading to the MD degree, must demonstrate appropriate performance in the Standards.

These Procedures, reviewed annually by the ACCM Board, are intended to provide schools of medicine with information about the accreditation process used by ACCM.

Overview of the accreditation process for schools that are fully operational

(See Footnote 2)

Term of accreditation

Programmes judged by ACCM to meet its Standards of Accreditation are designated as “accredited”. Programmes for which the ACCM has withdrawn or denied accreditation and those applying for accreditation for the first time but found to be not in compliance with ACCM Standards of Accreditation are considered “not accredited”.

An educational programme leading to the MD degree, once accredited, remains accredited for the period of accreditation granted until the programme voluntarily terminates its accreditation status or the ACCM terminates the programme’s accreditation through a formal action to withdraw accreditation. The status of the school does not change to “not accredited” until a formal action taken by the ACCM is finalized. A formal ACCM action is considered final when the programme has either chosen not to seek reconsideration or to appeal the decision to withdraw accreditation or when a withdrawal action by the ACCM has been confirmed following an appeal as described in Appendix 5. When the ACCM withdraws accreditation, the letter transmitting that decision specifies the date on which accreditation ceases.

The timing and assessment process for a school applying for re-accreditation is dependent on the period of accreditation previously granted and any conditions attached, and will be communicated to the school by ACCM.

Types of accreditation

Three or Six Year Accreditation

A school that is found to be in full compliance with the Standards following a Full Accreditation Review (FAR) during the final year of accreditation will be granted accreditation for a period of either three or six years. In some instances, areas for improvement may be identified with a recommendation that they be implemented by the time of the next mid-cycle inspection. The school is required to notify the Commission promptly of any substantive change, to remain in full compliance with the ACCM Standards of Accreditation, to pay the annual registration fee and to complete the annual database and other required documentation. The purpose of these requirements is to enable the Commission to determine if the school remains in full compliance with the Standards and should retain its accreditation status.

A school seeking re-accreditation that is not in full compliance with the ACCM Standards of Accreditation will be granted accreditation for a period of three years. The Commission will attach conditions such as the need for updates in relation to areas of weakness or deficiency. The School will undergo a FAR in the final year of the three-year period of accreditation. At this time the Board may choose to grant a period of accreditation for three or six years, continue accreditation but place the school on probation or withdraw accreditation.

Probationary Accreditation

In circumstances where a school has already been granted accreditation, the Commission may place it on probation if it falls out of substantial compliance with the Standards. The Commission will conduct detailed annual documentary reviews of a school that has been placed on probation to monitor its progress. In some circumstances, additional site inspections (medical school campus, clinical sites) may be necessary.

A school may spend a maximum of two years in probationary status. At the end of the two-year period, based on the annual reviews and site inspections as appropriate, ACCM will accredit the school to for three years, withdraw accreditation entirely, or extend the probationary period for achieving compliance for good cause shown.

Probationary period extensions for good cause shown are made at the sole discretion of the ACCM according to the following criteria:

  • The programme has demonstrated significant progress and has a realistic timeline for the resolution of any remaining non-compliance issues.
  • The programme has provided written and compelling evidence describing its plans to come into compliance within the extension period (e.g., a programme has documented the commitment of financial and human resources to resolve all remaining non-compliance issues within the extension period).
  • The programme has provided written and compelling evidence that the nature of the needed change (e.g., facilities construction or renovation, fundraising for scholarships) reasonably requires a time period exceeding two years and has provided a realistic timeline to address the deficiency.
  • The programme has provided documentation of the need for actions by groups external to the medical education programme (such as decisions by university or legislative bodies) and provided a timeline for when these actions are likely to occur.

Schools applying for accreditation for the first time

A medical school expressing an interest in ACCM accreditation will often commence its communications with a general enquiry and a request for further information about the accreditation process. Once a school makes a formal application for first-time accreditation the following steps are followed:

  1. Stage 1 – Preliminary assessment: An initial assessment by ACCM to determine whether the school meets ACCM’s basic requirements for consideration for eligibility. ACCM may reject an application at Stage 1 without any explanation.
  2. Stage 2 – Initial Review: An initial review of the School’s documentation by ACCM, on receipt of the initial application fee, in order to determine whether the school meets ACCM requirements to be considered as a candidate for accreditation. ACCM may reject an application at Stage 2 without an explanation.
  3. Stage 3 – In-Depth Assessment: Subsequent to a decision that the school meets the initial requirements, and on receipt of the 2nd application fee, an in depth assessment of additional documentation by a team of Commissioners, leading to a report to the ACCM Board, which then decides whether the candidate school merits an inspection.
  4. Stage 4 – Full Accreditation Review (FAR), to include on-site inspections of the medical school campus, the administrative headquarters and affiliated clinical sites.

An ACCM board decision regarding accreditation status is then made, which is communicated to the school and all relevant stakeholders.

A school that is found to be in full compliance with the ACCM Standards will be granted accreditation for a maximum of 6 years. A school that is not in full compliance with the ACCM Standards will be granted accreditation for three years. A school that falls out of substantial compliance with the Standards at any time during an accreditation period will be placed on probation. A new applicant school that has undergone a pre-clinical campus inspection but has not yet undergone inspection of the HQ or clinical sites will be granted Conditional Accreditation.

However, a new applicant school where all facilities are co-located, thus permitting a full accreditation inspection to be carried out by ACCM in a single visit, may be granted accreditation for a maximum of 6 years if it is found to be fully compliant with the Standards at that time.

Accreditation Inspections

Inspections will take place at the following locations:

  • Medical school campus (including pre-clinical campus)
  • Affiliated clinical sites (See Footnote 3)
  • Medical school administrative headquarters

There are three types of inspection:

Full Accreditation Review (FAR) is a planned inspection of a medical school programme, performed prior to the end of an accreditation period (three or six years) or when a school is seeking accreditation for the first time. This inspection includes the medical school campus, clinical sites and the administrative headquarters.

Mid-cycle inspections are planned inspections, between full inspections, of a medical school campus that has been granted six years accreditation.

Non-routine inspections are visits to schools under probationary accreditation, when a school experiences substantive change, has areas of non- compliance that require correction before the next planned inspection or when the ACCM Board deems that an additional inspection is required. These inspections may include one or all of the following: the medical school/pre-clinical campus, clinical sites and/or administrative headquarters.

An accreditation decision is based on an inspection and assessment of all elements and facilities involved in the delivery of a medical school programme. While some medical schools offer clinical training at or near the same location as their pre-clinical courses, others provide their clinical training in hospitals which are remote from the university campus. The following descriptions separate the accreditation procedures for pre- clinical education and clinical training sites, although for medical schools where pre- clinical courses, clinical training and perhaps also the administrative headquarters are in the same geographic location – the inspections can be amalgamated.

The full evaluation of a medical school (FAR) forms the basis for accreditation decisions and will therefore, in all instances, include an evaluation of pre-clinical education and clinical training programmes as well as the administrative headquarters. The full inspection begins with the medical school campus, and inspection of clinical sites and headquarters will be completed within one year of the medical school inspection. Accreditation decisions based on the medical school campus inspection are subject to modification should there be subsequent adverse clinical site or administrative headquarters inspection findings.

The ACCM Board is responsible for reviewing accreditation applications, overseeing the appointment of members to the inspection teams, reviewing inspection reports and making accreditation decisions. Each team for a full inspection of a medical school campus will be composed of three members, two members for a mid-cycle or unscheduled inspection, and two members for clinical site and administrative headquarters inspections. One member of a pre-clinical campus inspection team is a medical educator with a recent medical school appointment and with experience and expertise in the delivery and evaluation of a medical school pre-clinical curriculum. At least one member of a clinical site inspection team is an MD (or equivalent) with a background in clinical practice. The inspection process for each type of inspection (Full, Mid-cycle and Unscheduled) is described in appendices 1 and 2. The inspection process for clinical site visits (together with the requirements for oversight of clinical students), as well as procedures for an Administrative Headquarters inspection, are described in appendices 3 and 4.

Students are expected to play an important part in all accreditation reviews and inspections. For further details see Appendix 9. Prior to a FAR inspection, the student body is required to complete an Independent Student Analysis after disseminating a Student Opinion Questionnaire.

Accreditation Decisions

Accreditation decisions are made by the Board at a Board meeting following consideration of:

  • The Institutional Self-study and Annual Databases (as appropriate)
  • Independent Student Analysis
  • All additional relevant documentation requested by ACCM and submitted by the school
  • The full accreditation inspection report, incorporating reports of the medical school/pre-clinical campus, clinical sites and administrative headquarters inspections
  • The recommendations of the inspection team.

