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U.S. Department of Education

 

Initial Comparability Determination for Barbados

 
Prepared September 2016
 
Background
 
Barbados is seeking an initial determination from the NCFMEA that the accreditation standards it uses to evaluate its medical school are comparable to those used to evaluate programs leading to the M.D. degree in the United States.

The University of the West Indies (UWI) was formally chartered in 1962 by royal decree as an entity independent from the University of London where it had its roots. Shortly after Barbados became independent in 1966, a UWI campus was established in Barbados called Cave Hill. (UWI is a regional university with campuses throughout the Caribbean.)

The School of Clinical Medicine and Research (SCMR) was then established on the Cave Hill Campus and provided clinical training on Barbados for students who had completed their basic medical education at UWI campuses on other islands. During 2008-2010 (through Ordinance 53) UWI had upgraded SCMR to become the Faculty of Medical Sciences at Cave Hill (Cave Hill). The purpose was to provide students with their entire medical training on Barbados and not just the clinical training portion.

The General Medical Council of Great Britain decided that it would no longer be responsible for the accreditation of medical schools outside of Britain and the European Union after 2003. As a result, several countries in the Caribbean banded together to establish a regional authority to provide independent accreditation evaluations of their medical schools. That regional accreditation authority is called the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP).

In 2005 the government of Barbados signed the agreement that had established CAAM-HP. Furthermore, in May 2016 the parliament of Barbados enacted legislation to specifically confirm its commitment to the 2005 agreement to use the accreditation services of CAAM-HP in Barbados.

Based on the information provided, it appears that Barbados has an evaluation system that is substantially comparable to that used to accredit medical schools in the United States. While Barbados has provided much information regarding the quality assurance system and standards used for medical education in that country, there are some areas where further information may be helpful. Those issues are noted in the Summary of Findings and the Staff Analysis sections.
 
Summary of Findings
 
Additional information is requested for the following questions. These issues are summarized below and discussed in detail under the Staff Analysis section.

-- It is unclear what process and standards were used by the Barbados Accreditation Council to grant institutional accreditation to Cave Hill for a period of six years. It is also unclear how that process and standards related to those used by CAAM-HP. [Approval of Medical Schools, Question 1]

-- The NCFMEA may want to question the country further regarding the distinctive regional control structure and the Cave Hill campus. [Approval of Medical Schools, Question 3]

-- How and when the new standard on a medical school’s external authority will be implemented, and if it will be applied to the Cave Hill campus, are still unclear. [Governance, Question 2]

-- It is unclear if student performance outcomes measures or benchmarks are considered of genuine value and would serve a significant role in the country’s accreditation process. [Student Achievement, Question 4]

-- It is unclear if the required complaint mechanism will be revised to incorporate the name and contact information of CAAM-HP. In addition, it is unclear if the required complaint mechanism will be revised to clearly inform students that they may submit complaints to CAAM-HP that are not resolved at the institutional level. [Student Complaints, Question 2]

-- It is unclear if Barbados would consider requesting a site visit report from CAAM-HP that would provide a comprehensive and concentrated focus on all of the aspects of the medical education taking place at the Cave Hill campus. [Onsite Review, Question 1]

-- It remains unclear whether CAAM-HP will conduct an on-site review at new clinical sites inside or outside of Barbados within 12 months of the placement of Cave Hill students at those sites. [Onsite Review, Question 3]

-- It is still unclear if CAAM-HP will be adopting a written policy specifying that if a clinical program is located in the United States, or in an approved (NCFMEA-listed) third country, that CAAM-HP must have conducted an on-site visit and approved that clinical training program. [Onsite Review, Question 5]

-- It is unclear what substantive changes must be reported to CAAM-HP one year in advance, and what deadlines are applied to other types of substantive changes. [Substantive Change]

-- The NCMEA may still wish to ask for current documentation demonstrating the application of CAAM-HP’s conflict of interest policy. [Conflicts of Interest, Inconsistent Application of Standards, Question 1]

-- It is still unclear what future discussions CAAM-HP plans to hold on incorporating at least rudimentary graduate performance data into its accreditation decision-making process. [Accrediting/Approval Decisions, Question 2]

