Peer review site visit Peer review site visit reportingreporting

Dr. Nehal KhamisDr. Nehal Khamis

ProceduresProcedures

Portions of the survey report specifically assigned to Portions of the survey report specifically assigned to individual team members should be completed on site individual team members should be completed on site or sent to the team secretary within 7-10 days of the or sent to the team secretary within 7-10 days of the visit.visit.

The team secretary and the chair should require team The team secretary and the chair should require team members to use this guide when preparing their members to use this guide when preparing their individual sections. individual sections.

Team secretaries should use the survey report Team secretaries should use the survey report template including embedded tables, to ensure template including embedded tables, to ensure consistency across survey team reports. consistency across survey team reports.

The team secretary is expected to complete the draft The team secretary is expected to complete the draft report shortly after the visit (4 to 6 weeks is optimum).report shortly after the visit (4 to 6 weeks is optimum).

The secretary is responsible for The secretary is responsible for organizing and editing the organizing and editing the contributions from the other team contributions from the other team members, to ensure that the overall members, to ensure that the overall report is coherent, logical, and report is coherent, logical, and internally consistent. internally consistent.

If important areas have been omitted If important areas have been omitted from a team member’s write-up, it is from a team member’s write-up, it is the team secretary’s responsibility the team secretary’s responsibility either to contact that member for either to contact that member for additional details, or to supply the additional details, or to supply the missing content.missing content.

Team members and the team secretary Team members and the team secretary should feel free to include additional should feel free to include additional appendix material, but this should be appendix material, but this should be selected judiciously.selected judiciously.

It is necessary for the team secretary to It is necessary for the team secretary to compare the body of the draft report with compare the body of the draft report with the set of strengths, noncompliance, and the set of strengths, noncompliance, and transition issues identified by the survey transition issues identified by the survey team, to ensure that all summary findings team, to ensure that all summary findings are well documented in the text.are well documented in the text.

The team chair and secretary should edit The team chair and secretary should edit the report for the propriety of any the report for the propriety of any attribution to individual faculty members, attribution to individual faculty members, administrators, or students. administrators, or students.

While the commentary of individuals who While the commentary of individuals who meet with the team may be important for meet with the team may be important for documentation, citation of such comments documentation, citation of such comments in the report should be avoided wherever in the report should be avoided wherever possible.possible.

The draft survey report should first be sent for initial review The draft survey report should first be sent for initial review to the two LCME Secretaries. After the team secretary to the two LCME Secretaries. After the team secretary receives feedback from the Secretariat, the report should receives feedback from the Secretariat, the report should be modified as necessary and sent on to: be modified as necessary and sent on to:

(1) each member of the survey team, and(1) each member of the survey team, and (2) the dean of the medical school. (2) the dean of the medical school.

The team secretary should ask for comments to The team secretary should ask for comments to be returned within 7 to 10 working days. be returned within 7 to 10 working days.

If feedback from team members requires changes in If feedback from team members requires changes in findings, tone or content that the dean has not had an findings, tone or content that the dean has not had an opportunity to review, the secretary should call the dean or opportunity to review, the secretary should call the dean or send revised pages for review before finalizing the report. send revised pages for review before finalizing the report.

The dean should specifically be asked to correct The dean should specifically be asked to correct any errors of fact and respond to the draft report any errors of fact and respond to the draft report in writing, even if there are no corrections. in writing, even if there are no corrections.

The team chair and secretary should attempt to The team chair and secretary should attempt to resolve any disagreement that the dean may resolve any disagreement that the dean may have with the tone or conclusions of the report.have with the tone or conclusions of the report.

If significant irreconcilable differences remain, If significant irreconcilable differences remain, the dean should be invited to write a letter to the the dean should be invited to write a letter to the principal LCME Secretary for inclusion with the principal LCME Secretary for inclusion with the printed report.printed report.

