Accreditation

Accreditation for health educational programs is an opportunity for continuous quality improvement. Graduating from an accredited educational program demonstrates that graduates have attained a level of entry-to-practice competencies required for health care professionals.

Accreditation facilitates the achievement of quality program that leads to quality health care professionals and ultimately, improved patient care. As one of the shared resources within the Rady Faculty, the SPAU is committed to providing exceptional service in meeting the accreditation needs of educational programs by delivering best practices, administrative support and innovative solutions in a reliable and efficient manner.

The accreditation process starts with the writing of a self-assessment report that encompasses components such as program curriculum, program governance, faculty, staff, program evaluation and continuous quality improvement (CQI).

After the self-assessment report is submitted, external accreditation reviewers will conduct interviews with faculty, staff and students during site visit, which usually takes two to three days. On the last day, the reviewers generate a series of findings and recommendations to improve the quality of educational programs.

Proper planning is a key to success for program undergoing an accreditation. Our team members have several years of experience in assisting programs with their accreditation planning and providing admin supports throughout the accreditation process. Accreditation is a continuous quality improvement exercise; therefore, programs are recommended to start planning between 18-24 months prior to the site visit. Book a meeting with our team to start planning for your accreditation.

At our meeting we will review tools and services to support the accreditation process. These include:

Overview – of available program resources and the type of accreditation support being requested.

Proposed timeline – this includes key milestones such as data collection phase, site visit dates, drafting of reports and recommended scheduling. For example, meetings with senior university leadership must be booked as early as possible. Rooms for in-person accreditation site visits must also be booked early.

Project tracker – a tool designed to identify evidence required to meet the standards or requirements.

Checklist – a list of activities for accreditation, including who will be responsible for each task.

Data collection – when preparing for accreditation, programs need stakeholders’ input to determine program performance data such as surveys. The SPAU is available to create and distribute stakeholder surveys and prepare preliminary results (e.g., student, alumni, employer surveys) that will be used in the self-assessment report. We can also offer training on LimeSurvey.

Aside from site visit, the largest part of the accreditation process is the self-assessment report writing.

As the content experts, programs are required to write the self-assessment report. The SPAU is available for providing gap analysis, proofreading, formatting and converting the report into an easy-to-navigate and professional-looking document.

We can provide the following support to get the program started:

• A written template populated with narratives based on the previous self-assessment (Primer)
• Document management in Teams or SharePoint (we can provide training on how to use Teams/SharePoint, if needed)
• Tracking of required evidence and collating documents

The program will be required to review and validate the draft accreditation report (self-assessment report and appendices) before submission. 

The program and the SPAU will have regular meetings throughout the project to monitor the progress of the self-assessment report and ensuring a successful submission by the deadline. When the accreditation report package is complete, the SPAU can submit it to the accrediting body with a signed cover letter by the dean, Rady Faculty of Health Sciences.

After submission, the accrediting body and the reviewers may require additional documentation or updates. The SPAU will support the programs in meeting this requirement.

Programs should engage with the faculty and staff who will be meeting with the accreditors prior to the site visit.

The main goals of the preparatory workshops are to create awareness about the program’s accreditation process and build a sense of community by learning together about the program’s successful initiatives and opportunities for improvement.

The accreditation preparatory workshops also provide a great opportunity for recognition of faculty, students and clinical teachers’ achievements.

The preparatory workshops should take place after the submission of the self-assessment report or a few weeks before the site visit. 

The preparatory workshop can be done in various ways:

• Accreditation boot camps can be organized in a hybrid format: plenary and world café (virtual or face-to-face)
• Mock interviews/small group sessions facilitated by the SPAU team. Topics are related to program accreditation and are consistent with the self-assessment report
• Newsletters/fact sheets
• Short video presentations tailored to different group of stakeholders

The SPAU assists programs with workshop or session related logistics.

The SPAU is available to host the Program site visit virtually or in-person.

Preparing a site visit for health educational programs requires significant amount of coordination between the program, its faculty, staff, clinical instructors, preceptors and students. 

Our unit supports programs with their site visit logistics. This includes:

• preparing agendas
• sending calendar invites
• catering orders
• meeting room bookings
• hotel reservations
• arranging surveyors’ transportation to and from school
• creating signage
• hosting in-person and virtual site visits

The SPAU is available to design and develop Quality Improvement projects and action plans in response to accreditation findings.

After the site visit, our unit supports in responding to recommendations. We assist with drafting of status reports and in the implementation of Accreditation Monitoring Plans.

• Status (Progress) Report – SPAU provides templates, gap analyses and finalizes status reports before submission to the accrediting body. We also prepare cover letters signed by the dean of Rady Faculty, or the dean of the college to accompany the status report.
• Accreditation Monitoring Plan (AMP) – SPAU will co-develop a plan to collect and evaluate data to satisfy accreditation requirements for status reports such as accreditation monitoring plan or improvement projects. Having an annual accreditation monitoring plan or improvement projects plan will alleviate the burden of accreditation works for the next cycle.

As part of our mandate, we also foster and keep the institutional memory for accreditation content and processes in the Rady Faculty of Health Sciences. We ask programs to send us the final report and decision letters from the accrediting body as we collect and manage these documents to preserve institutional memory. With leadership and staff turnover, it is a good way to maintain the accreditation-related information within the Rady Faculty office.