-- It is still unclear if CAAM-HP has any plans to establish a structured mechanism for collecting data regarding each medical school’s graduates, including the range of performance data suggested by the NCFMEA guidelines, and to begin using that data in its decision-making process. [Accrediting/Approval Decisions, Question 3]

-- It is still unclear when CAAM-HP will realistically incorporate outcomes data analysis into its accreditation decision-making process. [Accrediting/Approval Decisions, Question 4]

 
Staff Analysis
 
PART 1: Entity Responsible for the Accreditation/Approval of Medical Schools
 
Approval of Medical Schools, Question 1
 
Country Narrative
Medical education in the Caribbean Community (CARICOM) began with 33 students in 1948 at the foundation of the University College of the West Indies (UCWI) at Mona, Jamaica as a constituent part of the University of London. Students graduated with the Bachelor of Medicine and Bachelor of Surgery degree, MBBS (London-UCWI).

In 1962, the UCWI sought independence from the University of London becoming The University of the West Indies (UWI) by Royal Charter (April 1962) hereinafter referred to as The Charter, which set out the legal standing of the University, with the authority to award its own degrees, Exhibit 1.

The Charter pre-dated Barbados’ Independence (November 30, 1966) and was enshrined in the country’s new Constitution. The Charter therefore has the force of law and no further instrument recognising its validity or binding nature on the Government is required. Barbados retains the British Monarchy as its Head of State.

The UWI expanded over the years and this saw the creation of other campuses including the Cave Hill Campus in Barbados in 1967 which started with the School of Clinical Medicine and Research. This clinical training and research site was upgraded in 2008 to a full Faculty of Medical Sciences offering the full five-year MB BS programme (Exhibit 2, Plans for Upgrading and Expanding School of Clinical Medicine and Research (SCMR), Cave Hill, 2008).

The UWI was not created by an individual government or country statute but conceived and nurtured as a regional institution to serve the needs of the English-speaking Caribbean territories which contribute financially to the operation of the University. Contributing countries are:

Anguilla, Antigua & Barbuda, The Bahamas, Barbados, Belize, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Grenada, Jamaica, Montserrat, St Kitts, St Lucia, St Vincent & the Grenadines, Trinidad & Tobago, Turks & Caicos Islands.

The Statutes and Ordinances of the Charter deal with the composition, powers and duties, for example, of The Council which is the University’s supreme governing body, Senate, Campus Councils, and faculties. The Senate regulates and manages the academic life of the University, subject to the Council’s control but it has the delegated power to award degrees, diplomas, to set degree and admission requirements, create or abolish faculties, revise curricula, devise and conduct examinations, appoint external examiners and deans of faculties and regulate student discipline. See paragraphs 7 and 13 of The Charter (Exhibit 1) and Statutes 19 and 21 of the Statutes and Ordinances (Exhibit 3).
 
Analyst Remarks to Narrative
As noted in the background section, several countries in the Caribbean banded together to establish a regional authority to provide independent accreditation evaluations of their medical schools called the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP). In 2005 the government of Barbados signed the agreement that had established CAAM-HP, and in May 2016 the parliament of Barbados enacted legislation to specifically confirm its commitment to the 2005 agreement to use the accreditation services of CAAM-HP in Barbados.

Currently, there is only one medical school in Barbados, the Faculty of Medical Sciences at Cave Hill (Cave Hill). Cave Hill is a campus of the University of the West Indies (UWI), which is headquartered on Jamaica (see background section). The Royal Charter of 1962 (amended 1972, cf. Exhibit 1) declared that the university’s Council would be the supreme governing body of UWI.

Although the Royal Charter gave the UWI Council ultimate authority, the Council delegated its authority over the entire academic life of the university to the UWI “Senate.” Since the Royal Charter predated the 1966 independence of Barbados, it became part of the new constitution of Barbados, which retains the British Monarchy as its Head of State.

CAAM-HP requires that a medical school has the legal authorization to operate in the country in which it is located. Typically, medical schools accredited by CAAM-HP can clearly document that they operate under the authority of their island government by maintaining official signed government documents specifically granting them permission to operate as medical schools.