The team members who carry out the onsite inspection and draft the report do not vote on an accreditation decision. The Commission then deliberates and makes its accreditation decision by a majority vote. The school may withdraw its request for accreditation at any time before an accreditation decision is made by forwarding a letter to the Commission.

Accreditation actions

When considering the accreditation status of a medical education programme leading to the MD degree, the ACCM may at any time, and under exceptional circumstances, take one of the following actions:

  • Grant for the first time or continue a three, six or probationary accreditation status.
  • Continue an accreditation status, with or without specifying the term of accreditation. (See Footnote 4)
  • Continue an accreditation status, with a shortened accreditation term.
  • Deny accreditation
  • Withdraw accreditation

A school that is to have its accreditation withdrawn will be given adequate notice to facilitate relocation of students.

The ACCM may also require one or more follow-up activities (unscheduled inspections, completion of an action plan, and/or completion of status reports) if there is evidence of unsatisfactory performance, if the ACCM has identified areas that require monitoring or where the final outcome could result in noncompliance with one or more accreditation standards.

Notification to the School of Accreditation Decision

After a final decision is reached, the Commission notifies the school of its accreditation decision.

When accreditation is granted, the notification includes an outline of the requirements attaching to maintenance of accreditation, in particular the mandatory submission of the annual database. In circumstances where the decision is to deny or refuse accreditation, the reasons for the decision are outlined. The notification letter is forwarded to the Chief Executive Officer (CEO), the Chief Academic Officer (CAO) and the Chair of the Board of Trustees.

Notification to Governmental Agencies of Accreditation Decision

Within thirty days the Commission must notify the accreditation decision to:

  1. The Government and educational/licensing authorities of the jurisdictions in which the medical school campus and the administrative headquarters are located.
  2. Where appropriate, NCFMEA/U.S. Education Department for the purpose of qualifying for the William D. Ford Federal Loan Programme.

In the event that accreditation is denied or withdrawn, the Commission may forward a brief summary of the underlying reasons for the decision in response to an appropriate governmental agency enquiry.

Responsibility of the School to notify accreditation decisions

In the instance of a decision to place a school on probation or to deny or withdraw accreditation, the school must, within 30 days of a decision (unless the school seeks reconsideration or appeal in writing to ACCM), notify all enrolled students, those newly accepted for enrolment, and those seeking enrolment, of the decision The school must also provide this information on its website. Should a school seek reconsideration or appeal, such notification will be required within 30 days of the final reconsideration or appeal decision. The school will also forward a copy of this notification letter to the Commission.

Reconsideration and Appeal

A request for reconsideration of an accreditation decision must be filed with the Commission within thirty days of receipt of the notification. If the outcome of the reconsideration fails to satisfy the school, it may then file for an appeal which must be lodged within thirty days of notification of the reconsideration decision.

The following ACCM accreditation actions are subject to reconsideration:

  • Continuation of accreditation but programme placed on probation
  • Denial of accreditation
  • Withdrawal of accreditation

The following ACCM accreditation actions are subject to appeal, following an unsuccessful outcome of reconsideration:

  • Denial of accreditation
  • Withdrawal of accreditation

Details of the Reconsideration and Appeal procedures is contained in Appendix 6.

Post Accreditation Oversight of School

Annual Surveillance of Accredited Programmes

The Commission requires all schools accredited by the Commission to demonstrate continued compliance with the Standards in order to retain their accreditation status. All schools are required to submit a detailed annual database complete with appendices to demonstrate continued compliance with the ACCM Standards. Schools are also required to notify ACCM of any substantive change in the curriculum or operation of the medical school. Database submissions are reviewed for accuracy and completion by an ACCM Board member. If there are concerns or questions, the school is contacted for an explanation with a set response date. The Commission forwards the Annual Database Questionnaire to the school in June for completion and return by 1st February of the following year.

The accreditation status of all schools is reviewed bi-annually at the May and November Board meetings. If concerns are identified on the basis of the bi-annual review, the Board may decide to amend the accreditation status and/or to impose conditions.

Non-compliance with any accreditation standard must be corrected within a stipulated period. Failure to achieve compliance within the stipulated period constitutes grounds for probation, denial or withdrawal of accreditation unless the period for achieving compliance is extended for good cause shown, at the discretion of the ACCM. Extension for good cause shown will not be a routine occurrence.

The ACCM may, at its sole discretion, extend the period for achieving compliance for “good cause shown” for 12 months beyond the standard two-year period. In its communication with a medical education programme, the ACCM will specify the reason(s) that it has granted an extension for good cause shown and the period within which the medical education programme must come into compliance with the cited standard(s).

Change in Ownership or Governance

A school that is undergoing a change in ownership or governance must complete the relevant sections of the Annual Database Report. The Commission will also schedule an on-site (non-routine) inspection of the school within six months of receipt of the school notification letter. The Commission will determine whether the new owner or governors can ensure that the school will continue to comply with the Standards of Accreditation and whether to continue, change or add certain conditions to the terms of its accreditation.

Establishment of a Branch Campus

A school must inform ACCM in writing of its intention to establish a branch campus. ACCM will determine if the proposed site meets the criteria for a branch campus or if it is a separate medical school. In order to meet criteria for a branch campus ACCM must be the accrediting body for the parent school. Once approval is granted, the school must complete the relevant sections of the Annual Database and furnish projections concerning the branch’s revenue and expenses. The Commission will also schedule an on-site (non-routine) inspection of the branch campus within six months of receipt of the school notification letter. The Commission determines whether the branch campus will be in a position to comply with the Standards of Accreditation and whether to continue, change or add certain conditions to the terms of its accreditation.

Investigation of Complaints to the Commission

The Commission will maintain records of all complaints it receives. The Commission will review only complaints that deal with a school’s compliance with the ACCM Standards of Accreditation. If the complaint is credible and supported by sufficient evidence, the Commission will forward a copy of the complaint to the school. The Commission will dismiss the complaint if the school provides evidence to refute the charges. If the school fails to refute the charges, then the Commission will open an inquiry. The inquiry will focus narrowly on the complaint. The Commission will notify the complainant of its findings on completion of the inquiry.

The Commission will not review nor interfere in routine business decisions or operations of the school. Routine school business includes student and faculty dismissals.

The Commission will notify all complainants of this policy. [See also Appendix 7]

Public Notice of Accredited School

The Commission publishes a list of the countries in which it acts as an accrediting agency and a list of the medical education programmes accredited by ACCM in those countries on its website. Accreditation decisions (without details) made by the ACCM Board will, in the public interest, be displayed on the ACCM website.

Financial Arrangements

Initial application for accreditation

The initial application for accreditation is a four stage process (See Appendix 10). Prior to Stage 2 the school pays the Stage 2 inspection fee. If the school passes the Stage 2 assessment it is asked to submit additional documentation for Stage 3, at which time it is required to pay the second application fee to cover administrative costs incurred in processing the school’s application.. If the school passes the Stage 3 assessment it is required to pay the Application Registration Fee to cover administrative costs incurred in processing the school’s application. Fees for the Stage 4 Full Accreditation Review (FAR) are the normal fees applied to schools seeking reaccreditation. Details of the fees are provided to schools applying for accreditation.

Annual registration

In order to maintain accreditation status, accredited schools must pay an annual registration fee to ACCM. The annual registration fee, which is set by the ACCM Board, is due for payment by February 15th.

Costs of inspections

The fees for an accreditation inspection visit include the inspection fee, the honorarium to inspection team members plus all expenses incurred by the team members in connection with the inspection including travel, accommodation, meals and other incidental expenses.

A school seeking accreditation for the first time is required to pay these fees in advance, i.e. the inspection fee plus an estimate of expenses that will be incurred by the inspection team.

A school seeking re-accreditation is required to pay the inspection fee in advance and the reimbursable expenses within 30 days of receiving the invoice from ACCM following completion of the visit.

A school is not permitted to pay or reimburse any member of an inspection team directly for any part of the cost of an inspection. Costs incurred, including airfares, hotel, accommodation and meals, will be paid by ACCM and invoiced to the school on completion of the inspection.

ACCM Board members are not permitted to accept gifts, other than small tokens of appreciation, from medical school personnel.

Costs of reconsiderations and appeals

A school filing a request for a reconsideration of a Commission decision will be required to pay a reconsideration fee. If a school wishes to appeal the decision, it will be required to pay an appeal fee. In addition, the school will be required to lodge an advance for ACCM expenses. Further advances may be necessary depending on the complexity and duration of the process. Should any part of these advances be unused, it will be reimbursed to the school.

