Accreditation Process

Application

To apply for accreditation, Medical Schools should apply via the SMART IMEAc program. The link to the program is
https://accreditation.imeac.org/#/pages/login


Accreditation Process

It is the policy of IMEAc that the accreditation process following international protocol with Transparency and Trust, Heartiness, Accountability and Fairness and Integrity.

1. Quality Assessment Requirements

1.1 Eligibility for Assessment

To be eligible for quality assessment, the applying medical school must fulfill the following condition:

  • The medical school and education program has been approved by the university council.

1.2. Requirements for Assessment

The applying medical school shall meet all the following requirements stated by IMEAc and assessors to ensure that the quality assessment is carried out efficiently and effectively.

  • Prepare an in-depth self-study report as indicated in item 3.2.1;
  • Fulfill all assessment, administrative and logistics requests made by IMEAc office and assessors for the purpose of carrying out the assessment efficiently and effectively;
  • Release and share best practices in IMEAc Benchmarking Database;
  • Pay the full assessment fees within 30 days before the site visit assessment.

1.3. Requirements for Logistics and Facilities

The logistics and facilities to be provided by the applying medical schools are as follows:

  • Preparing and arranging the site visit activities including opening and closing sessions, interviews, site tour, etc. as specified by assessor team;
  • Providing meeting rooms and secretarial support with all necessary equipment for the assessment team to discuss and prepare report and presentation;
  • Providing internet access to all assessors throughout the assessment;
  • Providing local transport between affiliated hospitals/institutes and other assessment site(s);
  • Providing meals as specified by IMEAc office;
  • Providing escorts or security personnel inside and outside the assessment site(s), if necessary

2. Accreditation Process and Procedure

 IMEAc is responsible for the accreditation of educational program and medical schools through our quality assessment. The accreditation process consists of the following steps: 1) medical school self-study, 2) application and assessor assignment, 3) site visit, and 4) assessment report and decision on accreditation.

2.1. Medical School Self-Study

The medical schools seeking accreditation have to prepare an in-depth self-study report (self-assessment report, SAR), using the IMEAc SAR template (see Appendix 3.1). This template consists of their respective ‘Organization Profile’ and all the 199 standards of TMC.WFME.BME standards (2017). SAR shall meet the following requirements:

  • The SAR should be written in font TH SarabunPSK or TH Sarabun New size 14 or in English font Times New Roman size 12. Organization chart, administrative medical program chart and a glossary of abbreviations and terminologies used in the report should be provided;
  • The SAR should not be more than 150 A4 pages. The content of the SAR should consist of:
    • Part 1: Introduction
      • Executive summary of the SAR
      • Organization profile: Brief description of the medical school, faculty and department – outline the history, vision, mission, assets, human resources (number of faculty staff and support staff), stakeholders, and other quality assessment and assurance frameworks used by the medical school
      • Details of medical student intake: number of student intake per year, track of entry and number of students in each track
      • Details of teaching hospital used for educational process including pre-medical, pre-clinical and clinical teaching
        • Site of pre-medical, pre-clinical and clinical teaching
        • Number of students in each site
        • Hospital bed capacity, bed occupancy rate per year, number and categories of patients
        • Mission
        • Academic activities and academic environment
        • Faculty staff-to-student ratio (for major wards including Medicine, Surgery, OB-GYN and Pediatrics)
        • Student-to-hospital bed ratio and student-to-outpatient ratio in each clinical year — years 4, 5 and 6)
        • Physical facilities (library/information center/student housing)
        • Academic administration including administrative structure and its responsible department (for private hospital)
      • Details of, if any, all affiliated/community hospitals used for clinical teaching
        • Number of physicians
      • Faculty staff-to-student ratio (for major wards including Medicine, Surgery, OB-GYN and Pediatrics)
      • Student-to-hospital bed ratio and student-to-outpatient ratio in each clinical year — years 4, 5 and 6
      • Duration of clinical teaching/learning
        • Provision of community-based education (for community hospitals)
      • Part 2: Standard Criteria Requirements

This section contains the write-up on how the medical school addresses compliance with the following set of global standards. These standards are structured according to AREAS which are defined as broad components in the structure, process, content, outcomes/competencies, assessment and learning environment of basic medical education and cover:

  • Mission and outcomes
  • Educational program
  • Assessment of students
  • Students
  • Academic staff/faculty
  • Educational resources
  • Program evaluation
  • Governance and administration
  • Continuous renewal

As a guide to medical schools completing SAR, besides the SAR template, IMEAc sends documents containing suggested guidelines to programs undergoing self-study. Specifically, these documents address the writing of SAR and describe the types of supporting evidence required. These documents can be downloaded from the IMEAc website www.imeac.org

For new medical school, the process is similar. The new medical school will use different standard and SAR template. The “Standard Criteria for New Medical School” and SAR template can be downloaded from the IMEAc website www.imeac.org

2.2 Application and assessor assignment

Application

The medical school seeking accreditation has to send an official letter requesting for accreditation to TMC. Simultaneously, the medical school submits a copy of the letter, an application form, together with one hardcopy of the SAR and the digital files of SAR and supporting evidence stored on a flash drive, to the IMEAc office.