The final, corrected report (with all The final, corrected report (with all appendices) should be sent to the appendices) should be sent to the LCME office indicated in the team LCME office indicated in the team mailing, along with copies of all mailing, along with copies of all correspondence between the team correspondence between the team secretary and the dean regarding the secretary and the dean regarding the draft report. draft report.

THE REPORT OF A FULL ACCREDITATION SURVEY

COVER PAGE. Use the cover page from the survey report template, adding specific details such as school name and survey date.

TABLE OF CONTENTS (including that for the Appendix).

World Health OrganizationWorld Health OrganizationEastern Mediterranean Regional OfficeEastern Mediterranean Regional Office

(WHO-EMRO)(WHO-EMRO)ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

ــــــــــــــــــــــــــــــــــــــ

Accreditation of Egyptian Health Professions Education Accreditation of Egyptian Health Professions Education Institutions Project, Phase IIIInstitutions Project, Phase III

Survey ReportSurvey ReportOn the PilotOn the Pilot

Peer- reviewing site visit Peer- reviewing site visit To To

The Faculty of Medicine,The Faculty of Medicine,October 6 UniversityOctober 6 University

"FOM-O6U""FOM-O6U"

Conducted on the:Conducted on the: October 1st , 2005October 1st , 2005

TABLE OF CONTENTS [SAMPLE]TABLE OF CONTENTS [SAMPLE]

Covering memorandum from team secretaryCovering memorandum from team secretary

IntroductionIntroduction

Summary of survey team findings Summary of survey team findings

Prior accreditation survey or progress reportPrior accreditation survey or progress report

The medical education database and school The medical education database and school

self studyself study

History and setting of the school History and setting of the school

Summary of survey team Summary of survey team findingsfindings

DISCLAIMER: DISCLAIMER: The summary findings that follow represent the The summary findings that follow represent the

professional judgment of the ad hoc survey team that visited the professional judgment of the ad hoc survey team that visited the

FOM-O6U on the 1st of October, 2005, based on the information FOM-O6U on the 1st of October, 2005, based on the information

provided by the school and its representatives before and during provided by the school and its representatives before and during

the accreditation survey, and by the project. The WHO, EMRO may the accreditation survey, and by the project. The WHO, EMRO may

come to differing conclusions when it reviews the team’s report come to differing conclusions when it reviews the team’s report

and any related information.and any related information.

The survey team findings are summarized in the following The survey team findings are summarized in the following

checklists as received from the team members following the visit:checklists as received from the team members following the visit:

CRITERIA AND GUIDELINES CRITERIA AND GUIDELINES SITE VISIT TEAM ASSESSMENTSITE VISIT TEAM ASSESSMENT

Area of StrengthArea of Strength Area of Weakness Area of WeaknessArea in TransitionArea in Transition

Mission and Objectives Mission and Objectives 1.1.1.1. StatementStatement √ √1.2.1.2. FocusFocus √ √1.3.1.3. Clarity √Clarity √1.4.1.4. Academic Excellence √Academic Excellence √1.5.1.5. Dissemination √Dissemination √1.6.1.6. Assessment Assessment

and Participationand Participation √ √1.7.1.7. Educational OutcomesEducational Outcomes √ √

TABLE OF CONTENTS [SAMPLE]TABLE OF CONTENTS [SAMPLE]

I. Institutional settingI. Institutional setting

II. Educational programII. Educational program

III. Medical students III. Medical students

IV. FacultyIV. Faculty

V. Educational resourcesV. Educational resources

After the paragraph introduction, list the members of the survey team, giving their names, titles and institutions, and their roles in the survey team as chair, secretary, member, or faculty fellow.

SUMMARY OF SURVEY TEAM SUMMARY OF SURVEY TEAM FINDINGSFINDINGS

Summarize the survey team's findings Summarize the survey team's findings under the following headings: under the following headings: – "Areas of Strength," "Areas of Strength," – "Areas of Partial or Substantial "Areas of Partial or Substantial

Noncompliance" (and, if appropriate, Noncompliance" (and, if appropriate, "Areas in Transition"). "Areas in Transition").