A school filing a request for either a reconsideration or an appeal is required to pay all expenses incurred by the Commission in connection with the review or the appeal even if the review or appeal is withdrawn. These expenses include travel, accommodation, meals, legal expenses and other incidental expenses.

Disputes

Any dispute or claim (including reconsiderations and appeals, and non-contractual disputes or claims) arising out of or in connection with it or its subject matter or formation shall be governed by and construed in accordance with the law of the Republic of Ireland.

Each party irrevocably agrees that the courts of the Republic of Ireland shall have exclusive jurisdiction to settle any dispute or claim (including non-contractual disputes or claims) arising out of or in connection with this agreement or its subject matter or formation.

Appendix 1: Procedures for inspections at a medical school campus

A full accreditation inspection takes place when a school is seeking accreditation for the first time or when a previous period of accreditation is due to expire. The focus of the inspection is to ensure adherence to ACCM Standards of Accreditation in relation to all aspects of the programme – pre-clinical education, clinical training and administrative oversight – and therefore incorporates a comprehensive inspection of the medical school campus as well as on-site inspections of clinical sites and the administrative headquarters. The mid-cycle inspection takes place at the mid-point of a six year accreditation period.

FULL ACCREDITATION REVIEWS AT THE MEDICAL SCHOOL CAMPUS

The Commission notifies the school approximately a year in advance of an inspection. The notification letter includes:

    1. A link to the ACCM Standards of Accreditation for Schools of Medicine
    2. A link to the ACCM Procedures for the Accreditation of Schools of Medicine
    3. A copy of the Annual Database and Institutional Self-Study Questionnaires (unless the annual database questionnaire has already been completed for the current year)
    4. A copy of the Independent Student Opinion Questionnaire
    5. The proposed dates for the on-site inspection
    6. The name and title of the leader of the inspection team.

The school is required to complete an up-to-date database and institutional self-study questionnaire prior to the on-site inspection and return these electronically (with all appendices) to the ACCM Secretariat by an agreed date. At the same time that the medical school initiates the data-collection portion of the self-study, the student leadership should begin a process to collect and review topic areas relevant to students, including the medical education programme, student services, the learning environment, and the adequacy of facilities and other educational resources. The Independent Student Analysis (ISA) process consists of the creation and dissemination of a student opinion questionnaire and the development of a report (the ISA) that includes the questionnaire results and an analysis and interpretation of the responses (Appendix 9). The school may also be required to provide any additional information requested by ACCM.

At the same time as the requested documentation is submitted to ACCM, ACCM requires the school to submit a formal letter signed by the president (or equivalent) of the school affirming that:

1. The school is committed to complying with the ACCM Standards, ACCM Procedures and any revisions that may be adopted by the Commission from time to time.

2. The school agrees to abide by the decision of the Commission and to hold it blameless for any adverse accreditation decision.

3. The school agrees to indemnify the Commission for disclosing to the public and any agencies its accreditation decision.

4. The school has disclosed all information to the Commission deemed necessary for its evaluation and states that the information submitted is a true and accurate account of the facts.

5. The school has disclosed to ACCM any current legal disputes involving the school, the school leadership or the school owners.

6. The school agrees to notify ACCM immediately of any substantive change in the educational delivery, operation, ownership, legal or financial status of the school.

All ACCM accreditation decisions will be displayed on the ACCM website after the school has been notified of the final Board decision.

All disputes must be disclosed. ACCM will evaluate the impact of such disputes on the accreditation process.

The inspection is conducted in a predetermined and structured format to ensure that all teams evaluate individual schools with uniformity and consistency. The school designates a coordinator to assist and guide the team around the school and, if co-located, the clinical teaching facilities, during its visit. The coordinator also arranges transportation for the team members throughout the visit.

Day 1 General overview of the school (Standards 1, 2, 3, 8, 9, and 11).

The intention on Day 1 is to concentrate on those standards that will require the presence of senior management and administrative staff including, if appropriate, members of the HQ team. All pre-clinical campus inspections begin with Interview 1. The scheduling of subsequent interviews is subject to agreement between the school and the team and may be adjusted to facilitate a meeting with the government.

Introduction, general overview, and Standard 1 (Mission and educational goals)

The team will meet with the school CEO (or equivalent) and CAO to confirm the structure and organisation of the school, to inquire about its strategy and future plans and any important issues that it is facing. They will also discuss the relevant parts of the Institutional Self-Study and Database, changes since the last accreditation visit and ask about the school’s strengths and weaknesses.

Standard 2 (Corporate Organisation)

The team meets with the Chair of the Board of Trustees and reviews the minutes of the Board and its role in providing broad institutional policies, selecting the CEO and CAO, securing financial resources, and overseeing management’s performance of its duties and responsibilities with the CEO. The team will also review the School by-laws.

Standard 3 (School Management)

The team meets with the deans for the pre-clinical and clinical sciences and course directors to discuss the management and integration of the pre-clinical and clinical science courses, oversight of multidisciplinary courses and senior electives. If appropriate, the inspection team meets with chief academic officers and faculty representatives from allied health care programmes.

Standard 8 (Admissions)

The team meets with the administrator for admissions and the Chair of the Admission Committee. The team reviews minutes of the Admission Committee for evidence that the Committee is compliant with selection policies and has a process that is fair and non-discriminatory.

Standard 9 (Student Promotion and Evaluation)

The team meets with the Chair of the Student Promotion and Evaluation Committee and reviews the minutes of the committee meetings. The team reviews methods for measuring student performance in the pre-clinical and clinical science courses as well as requirements and mechanisms for student promotion, graduation, and academic disciplinary actions. The team also reviews sample student evaluation and progress reports that are used to provide feedback to the students and faculty. The team reviews the students’ achievements in USMLE Steps 1 and 2, as well as the school’s first time and overall pass rates, where appropriate.

Standard 11: Financial Management

The team meets with the chief financial officer and CAO to review the school’s compliance with Standard 11. The team reviews the most recently independently audited financial accounts, sources of income, debt, the budget planning process, the adequacy of financial resources, student fees and fees refunds policy.

DAY 2 (Standards 10, 4, 5, 6, 7, 12, 13)

On Day 2 the intention is to focus on those standards which require the presence of students, pre-clinical faculty, clinical deans and core directors.

Standard 10: Student Support Services

The team meets in a closed door session with students who are selected by the student body, including students from different semesters and different cohorts, representative of the full spectrum of students on campus. The team elicits their views on the quality of the curriculum, the faculty and student support services and other matters pertinent to the ACCM Standards of Accreditation. The Team reviews the ISA report with the students.

Standard 4: Faculty and Teaching Staff

The team meets with faculty representatives from the pre-clinical science and the clinical science departments to review the school’s compliance with Standard 4. Faculty representatives consist of five faculty members from the basic science departments and selected members from the clinical chairs. New faculty (hired since the last inspection) should be included. The Team meets with faculty min a closed-door session without senior administrative presence.

Standards 5-7: Curriculum

The team meets with the Chair of the Curriculum Committee, all available department chairs, clinical deans and course directors in the pre-clinical and clinical science departments to review the school’s curriculum content, delivery, implementation, and management. The team reviews the minutes of the Curriculum Committee and the school’s process for obtaining student evaluation of faculty teaching effectiveness.

Standard 12: Facilities and Information services

The team inspects the facilities and equipment of the school with the CAO or designee. The inspection includes auditoriums/classrooms/teaching facilities, laboratories, clinical skills laboratory, student lounge, restaurant, sporting facilities, faculty and administrative offices, library and IT facilities. The team meets with the chief librarian, head of IT and head of security.

Standard 13: Postgraduate Progression

The school’s tracking of the postgraduate progression of its students is reported and includes information regarding residency placement and board pass rates.

Private team meeting

Day 3

Day 3 focuses on the meeting with Government officials, visits to any adjacent clinical sites, any outstanding issues not covered in the previous two days, and the exit interview:

  • Meeting with Government officials
  • Local hospital used for Introduction to Clinical Medicine
  • Visits to adjacent clinical sites used for clinical cores and electives (if appropriate)
  • Private team meeting
  • Exit Interview

The team meets with the school’s academic leadership to provide initial feedback and, in particular, to highlight any matters of concern that require urgent remediation.

Observations discussed during the exit conference do not necessarily represent a comprehensive reporting of the team’s findings nor should the school draw any inference regarding the final conclusions of the inspection report.

MID-CYCLE INSPECTIONS AT THE MEDICAL SCHOOL CAMPUS

(See Footnote 5)
An accredited school will undergo a routine mid-cycle inspection of its medical school campus three years after accreditation is granted, to ensure continued compliance with ACCM Standards of Accreditation. A mid-cycle inspection is carried out by a team of two Commissioners.