However, in this case, Department staff is unclear where it officially states that Barbados has the primary authority to approve or deny the operation of a medical school in Barbados, since the authority seems to have been ceded to UWI.

Barbados is requesting a comparability determination from the NCFMEA, not CAAM-HP. Therefore, the issue of ultimate authority needs to be clearly documented because there is always the potential that another medical school, totally independent of UWI, could seek approval to operate in Barbados.

Furthermore, the country application introduced (under “Governance” section) the fact that the Barbados Accreditation Council (BAC) was established to register schools. However, no evidence was presented to document that the Cave Hill campus was ever registered with the BAC. Alternatively, it is unclear if the BAC’s authority would allow it to remove any registration that may have been granted to the Cave Hill campus. (It could be that Barbados only requires BAC’s approval of a medical school if it is a private for-profit school, but that distinction was not documented.)

As a result, it is unclear if the country would require a medical school to obtain a specific authorization from Barbados to operate, such as from its Parliament or from the Barbados Accreditation Council, and where that requirement is documented. Or is the Cave Hill enterprise unique because the country automatically approves any school, medical or otherwise, that the University of the West Indies wishes to establish in Barbados?

The NCFMEA may wish to inquire further regarding these matters.
 
Country Response
The Cave Hill Campus is a campus of the regional institution, the University of the West Indies (UWI) which is supported by all the contributing countries including the government of Barbados. It is therefore not a national institution. Any decision to close the medical school would have to be a regional decision and not a national decision.

The Cave Hill campus was registered by the Barbados Accreditation Council (BAC) in 2013 and subsequently received institutional accreditation for six years up to 2019.

Exhibits 37A and 37B are evidence of the registration of the Cave Hill campus and institutional accreditation by the BAC.

Private medical schools must be granted a charter by the government of Barbados, must be registered by the BAC and must meet CAAM-HP’s minimum requirements for initial provisional accreditation before accepting its first cohort of students.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear whether the country would require a medical school to obtain a specific authorization from Barbados to operate, such as from its Parliament or from the Barbados Accreditation Council, and where that requirement would be documented. Alternatively, it was asked whether the Cave Hill enterprise was unique because the country automatically approves any school, medical or otherwise, that the University of the West Indies wishes to establish in Barbados?

The country response covered a few aspects. First, any decision to close Cave Hill would have to be made regionally, and not by Barbados alone. Second, Cave Hill (as part of the University of the West Indies) was registered by the Barbados Accreditation Council (BAC) in October 2009 retroactively for all of 2009; and again registered by the BAC in October 2010 retroactively for the period January 2010 until December 2012.

Finally, in June 2013 the BAC granted institutional accreditation to Cave Hill for a period of six years.

It is unclear what process and standards were used by the Barbados Accreditation Council to grant institutional accreditation to Cave Hill for a period of six years. It is also unclear how that process and standards related to those used by CAAM-HP.

The NCFMEA may wish to inquire further regarding these matters.
 
Staff Conclusion: Additional Information requested
 
Approval of Medical Schools, Question 2
 
Country Narrative
As signatories to the Inter-Governmental Agreement establishing the CAAM-HP (Exhibit 4) the participating countries have empowered CAAM-HP with the responsibility for the monitoring and continued certification/licensure of medical schools. In addition, the government of Barbados has enacted local legislation to give effect to the Inter-governmental Agreement. This Act is cited as the Caribbean Accreditation Authority (Education in Medicine and Other Health Professions) (Incorporation) Act, 2016 (Exhibit 5).
 
Analyst Remarks to Narrative
In 2005 the government of Barbados signed the agreement that had established the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP). In May 2016, the parliament of Barbados enacted legislation to specifically confirm and reinforce the implementation of the 2005 agreement to use the accreditation services of CAAM-HP in Barbados to approve and monitor the medical school. (See Question 1 regarding issues surrounding functional authority.)
 
Approval of Medical Schools, Question 3
 
Country Narrative
With respect to the Cave Hill Campus of the UWI, should circumstances warrant closure of the medical school such a decision would be taken by The Council on the advice/recommendation of the Senate.
 