Pre-screening of SAR

Following the medical school’s application, IMEAc will screen whether the medical school is eligible for site visit assessment using checklist. If the SAR is needed to be rewritten or revised, the medical school must amend the SAR and resubmit it to IMEAc within time limit. Otherwise, the medical school must submit a new application according to the steps mentioned above, with an application fee.

Assessor Assignment

 If the medical school is eligible for site visit assessment based on the pre-screening result of SAR, the assessment team will be appointed by the IMEAc director based on assessor’s background, experience and ability. The process for appointing assessors starts from assessor selection out of the registered assessor pool, to declaration of no conflict of interest, and official acceptance from the applicants. Each team typically consists of four assessors, usually no more than six members, from different medical schools.

2.3 Site Visit

 Site visit will take place approximately 3-4 months after IMEAC’s office has received application.

The assessors will carry out their assigned roles and tasks as outlined in item 5.2 of Chapter 5. The assessors need to establish contact with the members of the assessment team(s) and IMEAc office. It is important that the SAR reaches all assessors within 10-12 weeks before site visit so that the assessors have sufficient time to carry out individual assessment and seek clarification with the medical school to be assessed if needed. Accordingly, IMEAc will notify the medical school to send a set of SAR and supporting evidence directly to each of the rest of assessor members (except for lead assessor who has already received it at the time of SAR pre-screening) and another one set to IMEAc office.

The assessor team conducts a site visit according to the protocol. The assessor team informs the program of the site visit schedule ahead of time. To provide guidance to the site visit team on conduct of the site visit, IMEAc prepares the instruction and templates for the assessor to use for site visit assessment (see Assessor Guidance in Appendix 3.2).

Pre-work before site visit

Prior to site visit, the assessors independently review all the elements stated in the SAR and subsequently identify issues to be clarified with the medical schools and may request additional evidence to be further verified onsite, using Pre-work before site visit form.

After the individual assessment, the lead assessor gathers all of the reviews and communicates with team members to exchange his/her findings in a consensus meeting. The lead assessor facilitates and plans to clarify the SAR with the medical school and requests some more evidence, if necessary. The responses from the medical school will be used by the assessors to determine the specific areas and subareas to be verified at the site including the clinical training centers.

Schedule and Itinerary of Site Visit

The assessor team is required to prepare the schedule and itinerary of site visit. A typical site visit takes three days. An assessment itinerary may spread over 1-5 days, depending on the type of quality assessment, and the size and complexity of the medical school to be assessed.

Site visit consists of an opening meeting with key administrative representatives of the medical school. The opening meeting is normally followed by a presentation of the Dean or the Program director. After which, interviews would be held with the various stakeholders. Site tour may be arranged between the interviews or after the interviews. The assessment will conclude with an exit meeting.

During site visit, IMEAc will have one representative of IMEAc office to accompany the assessor team. The IMEAc representative will represent IMEAc in the opening and closing meeting and observe the assessment process. He or she will not intervene the assessment process. In the IMEAc Board meeting he or she cannot vote for accreditation decision of that medical school.

An opening meeting with the host medical school administrative representatives should be held prior to the commencement of the actual site visit activities. The purpose of the brief opening meeting is to:

  • Introduce the members of the assessment team to the host medical school administrative representatives
  • Establish official communication links between the assessment team and the host medical school
  • Review scope and objectives of the assessment
  • Confirm details of the assessment plan and schedule
  • Allow the host medical school to introduce the institute and its program normally done through a presentation

Normally, the site visit activities include:

  • Opening session
  • Site assessment
  • Interviews with stakeholders: administrative teams, academic staff/faculty, support staff, medical students, alumni, etc.
  • Document reviews
  • Main campus tour including branch campuses (if any): teaching and learning facilities, laboratories, library, dormitory, and other learning resources, etc.
  • Visits to teaching hospitals and all affiliated hospitals (with the study duration of 3 months and above) used for clinical clerkship
  • Observation of on-site activities
  • Report preparation by the assessor team
  • Exit meeting: oral feedback for the preliminary key findings of the assessment and site visit including strength and opportunity for improvements

IMEAc has provided the forms to be used for assessor team during site visit, which include Assessor worksheet (form B or Z), Assessor Worksheet for Site Visit at Affiliated Hospitals (form C), and Preliminary report to be verified by the applicant (form D).