The school is required to complete an up-to-date database and institutional self-study prior to the on-site inspection.

A mid-cycle inspection follows the outline of a comprehensive inspection but focuses on changes introduced since the previous ACCM inspection such as new faculty appointments, changes to the curriculum, new facilities and services which may have been introduced.

The inspection is conducted in a predetermined and structured format, based on an assessment of the Standards, to ensure that all teams evaluate individual schools with uniformity and consistency. The school designates a coordinator to assist and guide the team around the school and, if co-located, the clinical teaching facilities, during its visit. The coordinator also arranges transportation for the team members throughout the visit.

Day 1:

  • The team meets with the CEO and the CAO of the medical school.
  • The school reports any changes since that last on-site inspection and also identifies problems it must overcome.
  • The team meets with individuals and faculty Committee representatives that it identified prior to its arrival at the School.

Team Meeting: The team reviews the observations of the first day and summarises its findings for use during the exit conference and for inclusion in its mid-cycle inspection report.

Day 2:

  • The team meets in a closed-door session with students selected by the student body, who are representative of the spectrum of students present on the campus. If different semester groups are present, then at least one student from each semester group is selected. If the school intakes annually, then three from each intake year will be selected.
  • The team resumes meetings with individuals and faculty Committee representatives which it identified prior to its arrival at the school. Faculty meetings are closed-door meetings without the presence of school leadership.
  • The team continues meeting with individuals and faculty Committee representatives.
  • Team Meeting: The team reviews the observations of the second day and summarises its findings for use during the exit conference and for inclusion in the mid-cycle report.
  • Exit Conference: The team meets with the CEO and the CAO to share some of its observations. The aims of the exit conference are
    • To provide the school with immediate feedback of some of the team’s observations without commenting on the accreditation decision.
    • To offer the school the opportunity to correct any factual inaccuracies recorded by the team.

Observations discussed during the exit conference do not necessarily represent a comprehensive reporting of the team’s findings nor should the school draw any inference regarding the final conclusions of the inspection report.

Appendix 2: Procedures for Non-Routine Inspections

Non-routine inspections are triggered when a school has been granted probationary accreditation requiring determination as to whether the conditions attached have been met within the required timeframe, and/or in response to substantive change or a complaint about the school.

By its nature, the procedures for a non-routine inspection will be more flexible than for a full or mid-cycle inspection, although they follow the same general procedures. The emphasis of the inspection will be placed primarily, though not necessarily only, on the deficits or the substantial changes which have prompted the inspection. Non-routine inspections can be at the medical school campus, affiliated clinical sites or, in exceptional circumstances, at administrative headquarters.

If the inspection is for a programme on provisional accreditation, the school will be asked

    1. To complete selected portions of the Annual Database Report (and Institutional Self-study if applicable) which address the particular reason for the visit
    2. To submit documentation certain faculty members, students, administrators, facilities, finances or issues to a focused on-site review by an inspection team
    3. To submit evidence that demonstrates substantial improvement in those deficits identified at the previous inspection.

If the non-routine inspection is made in the light of substantive change, the school will be required (as above) to complete selected portions of the Annual Database Report (and Institutional Self-study if applicable) and to submit documentation on certain faculty members, students, administrators, facilities, finances or issues to a focused on-site review by an inspection team.

Appendix 3: Procedures for affiliated clinical site inspections

Clinical site inspections are made either as part of a full accreditation inspection or, non-routinely, when issues – identified during a prior clinical site inspection – have led to conditions being attached to an accreditation decision.

The following is a summary of the inspection process for clinical sites where students undertake core rotations.

  • As part of the FAR, ACCM visits all of the medical school’s clinical sites and evaluates strengths, areas of noncompliance with accreditation/approval standards, and any areas in transition which could affect compliance with the accreditation/approval standards.
  • At sites that have never been inspected, an on-site review must be held within 12 months of the accreditation review of the pre-clinical science campus or within 12 months of student placement at the site.
  • Inspection of clinical sites in the same geographical location as the pre-clinical science campus may be incorporated in the full inspection.
  • Each clinical site must have an on-site review at least once during the accredited period.
  • Under exceptional circumstances ACCM may institute alternative arrangements.
  • At new sites (sites opened during the accredited period and that have never been visited previously), an on-site review must be held within 12 months of the placement of students at those sites.
  • As new clinical sites are introduced, the Commission will carry out a review based on submitted documentation, and will determine the timing and date of inspections.
  • Even if a clinical site has been reviewed previously and approved in relation to another school under accreditation by the Commission, an additional onsite review may take place at the discretion of the Commission.
  • Sites where the inspection team have made recommendations for improvement may receive further inspections to verify if the recommendations have been implemented.

If the clinical training site takes students from more than one school under accreditation by the Commission, then where possible and, with the agreement of the schools concerned, a single inspection will be made in relation to all such schools whose students are present. Faculty and students from the different schools will be interviewed separately and separate reports will be produced. Where that site has a single coordinator responsible for the educational experience of students from multiple schools, and where the Commission, whenever it visits that site, interviews students from all schools, then that site does not need to be visited more than once during the accredited period.

Procedures for clinical site visits:

The procedures for the visit or visits will be as follows:

  1. The Convenor for the school makes contact with the Chief Academic Officer or Associate Dean for Clinical Medicine, as appropriate, to request a date for a visit, giving approximately three months’ notice.
  2. The Convenor seeks a second team member for the inspection team. Ideally, the Convenor for the school will be a member of the two-person team, but in some instances, the clinical site visit may be conducted by other qualified members of the Commission.
  3. Dates of visit or visits are agreed and a schedule planned by the Chief Academic Officer or the Associate Dean or designated staff member of the school.
  4. The school completes the ACCM hospital site visit questionnaire, Part 1 in advance of the visit.
  5. The school forwards the ACCM hospital site visit questionnaire, Part 2 for completion by the hospital site in advance of the visit.

At least three weeks in advance of the clinical visit the following documentation should be sent electronically to ACCM:

  • The completed Part 1 & Part 2 questionnaires.
  • The School/hospital Affiliation Agreement(s).
  • The CV’s of any new Medical Faculty not included in the latest Annual Database. These include department chairs, medical education director(s) and course director(s) or coordinator(s).
  • Letters of Appointment/Certificates for new hospital/preceptor faculty or all faculty if this is a first visit by ACCM.
  • Previous Medical School/Clinical Site Inspection Reports where relevant.
  • List of Medical Students available for interviewing with details of how selected. Elective students should be included where applicable.
  • Contact details for key Clinical Site visit personnel and cell phone number for the local clinical site coordinator.
  • Hospital Visit Agenda with the student interviews as the first agenda item.
  • Itinerary for Transport Arrangements (if applicable)

The following are required for each core clerkship at the clinical site:

  • Student Logs
  • Sample patient list
  • Weekly Teaching Schedule
  • A minimum of three representative evaluations of students by faculty
  • A minimum of three representative evaluations of faculty by students

The Team meets with:

  • Students from all clinical cores taught at the site (including Family Medicine), as well as students from the school who are doing clinical electives, in a closed-door session This may be by video-conference if face-to-face interviews cannot be arranged at time of visit, or if the site has already been inspected for another school within a period of six months. Students for interview are to be selected by the current student body.
  • The hospital’s medical education/clerkship director
  • The Clinical Department Chairs
  • The course director/coordinator and/or preceptor
  • Senior hospital executive(s).

In instances where the team is conducting site visits at the same clinical site(s) on behalf of more than one School, with the permission of the schools, all efforts must be made to ensure confidentiality by interviewing each student group separately. Where the schools do not share faculty, the faculty should also be interviewed separately.

The hospital programme directors and department Chairs guide the team through the clinical facilities. The tour includes inspection of:

  • The major clinical departments
  • Ambulatory facilities
  • Other facilities where students receive clinical training
  • Hospital library and IT facilities
  • Sleeping quarters for students scheduled to take calls

Team Meeting: The team reviews its observations and summarises its findings for use during the exit interview and for inclusion in its report.

Exit Interview

At the end of the visit the inspection team may meet with key personnel from the hospital or the school. At this time the Team may choose to seek clarification on matters arising.

If there is some significant area of noncompliance requiring immediate attention this should be mentioned at this time.

Observations discussed during the exit conference do not necessarily represent a comprehensive reporting of the team’s findings nor should the school draw any inference regarding the final conclusions of the inspection report.