– Findings within each of these categories Findings within each of these categories should be listed in the order of the should be listed in the order of the sectionssections

The summary of team findings should The summary of team findings should begin with the following text:begin with the following text:

DISCLAIMER: The summary findings that DISCLAIMER: The summary findings that follow represent the professional follow represent the professional judgment of the ad hoc survey team that judgment of the ad hoc survey team that visited [school name] from [visit dates], visited [school name] from [visit dates], based on the information provided by based on the information provided by the school and its representatives before the school and its representatives before and during the accreditation survey, and and during the accreditation survey, and by the LCME. The LCME may come to by the LCME. The LCME may come to differing conclusions when it reviews the differing conclusions when it reviews the team’s report and any related team’s report and any related information.information.

Areas of StrengthAreas of Strength

(1) an aspect of the medicalschool (1) an aspect of the medicalschool that is deemed critical for the that is deemed critical for the successful achievement of one or successful achievement of one or more of the school’s missions or more of the school’s missions or goals, or goals, or

(2) a truly distinctive activity or (2) a truly distinctive activity or characteristic that would be worthy of characteristic that would be worthy of emulation.emulation.

Strengths should relate to positive Strengths should relate to positive institutional outcomes and should not institutional outcomes and should not simply reflect the school’s simply reflect the school’s compliance with accreditation compliance with accreditation standards. Strengths should be listed standards. Strengths should be listed in bulleted format, and do not require in bulleted format, and do not require citation of relevant accreditation citation of relevant accreditation standards.standards.

Areas of Partial or Substantial Areas of Partial or Substantial NoncomplianceNoncompliance

Findings of noncompliance should use the following format:Findings of noncompliance should use the following format:(1) the number and text of the standard (1) the number and text of the standard (2) a paragraph or bulleted list delineating the principal evidence (2) a paragraph or bulleted list delineating the principal evidence

indicating noncompliance.indicating noncompliance.

An example of the preferred format follows:An example of the preferred format follows:MS-24. To the extent possible, a school should develop its own MS-24. To the extent possible, a school should develop its own

resources for providing financial aid to students, thereby reducing resources for providing financial aid to students, thereby reducing their dependence upon external sources. Tuition has gone up by an their dependence upon external sources. Tuition has gone up by an average of seven percent in each of the past four years, while the average of seven percent in each of the past four years, while the level of institutional funding for grants and scholarships has level of institutional funding for grants and scholarships has decreased by an average of three percent per year over that period. decreased by an average of three percent per year over that period. Student indebtedness now exceeds $130,000 on average, with Student indebtedness now exceeds $130,000 on average, with federal loans comprising over 90% of the student debt portfolio.federal loans comprising over 90% of the student debt portfolio.

If a noncompliance issue relates to multiple standards, the team If a noncompliance issue relates to multiple standards, the team should identify that standard which most closely reflects the should identify that standard which most closely reflects the underlying issue. Any related standards can be mentioned in the underlying issue. Any related standards can be mentioned in the body of the report.body of the report.

Areas in TransitionAreas in Transition These findings indicate significant events or These findings indicate significant events or

activities taking place which, depending on their activities taking place which, depending on their final outcome, could result in noncompliance with final outcome, could result in noncompliance with one or more accreditation standards. Examples of one or more accreditation standards. Examples of such events include recurring decreases in a such events include recurring decreases in a major funding source (like state allocations or major funding source (like state allocations or practice plan revenues), reorganization of the practice plan revenues), reorganization of the school’s administrative leadership, or school’s administrative leadership, or fundamental changes in the structure or fundamental changes in the structure or implementation of the educational program. implementation of the educational program. Items in transition should be listed in bulleted Items in transition should be listed in bulleted format, and do not require citation of relevant format, and do not require citation of relevant accreditation standards.accreditation standards.

