The impact of an accreditation system on the quality of undergraduate medical education in Saudi Arabia
thesisposted on 27.02.2017, 03:15 by Alrebish, Saleh Ali
The accreditation of undergraduate medical education is a universal undertaking. Despite the widespread adoption of accreditation processes and an increasing focus on accreditation as a mechanism to ensure minimum standards are met in various fields, there is little evidence to support the effectiveness of accreditation. The new accreditation body in Saudi Arabia, the National Commission for Academic Accreditation and Assessment (NCAAA), is viewed anecdotally as a positive development; however, its effect on the quality of medical education has not been formally assessed. This thesis uses a mixed methods approach to address this gap in understanding. Accreditation systems for undergraduate medical educational programs can have many goals including ensuring minimal quality standards are met; encouraging continuous improvement; fostering international recognition of medical programs; guaranteeing that students and graduates of accredited programs have comparable opportunities in the global market; and providing relevant stakeholders with transparent and credible information on the quality of various educational programs. Limited published research was found on the impact of accreditation and its outcomes, with the majority of literature comprising opinion pieces. While many studies provide speculative evidence about the value and impact of accreditation, they are commonly narrow in scope; many are from specific geographical areas and only a few are in the field of undergraduate medical education. Therefore, the value of accreditation in medical education remains to a certain extent unclear, with many unanswered questions regarding its legitimacy, influence and effectiveness. In addition, confounding factors such as internal quality management, external evaluation, and other developmental processes like student capacity, teacher ability and natural improvement, make the causes and effects of accreditation difficult to analyse. The theoretical frameworks for this thesis were chosen in light of the research questions, the literature review and the context and nature of accreditation in Saudi Arabia, which is administered by a mandatory governmental regulatory body. The Hogwood and Gunn (1984) policy analysis model was chosen as a theoretical framework for this thesis as well as Boud’s concept of ‘sustainable assessment’; both hone in on the purposes of accreditation and stakeholders’ experience of accreditation, particularly in relation to perceptions of the long-term impact of accreditation on programs. This study consists of two phases, guided by the theoretical framework and the literature review findings, for evaluating the impact of accreditation processes. Phase one of the study involved a comprehensive review of international accreditation models and comparison between these and the Saudi model in relation to the purpose of accreditation and accreditation procedures. Secondly, phase one entailed a systematic review of the evaluation of accreditation processes and quality assurance mechanisms in international higher education generally and medical education specifically. Phase two of the study used a mixed methods approach. Three key approaches were employed to explore the research questions. Quantitative data on graduate performance was analysed pre- and post-accreditation, document analysis was undertaken (self-review and external panel reports), and interviews and focus groups were conducted with students, educators and medical education leaders to examine the perceived impact of the NCAAA on the quality of undergraduate medical education. Analysis of the quantitative graduate performance data showed a significant increase in pass rates following the accreditation process. Although these pass rates have increased, it was important for students and educators to provide feedback to the researcher about how accreditation has impacted on the educational process. A majority of students and educators concluded that the accreditation process had been helpful in improving the learning experiences of medical students, especially female students, in Saudi Arabia. Some changes included greater power for student bodies, improved teaching and learning practices, opportunities for student feedback, and better extracurricular facilities. Thus, the NCAAA has played a crucial role in promoting change in medical schools. However, building an effective quality culture takes great effort and time on the part of all members of the organisation. Improving quality in medical colleges is not a one-person job. It needs to involve different stakeholders in the planning and implementation stages. As the external driver of higher education quality, the NCAAA needs to be a supportive body, rather than a punitive one, in order to achieve the goal of implementing a quality culture and continuous quality improvement. Otherwise, the danger is that unless stakeholders in medical schools believe in quality as a culture, and gain knowledge and skills in how to evaluate and change practices, seeking accreditation will be a superficial exercise characterised by ‘ticking boxes’ and ‘performing well on the day.’ In this study, respondents emphasised the need for a specialised body to regulate medical schools in Saudi Arabia. A specialised body is needed because the NCAAA, in its current capacity, cannot regulate medical schools in Saudi Arabia, given the huge expansion of medical schools in a short period of time. However, by creating standards specifically for medical schools and supporting the NCAAA with more quality assurance experts from health professional backgrounds, the accreditation process could become more focused, easier to carry out, and more effective. This thesis examined the impact of the NCAAA on undergraduate medical education and identified key ways that the process has influenced quality, and at times, constrained productive educational practices. Of particular importance were stakeholders’ variable experiences of accreditation. Some study participants expressed the view that the process added stress and burden, and that the resultant changes were short-term in nature, as they were undertaken in order to satisfy the examiners during the site visit. In contrast, other participants gave vastly different accounts of accreditation and its impact. These participants raised the concept of developing a quality culture through accreditation, and highlighted the importance of leadership and the development of targeted ‘quality’ roles in order to monitor and improve practices over time. Analysis of the data led the researcher to assessment literature in higher education, which describes the ‘double duty’ assessment can serve within a ‘sustainable assessment’ model. This paradigm was borrowed to develop a model of ‘sustainable accreditation’ in medical education. The characteristics of sustainable accreditation are outlined in this study, and it is hoped that these features may reach policy makers and educators, prompting more effective practices in medical education accreditation in Saudi Arabia. The implications of this study for the accreditation body and related quality assurance sectors, stakeholders, and future researchers in accreditation of medical education practice, are also outlined.