Requirements for oversight of clinical students

In reviewing clinical education, the team examines the school’s oversight of clinical students in hospital wards and clinics. The team confirms that the school:

  • Ensures that the students at clinical sites receive the same curricular material, same quality of education and same standard of student evaluation found at the parent campus
  • Ensures each medical student in a medical education programme participates in required clinical experiences conducted in a health care setting in which s/he works with resident physicians currently enrolled in an accredited programme of graduate medical education
  • Each medical student in a medical education programme participates in one or more required clinical experiences conducted in a healthcare setting in which he or she works with resident physicians in an accredited programme of graduate medical education.
  • Provides a structured environment for students to learn and work
  • Provides an academic organisation that is controlled by the medical school in all clinical departments where students receive training, staffed by physicians who are faculty members of the medical school and who report to the chief of the department or the course director.
  • Defines and distributes to students and to supervising faculty members a list of learning objectives upon commencement of the clerkship. Learning objectives refers to the knowledge and skills students must acquire by the end of the clerkship.
  • Schedules adequate free time for students to study, read and to reflect on the lessons and cases of the day.
  • Provides students with practice to develop clinical skills and concepts

Confirms that:

  • In the beginning of the clerkship, the faculty guide the students by demonstrating the proper methods for taking a patient history, performing physical examinations, working up patients, and performing protocols?
  • The faculty assigns to each student new patients to work up every week
  • The faculty require students to write daily patient progress notes, and promptly review these notes, critique them and give students timely feedback?
  • The faculty assign students to clinical tasks that are commensurate with the level of skills they have attained
  • The faculty assign greater responsibilities to students as their proficiency levels grow and their knowledge expands – with the ultimate goal of moving students towards greater competency.

Confirms that the school monitors students’ clinical exposure to ensure that they encounter a broad range of learning experience:

  • The students attend daily ward rounds, weekly conferences, student lectures and have an on-call experience.
  • The faculty regularly assign and critique student case presentations.
  • The faculty or the course coordinator regularly monitor the breadth of clinical exposure students receive.

Confirms that the faculty fosters problem solving and critical appraisal skills in students:

  • The faculty insist on active student participation in the process of identifying patient illnesses and developing management plans

Confirms that the faculty regularly observes students working and offer timely feedback

Confirms that the faculty evaluates clinical students regularly and provide prompt feedback

Confirms that the school requires student attendance

Confirms that the faculty provides students with professional support and encouragement.

Appendix 4: Procedures for Administrative Headquarters inspections

The inspection of administrative headquarters forms part of the full accreditation inspection of a medical school, together with the pre-clinical campus and the clinical sites. In certain cases, the administrative headquarters may be located on the same site as the medical school and will form part of the same visit. However, if not, the information requested from the school will be similar to that requested for the relevant standards of a full inspection.

The team meets with senior management, relevant administrative team members and senior academic staff at the site, and the team will also tour the facility. The visit concludes with an exit interview.

The agenda will address the following Standards (see Day 1 of full inspection):

  • Standard 1 (Mission and educational goals)
  • Standard 2 (Corporate Organisation)
  • Standard 3 (Management)
  • Standard 8: (Admission)
  • Standard 11: (Financial Management)
  • Standard 13: (Postgraduate progression)

The issues addressed will include:

  1. Corporate issues
    • General update
    • Strategic plans for the school
    • Finances/student loans
  2. Student affairs
    • Admissions
    • Student records
    • Allocation/placement for cores/electives
    • Alumni/tracking of graduates
  3. Academic and clinical affairs
    • Role of administrative headquarters/personnel in the oversight and coordination of the clinical teaching programme
    • Ensuring comparability across various clinical sites
    • Clinical sites – affiliation agreements, inspections
  4. Clinical faculty – appointment, evaluation

Appendix 5: Procedures for reconsideration and appeals

A school that has been notified of an accreditation decision that constitutes withdrawal or denial of accreditation or probation may request a reconsideration in writing within 30 days of receipt of the decision. This gives the school an opportunity to argue why the accreditation decision should not be imposed and be made final, while the formal appeal provides a subsequent opportunity to appear before the Commission.

The ACCM Chair may dismiss an appeal as administratively defective if the school fails to abide by these procedures, including:

  • Failing to file a timely Notice of Appeal
  • Failing to specify the specific grounds for the appeal in the Notice of Appeal with supporting evidence
  • Failing to submit the required fee or deposit against costs
  • Not being current in the payment of its fees to the ACCM and not settling the payment of arrears within one week of being advised that the Reconsideration/Appeal would be dismissed if payment were not remitted immediately.

The following ACCM accreditation actions are subject to reconsideration:

  • Continuation of accreditation but programme placed on probation
  • Denial of accreditation
  • Withdrawal of accreditation

The following ACCM accreditation actions are subject to appeal, following an unsuccessful outcome of reconsideration:

  • Denial of accreditation
  • Withdrawal of accreditation

5.1 Reconsideration

If the leadership of the medical education programme wishes to request reconsideration of an ACCM accreditation decision, the medical school dean must address this request to the ACCM Secretariat within 30 calendar days from the date of the written accreditation letter containing notice of the ACCM action.

If a request for reconsideration is not received by the ACCM within 30 calendar days of the date of the written accreditation letter containing notice of the ACCM action, the ACCM’s initial action shall constitute the final action by the ACCM.

The request should outline the reasons for the reconsideration, i.e. that the ACCM accreditation action relating to non-compliance with ACCM standards was not supported by evidence or was not made in substantial accordance with ACCM policies and procedures.

The reconsideration shall be limited to the time and circumstances that triggered the ACCM action (e.g., an inspection report, status report). Descriptions of changes made since that time will not be considered.

Independent review panel

The Independent Review Committee shall be appointed by the ACCM Chair and shall consist of three individuals who are former ACCM members or who otherwise meet the qualifications for ACCM membership. No person shall be included on an Independent Review Committee for a given programme if he or she has participated in an inspection visit that triggered the ACCM action; has reviewed recent inspection findings, status reports, or other ACCM findings or conclusions regarding that programme on behalf of ACCM; or has a conflict of interest as determined under the ACCM Conflict of Interest Guidelines.

Reconsideration procedure

The ACCM Secretariat shall forward to each of the members of the Independent Review Committee the following materials, which shall constitute the Review Record: a complete file of all documents concerning the programme that were available to the ACCM and upon which the ACCM relied in the action that is the subject of the reconsideration.

At the conclusion of its review of the documentation, the Panel shall determine by majority vote whether substantial evidence supports the existence of each of the cited areas of noncompliance with accreditation standards and/or whether ACCM policies and procedures were substantially followed. They will then determine whether the adverse action should be affirmed, modified or reversed.

The decision of the Independent Review Panel shall constitute the final decision which will be communicated to the ACCM Board. The ACCM Secretariat shall notify the school in writing of the Independent Review Panel decision, in a timely manner.

Costs of reconsideration

A school filing notice of a review is required to pay all expenses incurred by the Commission in connection with the review. Reimbursable expenses include travel, lodging, meals and any other incidental expenses.

In addition, the School will be required to pay a non-reimbursable fee to the Commission. Upon receipt of the notice of a request for review, the Chair of the Commission will estimate the total reimbursable costs and will request advance payment from the school. Any unused funds will be refunded after the reconsideration process.

The appeal process is an administrative, not a judicial proceeding and therefore, is not subject to legal rules of evidence, cross examination, subpoena of witnesses, objections to testimony etc. Throughout the process the burden of proof rests with the school to demonstrate clear and credible evidence to support one or more of the grounds for appeal.

Composition of the Board of Appeal

The Board consists of all members of the ACCM Commission, excluding those with any conflict of interest (e.g. those involved in the site visit) with an external Chair, appointed by the ACCM.

Filing an Appeal Suspends Execution of the Accreditation Decision

An accreditation decision is not considered final during the period of appeal. The school is given a reprieve from further action by the Commission until the conclusion of the appeal process. Furthermore, the school is entitled to all the rights and privileges that existed prior to the decision. However, the Commission is permitted to disclose to all enquirers that the school is appealing a decision.

The Notice of Appeal

The school initiates an appeal by filing the notice of appeal. The notice must be filed in writing within 30 calendar days after the decision of the review was notified to the school. The appeal may only present arguments and documents that were submitted to the Commission as part of the original inspection. The school may not introduce new arguments or documents other than the notice of appeal.

In general, the notice of appeal should summarise and present evidence why the decision should be overturned. The appeal should be organised and presented in the following format:

Introduction

In this section, the school should state that it is appealing a decision of the Commission or conditions imposed on the school. The school should also summarise the history of events which led up to the appeal.

List of findings, conditions and decision(s) which the School does not contest

In this section, the school should identify the findings, conditions and decisions with which the school agrees with and does not contest.