The assessor will subsequently generate a preliminary report.

 

2.4. Assessment Report and Decision on Accreditation

IMEAc has its decision making process. After site visit, an assessor team will fill the forms B, C and D. The medical school has an opportunity to review the preliminary result of assessment and respond to the findings or comments of the assessor team within two weeks. The medical school can respond to the preliminary result in any of 2 options (as shown in form D) which are ‘Accept as presented’ and ‘Propose amendments’ and subsequently confirms the findings in form D. The response from the medical school together with the evidence will be considered by the assessor team before submitting form D (the confirmed version) for consideration of Review Committee. Then, the assessor team prepares assessment summary (form E) from the findings in forms B, C and D (the confirmed version). The assessment summary will be reviewed by Review Committee appointed yearly by IMEAc. The Review committee comprises one representative from IMEAc Executive Board, experts from medical schools and external experts from other health professions. This committee will review the assessment summary (form E) and finalize key issues in the assessment report (form A) to be submitted to the Executive Board for approval and certification. The director of IMEAc is responsible for creating the final report based on all evidence, the on-site findings, and Review Committee’s conclusion. The report contains brief organization profile, strengths, opportunities for improvement, suggestions, and detail of not met standards. The main findings are drawn from the gist in the earlier filled forms of B, C, D, and E provided by the IMEAc office.

Decisions on accreditation must be based solely on the fulfilment or lack of fulfilment of the criteria or standards.

The categories of accreditation are:

  • Full accreditation. For the maximum period of six (6) years if ALL basic standard criteria (“B” criteria) are fulfilled, but with the provision that the IMEAc can visit the school at any time if the school performance is not adequate or if some standards are not met during the accreditation period. The medical program of the medical schools must be revised within six (6) years after being accredited. If the medical school fails to have newly revised medical program being accredited within six (6) years, the accreditation status will be automatically changed into “Accredited with condition” for 12 months. If the medical school still fails to have newly revised medical program being accredited within another 12 months, the accreditation status of that medical program will turn to be “Not accredited”.
  • Accreditation with condition(s). This status will be issued when the assessed medical school does not fully comply with ALL basic standard criteria (“B” criteria). Those criteria not fully met are partially met and are minor ones considered to have no serious impact on overall quality of medical education. The medical school is regarded that it has potential to solve the deficiencies within time limit, as specified and approved by the IMEAc Board. The other condition is the medical school fails to have newly revised medical program being accredited after time limit as described above.
  • Denial or withdrawal of accreditation. This decision can be taken, if many basic criteria or standards are not fulfilled, signifying severe deficiency in the quality of the program that cannot be remedied within a short period of time.

Once the final assessment report and accreditation is endorsed by IMEAc Executive Board, the result will be sent to Thai Medical Council (TMC) via COTMES. Then after consideration in the meeting, TMC will send the accreditation result and findings to the applying medical school. The accreditation status of all medical schools will be posted on IMEAc website. Best practices observed during the assessment will be included into the IMEAc Benchmarking Database.

The accreditation status stays valid for six (6) years. Accredited medical schools will submit annual progress reports to confirm that they comply with current standards. In case some gaps are identified, IMEAc will offer advice in writing and propose consultations/visit on request.

At any time, the IMEAc Executive Board has the right to revoke the accreditation status of medical school through the Medical Council if it fails to honor and fulfill its public and social duties, undertakings and obligations to its stakeholders.

3. Assessment Scheme and Fees

3.1. Assessment Scheme

The accreditation certificate which will be provided after the assessment period by IMEAc is valid for six (6) years only.

3.2. Assessment Fees

To maintain the sustainability of the IMEAc quality assessment system, it is imperative that the adequate funding and financial support be secured with consistency.

The assessment fee schemes for medical school undergoing IMEAc accreditation are as follows:

Item

Fee

1. Administrative Fee to IMEAc 

To be announced yearly by IMEAc

(Paid by host)

2. Local Hospitality (meals, transportation and accommodation)

Paid by host

3. Honorarium for Lead Assessors

Paid by IMEAc

4. Honorarium for Assessors

Paid by IMEAc

The above fee includes honoraria of assessors. All other expenses occurring during site visit, such as transportation of the assessors, transportation between the main campus and teaching/affiliated/community hospitals, meals and accommodation are taken care by medical school.