It is essential that noncompliance and It is essential that noncompliance and transition issues be fully documented in the transition issues be fully documented in the body of the report; where possible, the basis body of the report; where possible, the basis for judging an item as an institutional for judging an item as an institutional strength should also be adequately strength should also be adequately documented in the narrative of the report. documented in the narrative of the report. The documentation in the body of the report The documentation in the body of the report regarding noncompliance and transition regarding noncompliance and transition issues should give a sense of relative issues should give a sense of relative magnitude of the problem, indicate if it has magnitude of the problem, indicate if it has persisted for a lengthy period, and identify persisted for a lengthy period, and identify any progress towards resolution.any progress towards resolution.

PRIOR ACCREDITATION SURVEY(S) PRIOR ACCREDITATION SURVEY(S) AND PROGRESS REPORT(S)AND PROGRESS REPORT(S)

Summarize the key findings and Summarize the key findings and recommendations of the most recent recommendations of the most recent survey.survey.

THE MEDICAL EDUCATION DATABASE THE MEDICAL EDUCATION DATABASE AND INSTITUTIONAL SELF-STUDYAND INSTITUTIONAL SELF-STUDY

Comment on the organization, Comment on the organization, completeness, and internal completeness, and internal consistency of the database. Were consistency of the database. Were quantitative data (applicant quantitative data (applicant numbers, admissions data, USMLE numbers, admissions data, USMLE scores, financial information, etc.) scores, financial information, etc.) updated to the current year?updated to the current year?

Comment on the self-study, in terms of the Comment on the self-study, in terms of the degree of participation by medical school degree of participation by medical school faculty, administrators, students, and others; faculty, administrators, students, and others; the comprehensiveness and depth of analysis; the comprehensiveness and depth of analysis; thethe

organization and quality of the conclusions organization and quality of the conclusions and recommendations; and the dissemination and recommendations; and the dissemination of the report’s findings to the academic of the report’s findings to the academic community. Note the degree to which the community. Note the degree to which the survey team's major conclusions are survey team's major conclusions are concordant with those of the self-study.concordant with those of the self-study.

Comment on the methods used in the students' Comment on the methods used in the students' self-study, including the level of student self-study, including the level of student participationparticipation

obtained. Note whether/how the results of the obtained. Note whether/how the results of the student self-study will be used in the survey student self-study will be used in the survey report. Also note if other sources of data, such as report. Also note if other sources of data, such as the Association of Medical Colleges Medical School the Association of Medical Colleges Medical School Graduation Questionnaire (AAMC GQ), will be used Graduation Questionnaire (AAMC GQ), will be used (provide the response for the AAMC GQ). Include (provide the response for the AAMC GQ). Include in the Appendix a listing of the various self-study in the Appendix a listing of the various self-study task forces and committees, and a copy of the task forces and committees, and a copy of the overall or executive summary of the self-study overall or executive summary of the self-study findings (not the complete self-study report).findings (not the complete self-study report).

HISTORY AND SETTING OF THE HISTORY AND SETTING OF THE SCHOOLSCHOOL

Briefly summarize the history of the school. Describe the setting of the medical school in

terms of its public or private status, and its relationship with the parent university, health sciences center, geographically separate campuses/programs, and principal teaching hospital(s).

Describe the geographic relationships of the main campus to major clinical teaching sites and, where appropriate, remote campuses; include relevant maps in the Appendix.

ComponentsComponentsI. INSTITUTIONAL SETTING

A. Governance and Administration B. Academic Environment

II. EDUCATIONAL PROGRAM A. Educational Objectives B. Structure C. Teaching and Evaluation D. Curriculum Management E. Evaluation of Program Effectiveness

III. MEDICAL STUDENTS A. Admissions B. Student Services C. The Learning Environment D. Student Perspective

IV.FACULTY A. Number, Qualifications, and

Functions B. Personnel Policies C. Governance

V. EDUCATIONAL RESOURCES A. Finances B. General Facilities C. Clinical Teaching Facilities D. Library/Information Services

List of AppendicesList of AppendicesAppendix 1: October 6 University bookletAppendix 1: October 6 University bookletAppendix 2: Mission, general and specific objectives of the Appendix 2: Mission, general and specific objectives of the

schoolschoolAppendix 3: Student's and staff questionnaires for objectives Appendix 3: Student's and staff questionnaires for objectives

formulation formulation Appendix 4: Histology course, objectives and specifications.Appendix 4: Histology course, objectives and specifications.Appendix5: Examples of student records, " the training Appendix5: Examples of student records, " the training

guidelines: activities and skills for medical students" guidelines: activities and skills for medical students" program.program.