List of findings, conditions and decision(s) the School is appealing

In this section, the school should identify the findings, conditions and decisions that the school is appealing.

List of documents used for the appeal

In this section, the school should list in chronological order all documents it intends to use in the appeal. Each document should be identified by date, authorship, and the name of the organisation.

Arguments

In this section, the school presents its arguments. The arguments should be organised in the same order as they appear in the Commission notification letter. The school should keep its arguments succinct so that issues under appeal are narrowly focused.

Declaration, Date, and Signature of Appellant

In this section, the chief academic officer declares that the information provided is accurate and complete. S/he then dates and signs the appeal.

The notice of appeal is forwarded to the ACCM Secretariat.

Scheduling of Appeal

Upon receipt of the notice of formal appeal, the chair of the Board of Appeal must schedule a hearing. The chair notifies the school of the time and place of the hearing and membership of the Board. The chair must convene the hearing within 90 days of receipt of the request for an appeal. The school must be represented at the hearing of the appeal in person. Hearings of the Board of Appeal shall be held in Dublin, Ireland.

Hearing before the Board of Appeal

In considering the appeal, the board must review:

  1. The Profile/Annual Database
  2. The Institutional Self-study
  3. The inspection team report
  4. The notice of accreditation decision of the Commission
  5. All correspondence related to the action under consideration between ACCM and the school
  6. The notice of appeal
  7. The decision of the Review Committee
  8. Oral presentation by representatives of the school

Decision of the Board of Appeal

After reaching its decision, the Board must prepare a written report that outlines its findings and recommendations. The decision may affirm, modify or reverse the original accreditation decision. The decision and the report must be notified to the school within 30 days of the hearing. The decision of the Board of Appeal is final and there can be no further appeal.

Withdrawal of Appeal

The school may withdraw its appeal at any time before the final decision is reached, but will be responsible for all costs to date. The appeal process is suspended upon receipt of a letter from the chief academic officer stating the school’s desire to withdraw the appeal.

Cost of the Appeal

A school filing notice of appeal is required to pay all expenses incurred by the Commission in connection with the appeal even if the appeal is withdrawn.

Reimbursable expenses include:

  • Travel
  • Lodging
  • Meals
  • Legal expenses
  • Other incidental expenses

The School will be required to pay a non-reimbursable fee for an appeal. In addition, the school will be required to lodge an advance for ACCM expenses. Further advances may be necessary depending on the complexity and duration of the process. Should any part of these advances be unused, it will be reimbursed to the school. The ACCM Schedule of Fees is reviewed annually and available for applicant schools on request.

Appendix 6: ACCM Procedure for handling complaints about programme quality

Standard 10.6 addresses Student Complaints.

Only those complaints will be investigated that, if substantiated, may constitute non-compliance with accreditation standards. The submission should reference the relevant Standard(s). Complaints will only be accepted from the complainant. In exceptional circumstances, ACCM will accept a complaint from a representative of the complainant – for example, the parent of a student – and in these circumstances the written consent of the student must be submitted. Complainants must provide evidence that the complaint has already been addressed by the school through the relevant internal school procedures following which a decision/recommendation/conclusion has been issued.

ACCM will ensure that schools under accreditation publish on their website and in their student handbook the contact information for ACCM, so that unresolved student complaints about programme quality, which indicate a departure from the standards outlined in the Standards of Accreditation, may be addressed.

ACCM will not intervene on behalf of an individual complainant regarding matters of admission, appointment, promotion or dismissal of faculty or students. In its overall review of medical schools, ACCM will ensure that appropriate procedures are in place to handle these internal matters.

Any complaints about educational programme quality must be submitted in writing to ACCM. Anonymous complaints will not be considered. The complaint should contain as much information as possible about the circumstances that form the basis of the complaint and should cite the relevant accreditation standard/s in question. If such a complaint does appear to indicate non-compliance with the Standards of Accreditation further information may be requested from the complainant.

ACCM will endeavour to maintain the confidentiality of complaints and of the corroborating material. However, information about a programme/school may be released by law or necessity, at the discretion of ACCM, to fully investigate the complaint. The complainant and any corroborators will be required to sign an authorisation to release the relevant documentation and to authorise the release of information required by ACCM. ACCM will consider the complaint and, if appropriate, request further information from the Chief Academic Officer of the medical school, to be submitted within 30 days.

If the matter/s complained of cannot be dealt with by correspondence, a limited site visit by an ad hoc Sub-Committee of ACCM will be carried out. The Sub-Committee will report to the next scheduled ACCM board meeting. The decision ACCM will be conveyed to the complainant and to the medical school within 30 days of this meeting.

The decision of the ACCM complaints process is final and there is no appeal.

Appendix 7: Government Resolution to approve ACCM as Accrediting Agency

  1. The Government reviews the Standards and Procedures of ACCM and by formal resolution finds such standards and procedures appropriate.
  2. By formal resolution, the Government approves ACCM as the accreditation agency for the particular medical school concerned and sends ACCM a Letter of Resolution accordingly.
  3. The Government issues an invitation to ACCM to undertake the evaluation of the medical school.
  4. The complete Process of Accreditation takes place in four stages. After a Stage 1 Preliminary Assessment (see Appendix 10) ACCM will examine the Profile Database (Stage 2) and Self-Study documentation (Stage 3) from the medical school which may be submitted in advance or concurrently with the Government’s invitation. If the information contained in the Profile Database and Self-Study is deemed to be satisfactory, ACCM will arrange for an inspection visit to be made to the pre-clinical campus (Stage 4). This Stage 4 Inspection cannot take place until the Letter of Resolution has been sent to ACCM. During this visit the ACCM inspection team will expect to meet with the appropriate Minister and/or Head of Government and the Heads of Agreement will be submitted to the Government for signature.
  5. After the visit, the inspection team will report to the next ACCM Board Meeting and a decision is then made as to whether ACCM is able to accredit the medical school or whether it recommends actions on the part of the school before the school can be accredited.

If the decision is to undertake accreditation, the following steps are required in order to formalise the appointment of ACCM as the Government’s medical accreditation agency:

  • ACCM will appoint a Convenor.
  • Where appropriate, ACCM is authorised by the Government to work with the U.S. Department of Education and to receive reports and information on behalf of the Government concerned.
  • The Government send ACCM the Letter of Resolution (see 2 above)
  • An Accreditation Agency Agreement (Heads of Agreement) is signed between ACCM, the Government and the medical school to formalise the understanding between the three parties.
  • The Convenor undertakes to provide to the Government inspection and mid-cycle inspection reports on activities ACCM has undertaken during the previous year in relation to its role as accrediting agent.

Appendix 8: Review of Standards of Accreditation

The ACCM conducts planned reviews of all accreditation standards over a five-year cycle. In the course of a planned review ACCM may solicit comment from appropriate stakeholder groups, including medical school leadership and faculty regarding the importance and clarity of the standards.

In addition to planned reviews the ACCM may also re-evaluate any existing standards when circumstances warrant. If the ACCM determines a need to revise one or more standards, action will be taken at the next meeting of the ACCM Board. The ACCM will seek comment from schools accredited by ACCM prior to initiating the needed change(s).

Requests for new standards or modification to existing standards are sent to the ACCM Secretariat for initial review. If the suggestion for change or for a new standard is deemed to have merit it is referred to the ACCM Board for further action.

Any new or revised standard adopted by the Board will be published on its website and in the ACCM Standards of Accreditation for a Medical School along with the date and academic year in which the standard will be effective.

Final decision on the content of any accreditation standard is at the sole determination of the ACCM Board.

Appendix 9: Student Participation in the Accreditation Process

When a school is informed of an upcoming ACCM accreditation review, the student body should be notified of the proposed dates and briefed on its role in the accreditation process. The students should be invited to establish a committee (ISA committee) to coordinate their input into the accreditation review and the school should provide appropriate administrative support. The committee members should be selected or approved by the student body and include students from all class years.

Student Participation in the Self-Study

Students should be included on the institutional self-study task force and on any committees on which they can provide meaningful input. Each review committee should contain appropriate membership for its specific topic, and students ought to participate in review of areas that affect their education and student life.

Preparation of the Independent Student Analysis (ISA)

The ISA process consists of the creation and dissemination of a student opinion questionnaire and the development of a report (the ISA) that includes the questionnaire results and an analysis and interpretation of the responses.

The process for creating the questionnaire and analyzing the data should be coordinated by the ISA committee. The ISA committee should develop and disseminate a student opinion questionnaire to each medical student class, using the required items in the questionnaire (provided by ACCM together with the self-study questionnaire) and adding items relevant to the school. The questionnaire should include questions that directly relate to ACCM accreditation standards and should have space for students to add comments.

In addition to conducting a survey of student opinion, the ISA committee may also choose to hold one or more class meetings or focus groups to discuss student concerns, or request that each class submit reports delineating areas that require attention.

Once the committee has collected its data, the committee or a subgroup of members should analyze and summarize the data and prepare the report to be submitted to ACCM as part of the self-study packet.

Student Participation in ACCM inspections

While it is desirable that the inspection team should meet with a representative group of students from all class years, the nature of the inspection location may determine this. For example, a site inspection of a pre-clinical campus will involve a meeting with year 1 and year 2 students, while a clinical site inspection will involve year 3 and possibly year 4 students.

Ideally, the student group should include some who were directly involved in the questionnaire design, data analysis, and the drafting of the ISA and who are familiar with the ISA results. These meetings could take place via video-conference or in person.

The medical school and its programmes are more likely to be effectively represented if the student attendance is balanced between those selected by medical school officials (administrators and faculty) and by the students themselves. The inspection team would likely be concerned if students had no voice at all in deciding which of them met with the team.

As well as meeting formally with the ACCM inspection team, the students may act as guides for the tour of the campus/clinical site facilities, providing the team with a further opportunity for student feedback.

Appendix 10: Procedures for New Applicant Medical Schools

ELIGIBILITY REQUIREMENTS:

At the present time ACCM will only consider applications from a medical school that:

  • Is in operation.
  • Sponsors one or more degree programmes leading to the MD degree or equivalent.
  • Has a published mission statement.
  • Has admission policies which are published, and appropriate for the school’s stated educational goals.
  • Discloses all information to ACCM deemed necessary for evaluation.
  • Is chartered, licensed and authorised to award the M.D. degree or equivalent by the regulatory body that governs education institutions in the country. Documentary evidence must be provided.
  • Is governed by a board of trustees/directors who are neither employed by, nor maintaining a business relationship with the medical school.
  • Employs a full-time Chief Executive Officer, Chief Academic Officer and a full administration staff.
  • Has the necessary administrative, educational, financial and learning resources to fulfil its educational goals.
  • Has assembled a faculty whose members possess appropriate qualifications in their areas of instruction

PROCEDURES:

The following four step procedure is used for schools applying for accreditation for the first time.

Schools will not be permitted to proceed to Stage 4 unless formal Government approval for ACCM to act as the accreditation agency has been received by ACCM. In order to avoid delay, schools are encouraged to seek Government approval at the point when they are invited to proceed to Stage 2. Stages 2 and 3 do not imply any commitment on the part of ACCM to proceed to Stage 4.

  • Stage 1. On receipt of the initial enquiry from a school, a preliminary assessment will be made to determine whether the school is eligible for consideration. This assessment, made on analysis of the school’s website and other publicly available information, will consider geographical, quality and viability criteria. ACCM will either decline the request for accreditation, or invite the school to continue to Stage 2. ACCM may reject an application at Stage 1 without any explanation.
  • Stage 2. Initial review. On receipt of the invitation to proceed to Stage 2, the following information should be submitted to ACCM, together with the initial application fee.
    • The Annual Database;
    • A brief self-assessment of the school’s compliance with ACCM’s Standards of Accreditation (maximum 2 pages);
    • A brief description of the school’s ownership, financial situation and future plans (maximum 2 pages).

Within one month, ACCM will either decline the request for accreditation or invite the school to proceed to Stage 3. ACCM may reject an application  at Stage 2 without any explanation.

  • Stage 3. On receipt of the 2nd application fee, an in-depth assessment of documentation submitted by the school will be considered by a team of Commissioners. The following additional documentation is required for the Stage 3:
    • The Self-Study document.

Within two months, a report will be considered by ACCM and a determination made as to whether the candidate school merits a full accreditation review.

Prior to proceeding to Stage 4, the school must obtain a Letter of Resolution indicating formal Government approval for ACCM to act as the accreditation agency for the school. Stage 4 may not proceed without such approval (see Appendix 7).

  • Stage 4. A Full Accreditation Review (FAR), to include on-site inspections of the medical school campus, the administrative headquarters and affiliated clinical sites (see Appendices 1 and 3 for details).

On the basis of the report of the inspection team, a decision will be made by the ACCM Board at its next meeting regarding accreditation status, which is then communicated to the school and relevant stakeholders.

An Accreditation Agency Agreement (Heads of Agreement) is required between ACCM, the Government and the medical school to formalise the understanding between the three parties.

Appendix 11: Procedures for Developing Schools

(See Footnote 6)

The accreditation review process for a new medical education programme formally begins when the chief executive officer or equivalent of the institution planning to offer the new programme submits a formal letter to the ACCM stating the goal of seeking ACCM accreditation. The letter must affirm that the medical education programme intends to meet the following eligibility criteria:

1. That the school is committed to complying with the ACCM Standards, ACCM Procedures, any revisions that may be adopted by the Commission from time to time, and that the school agrees to abide by the decision of the Commission and to hold it blameless for any adverse accreditation decision.

2. The school further agrees to indemnify the Commission for disclosing to the public and any agencies its accreditation decision.

3. The school fully discloses all information to the Commission deemed necessary for its evaluation and states that the information submitted is a true and accurate account of the facts.

4. The school is authorised to award the M.D. degree (or equivalent) by the regulatory body that governs educational institutions in that country / territory.

5. The school has identified a board of trustees/directors to govern the school who are neither employed by nor maintain ongoing business relationship with the school.

6. The school has identified a full-time chief executive officer, a full-time chief academic officer, and a full-time staff of professional managers, and secretaries for the administration of the school.

7. English will be the language of instruction.

If authorization has not already been granted, the developing applicant school must have applied for MD-granting authority from the entity/agency of the government that grants such authorization in the institution’s home country/ territory. ACCM will not initiate the process of preliminary accreditation review until such authority is in place.

ACCM will only consider developing school applications from medical education bodies that in the opinion of the ACCM Board, have a proven track record in medical education as evidenced by the ownership/operation of another established medical school or health sciences programme. The application should be from individuals with the appropriate experience and financial support to operate a medical school. ACCM will also take into consideration the geographical location of the medical school and clinical sites and the feasibility of travel to such sites.

Before a developing medical education programme admits its charter class, it must be legally authorized under applicable law in the country/territory to provide a medical education programme leading to the MD degree and must have received degree-granting authority.

If there are appropriate plans to meet these eligibility criteria, the program will be required to pay the application fee as described under Fees for Accreditation Reviews and will then be listed on the ACCM website as an Applicant. A programme with applicant status is not accredited.

ACCM reserves the right to deny applicant status without stated reason and without appeal.

Step 1: Consideration for preliminary accreditation

Upon receiving Applicant status, the ACCM will direct the applicant programme to conduct a self-study and to complete a Database Questionnaire for Preliminary Accreditation. These documents includes all accreditation standards and accreditation elements that are deemed by the ACCM to be essential prerequisites for a charter class to be admitted. Developing schools that have not yet enrolled students should provide an implementation plan with a timeline for each standard and indicate those elements of a standard that may need more time for full implementation.

If a developing program granted applicant status does not submit the completed Database Questionnaire for Preliminary Accreditation and Planning Self-Study Document within 18 months, its applicant status will lapse, and it must re-apply and pay the reapplication fee (see Fees for Accreditation Reviews).

At one of its regularly scheduled meetings, the ACCM Board will review the completed Database Questionnaire and the Planning Self-Study to determine if sufficient progress has been made to warrant an on-site inspection. This responsibility may be delegated to the ACCM Executive Management Group. The school will retain applicant status until the onsite inspection has been performed and the report has been reviewed by the ACCM Board.

A developing medical education programme may have a total of three reviews for preliminary accreditation status. The timing between reviews for preliminary accreditation status will be no sooner than 12 months and no later than 18 months from the last date of denied candidate status. If the ACCM does not grant preliminary accreditation status after the third review, the programme must re-apply for applicant status and pay a resubmission fee, as described under Fees for Accreditation Reviews. Denial of preliminary accreditation status, which allows an opportunity to reapply, is not subject to appeal.

Once the ACCM agrees to proceed to a consideration of preliminary accreditation, the ACCM Secretariat will schedule a survey visit (see Costs of Inspections in Procedures for details of the costs incurred by the programme in inspections). After that visit, the team will prepare a report for the ACCM Board to consider at one of its regularly scheduled meetings. If, after review of that report, the ACCM determines that the medical education programme has made sufficient progress toward compliance with relevant accreditation standards and toward satisfactory performance in accreditation elements for this stage in its development and has developed satisfactory plans for its educational programme, it will grant preliminary accreditation. If minor issues related to performance in accreditation elements are noted, the ACCM may grant preliminary accreditation but require written status reports addressing the issue(s). Once the ACCM grants preliminary accreditation, the programme may begin reviewing and accepting applications for enrollment. Preliminary accreditation becomes effective as of the date that the ACCM Board acts to grant preliminary accreditation status. Preliminary accreditation status will never be applied retroactively.