Appendix 6: School by-laws for undergraduate students.Appendix 6: School by-laws for undergraduate students.Appendix 7a: Examples of written exams (2005).Appendix 7a: Examples of written exams (2005).Appendix 7b: Measures to improve student assessment, faculty Appendix 7b: Measures to improve student assessment, faculty

council minutes.council minutes.Appendix 8a: Students admission requirementsAppendix 8a: Students admission requirementsAppendix 8b: Numbers of students in different educational Appendix 8b: Numbers of students in different educational

years (2005-2006).years (2005-2006).Appendix 8c: Curriculum committee constitutionAppendix 8c: Curriculum committee constitution

List of AppendicesList of AppendicesAppendix 9: Tuition fees and financial aid servicesAppendix 9: Tuition fees and financial aid servicesAppendix 10: Youth care office students' servicesAppendix 10: Youth care office students' servicesAppendix 11: Students committee compositionAppendix 11: Students committee compositionAppendix 12: Students feedback checklistAppendix 12: Students feedback checklistAppendix 13: Dean and staff efficiency reports Appendix 13: Dean and staff efficiency reports Appendix 14: Staff appointment policy. Appendix 14: Staff appointment policy. Appendix 15: Staff development activitiesAppendix 15: Staff development activitiesAppendix 16: Faculty participation in one of the tempus Appendix 16: Faculty participation in one of the tempus

projectsprojectsAppendix 17: Financial budget of the year 2004-2005.Appendix 17: Financial budget of the year 2004-2005.Appendix 18: October 6 University Teaching hospital brochure.Appendix 18: October 6 University Teaching hospital brochure.Appendix 19:Agreements between the October 6 University Appendix 19:Agreements between the October 6 University

Teaching Hospital and other Health Care Institutions and Teaching Hospital and other Health Care Institutions and mother hospitals for exchange of expertisemother hospitals for exchange of expertise

Appendix 20: The organizational structure of the facultyAppendix 20: The organizational structure of the facultyAppendix 21: Examples of job description statements Appendix 21: Examples of job description statements

Organization of Report BodyOrganization of Report Body

The body of the report should give The body of the report should give the team's narrative description and the team's narrative description and comments, referring as needed to comments, referring as needed to database items or other documents database items or other documents collated sequentially in the Appendix collated sequentially in the Appendix at the rear of the report. at the rear of the report.

The report should be careful to The report should be careful to differentiate team commentary from differentiate team commentary from that of the institution.that of the institution.

Please make a reference in the narrative Please make a reference in the narrative text to material that is included in the text to material that is included in the Appendix, e.g., "See charts of organization Appendix, e.g., "See charts of organization in the Appendix” or “See Appendix X for in the Appendix” or “See Appendix X for membership of admissions committee and membership of admissions committee and characteristics of applicants and characteristics of applicants and matriculants.” matriculants.”

The Table of Contents should show the The Table of Contents should show the title and page number of each Appendix title and page number of each Appendix document.document.

follow carefully the “Style Guide for follow carefully the “Style Guide for Report Preparation” at the end of this Report Preparation” at the end of this guidebook, especially the guidebook, especially the requirements that material be on one requirements that material be on one side of the page only, and that the side of the page only, and that the type style be conventional (for type style be conventional (for example, Times New Roman, 11pt as example, Times New Roman, 11pt as in the survey report template).in the survey report template).