On being granted preliminary accreditation, the programme is required to pay the annual registration fee (see Fee Schedule), which shall then be paid annually for such time as the programme remains accredited by ACCM.

If the ACCM denies preliminary accreditation to the programme, the decision may be appealed according to the ACCM Accreditation Procedures Appendix 5. Procedures for Reconsideration and Appeals. A programme that has been finally denied preliminary accreditation may not reapply for a period of one year from the time of the final decision to deny accreditation. If students are admitted after preliminary accreditation has been denied, the program will forfeit its eligibility for reapplication for preliminary accreditation until its medical educational programme has graduated at least one class.

Step 2: Evaluation for provisional accreditation

The purpose of the review for provisional accreditation is to evaluate progress to date in the implementation of the medical education programme and the status of planning for later stages of the programme. After the programme admits a charter class, it must complete the Database Questionnaire for Provisional Accreditation and have the student body conduct an Independent Student Analysis (ISA). The review for provisional accreditation, which typically occurs when the first entering class is in the second year of the curriculum, includes all 13 accreditation standards and a focused set of elements appropriate for a medical education programme at this stage of its development. No institutional self-study is required in the review for provisional accreditation. Schools being reviewed for provisional accreditation will have an inspection visit. See Costs of Inspections in Procedures for details of the costs incurred by the programme in inspection visits. The ACCM will grant provisional accreditation if, from its review of the inspection report, it identifies no significant areas of concern related to performance in accreditation elements, compliance with standards, and planning for the later stages of the medical education programme. The ACCM may require one or more written status reports if there are minor areas that require follow-up. Provisional accreditation becomes effective as of the date that the ACCM Board acts to grant provisional accreditation status. Provisional accreditation status will not be granted retrospectively.

If, after the provisional inspection visit, the ACCM determines that there are significant issues related to performance in accreditation elements and/or compliance with standards that could be resolved within a relatively short period of time, it may continue the programme’s preliminary accreditation instead of granting provisional accreditation. If the ACCM continues a programme’s preliminary accreditation, it may expect the programme to delay plans for a class size increase and focus its resources on students already enrolled. The ACCM may also place the programme on warning or on probation. The specific actions taken by the ACCM will determine the nature and timing of further reviews. The ACCM will schedule a status report or a limited inspection to address the cited areas, bearing in mind the need for the programme to demonstrate compliance with all standards within two years. If the programme demonstrates satisfactory performance and compliance based on review of the status report or limited inspection, the ACCM Board may then grant provisional accreditation, which will never be applied retroactively.

If the ACCM Board determines that a programme has failed within a specified time depending upon the nature of the concern to remedy the problems identified at the time that its preliminary accreditation was continued, it will give notice to the medical school that it intends to withdraw preliminary accreditation. A decision to withdraw preliminary accreditation is subject to appeal in accordance with the ACCM Accreditation Procedures Appendix 5. Procedures for Reconsideration and Appeal. If the ACCM withdraws preliminary accreditation after an appeal or after the programme has waived its right to appeal, the programme may not reapply for ACCM accreditation for a period of one year from the date that the final decision to withdraw accreditation was communicated in writing to the institution. At that time, the programme may reapply by submitting a new application and an application fee as described under Fees for Accreditation Reviews.

Step 3: Evaluation for full accreditation

For medical education programmes with provisional accreditation, the ACCM Secretariat will schedule a full accreditation inspection, typically when the first entering class is in the final year of the curriculum. A full accreditation inspection will be conducted in accordance with the ACCM Accreditation Procedures Appendices 1,3 and 4 and will include the administrative headquarters and all clinical sites in which students participate in clinical cores. All inspections are conducted in a predetermined and structured format to ensure that all teams evaluate individual schools with uniformity and consistency and cover all elements of the ACCM Standards of Accreditation. If clinical sites and / or the administrative headquarters are geographically distant from the pre-clinical campus, the onsite inspection may take up to one year to complete. See Costs of Inspections in Procedures for details of the costs incurred by the programme in inspection visits.

If the ACCM Board determines that the programme demonstrates satisfactory performance in accreditation elements and compliance with accreditation standards, it will grant accreditation for a period of three years. A full six-year period of accreditation will not be granted at the first full inspection. If the ACCM finds minor performance/noncompliance issues it may grant full accreditation but require additional status reports. Full accreditation becomes effective as of the date the ACCM Board votes to grant full accreditation status and will never be applied retroactively.

If the ACCM Board determines that there are performance and noncompliance issues that could be resolved within a relatively short period of time, it may continue the programme’s provisional accreditation status for a specific period of time and schedule a status report or a limited inspection visit to address compliance/performance issues. If the ACCM continues provisional accreditation, the programme may be expected to delay plans for a class size increase and focus its resources on students already enrolled. If the programme demonstrates satisfactory performance and compliance based on ACCM review of the status report or survey visit, the ACCM may then grant full accreditation.

If the ACCM determines that performance and noncompliance issues remain that cannot be resolved within a relatively short period of time, it will give notice that it intends to withdraw provisional accreditation. A decision to withdraw provisional accreditation is subject to appeal in accordance with the ACCM Accreditation Procedures Appendix 5. If the ACCM withdraws provisional accreditation after an appeal or after the programme has waived its right to appeal, the programme may not reapply for ACCM accreditation for a period of one year from the date the final decision to withdraw was communicated in writing to the institution. At that time, the programme will be required to submit a new application for accreditation, along with a new application fee as described under Fees for Accreditation Reviews.

A medical education programme must achieve full ACCM accreditation within five years from the date that the ACCM granted provisional accreditation. If this does not occur, the ACCM will withdraw the current accreditation status achieved by the medical education programme and require the programme to wait one year to submit a new application for accreditation, along with a new application fee, as described under Fees for Accreditation Reviews. Withdrawal of accreditation is subject to appeal as outlined in ACCM Accreditation Procedures Appendix 5.

Schedule of reports and inspections for schools with Provisional Accreditation Status

A developing school that has been granted preliminary accreditation may begin admitting its First year class. It is also required to submit annual database reports and submit to an onsite inspection in Year 2 and Year 4. See Costs of Inspections in Procedures for details of the costs incurred by the programme in inspection visits. If circumstances change, or if a concern is noted on an annual database, the school may be required to undergo a non-routine inspection as outlined in the ACCM Accreditation Procedures Appendix 2.

First Year

The school is required to complete an Annual Database and a status report. The Commission reviews the educational programme already under way and the plans for the implementation of the second, third and fourth-year programmes. The Commission prepares a brief report of its observations and recommendations.

Second Year

The school is required to complete an Annual Database and Independent Student Analysis and submit to an on- site inspection before the end of the second year. The Commission reviews the educational programme of the second year and the plans for clinical instruction during the third and fourth years. The Commission prepares a brief report of its observations and recommendations.

Third Year

The school is required to complete Annual Database and status reports. The Commission reviews the educational programme of the third year and advises the school on any deficiencies. The Commission also prepares a brief report of its observations and recommendations. The school submits to a full accreditation inspection of all clinical sites in which students participate in clinical cores.

Fourth Year

The school submits to a full accreditation inspection of the preclinical campus, the administrative headquarters and any new clinical sites or sites that were not inspected in Year 3. Annual Database and Institutional Self-study Reports must be submitted to the Commission at the beginning of the fourth academic year.

Footnotes:

1. Medical School refers to programmes leading to an MD Degree.

2. Fully operational refers to schools that have graduated at least one class of medical students.

3. A clinical site is a hospital or clinic incorporating a clinical teaching structure where the medical student teaching programme is directly controlled by the medical school. Each clinical department delivering a core rotation is staffed by physicians who are faculty members of the medical school and who report to the chief of the department or the course director.

4. ACCM may grant a medical education program an indeterminate term if ACCM identifies a need for the program to document credible and timely plans to address ACCM findings of non-compliance or unsatisfactory performance before specifying the end of the accreditation period.

5. ACCM is currently reviewing the process for conducting a mid-cycle inspection based on the revised Standards and Procedures.

6. The procedures for developing schools are adapted from the LCME Rules of Procedures. A developing school is one that has not yet admitted a medical school class. ACCM is not currently accepting applications from schools that have enrolled but not yet graduated a class of medical students.