Analyst Remarks to Narrative
In Barbados there may be no governmental entity with the ability to close a medical school. The country application notes that the power to close the school rests not even with CAAM-HP, but with the Council of the University of the West Indies.

It is unclear what would happen if CAAM-HP recommended that Barbados close the medical school for academic reasons.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
The Cave Hill Campus is a campus of the regional institution, the University of the West Indies (UWI) which is supported by all the contributing countries including the government of Barbados. It is therefore not a national institution. Any decision to close the medical school would have to be a regional decision and not a national decision.

Medical schools which are not part of the regional structure of the UWI would be subject to the authority of the Government of Barbados. These schools are required to seek accreditation from the CAAM-HP as the designated accrediting body for medical schools in Barbados. Any decision regarding the accreditation status of a programme is communicated in writing by CAAM-HP to the Government of Barbados.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear what would happen if CAAM-HP recommended that Barbados close the medical school for academic reasons. The country response indicated that Barbados does not have the authority to close the Cave Hill medical school since it is a regional institution. However, should a medical school ever be established that is not part of a regionally-established institution then Barbados could close it if necessary.

The NCFMEA may want to question the country further regarding this distinctive regional control structure.
 
Staff Conclusion: Additional Information requested
 
Accreditation of Medical Schools
 
Country Narrative
On December 15, 2005 the Government of Barbados, a member of the Caribbean Community (CARICOM), a community of nations established and recognized under the Revised Treaty of Chaguaramas Establishing the Caribbean Community including the CARICOM Single Market and Economy, 1993, (Exhibit 6), signed the Inter-Governmental Agreement Establishing the Caribbean Accreditation Authority for Education in Medicine and other Health Professions (CAAM-HP), (Exhibit 4). Other members of CARICOM are, Antigua, Barbuda, The Bahamas, Barbados, Belize, Dominica, Jamaica, Grenada, Guyana, Montserrat, St Kitts & Nevis, St. Lucia, St. Vincent and the Grenadines, Suriname and Trinidad & Tobago. The CAAM-HP was officially launched on July 14, 2004 under the aegis of CARICOM as a legally constituted body empowered to determine and prescribe standards and to accredit programmes of medical, dental, veterinary and other health professions education on behalf of the contracting parties in CARICOM.

The Government of Barbados has enacted local legislation to give effect to the Inter-governmental Agreement (Exhibit 5).

With respect to the accreditation body, CAAM-HP, in 2011 the World Federation for Medical Education (WFME) granted recognition to the CAAM-HP as part of an evaluation and recognition process that WFME developed in collaboration with the Educational Commission for Foreign Medical Graduates’ Foundation for Advancement of International Medical Education and Research (Exhibit 7, WFME Recognition Letter). The CAAM-HP was the first accrediting agency to be recognized through this process and such recognition came after a formal review of the CAAM-HP’s standards and procedures. As stated in the WFME policy on the Recognition of Accrediting Agencies, “Recognition of an accrediting agency by the WFME Recognition Committee confers the understanding that an agency has been deemed to be credible in its policies and procedures to assure the quality of medical education in the programmes and schools it accredits”.

In 2013, 2014 and 2016, the NCFMEA reviewed the information regarding the CAAM-HP’s medical education accreditation activities contained in the application the CAAM-HP submitted on behalf of the governments of Antigua & Barbuda, Jamaica and Grenada respectively for an initial determination of comparability and determined that the standards and processes used by the CAAM–HP to accredit medical schools in Antigua & Barbuda, Jamaica and Grenada are comparable to those used to accredit medical schools in the U.S. (Exhibits 8A, 8B and 8C, NCFMEA Comparability Determination, Antigua, Jamaica and Grenada).

As stated in the CAAM-HP’s document Procedures of the Caribbean Accreditation Authority for Education in Medicine and other Health Professions, (Exhibit 9) under the heading, Functions of the Secretariat, sub-paragraph (e) the Secretariat shall provide information on the work of the Authority to the Contracting parties; furthermore, the section entitled, Reporting of CAAM-HP Actions to External Groups, states that the Contracting Parties will be notified, through the Secretary-General of CARICOM, within one month of final accreditation decisions taken at a CAAM-HP meeting.
 
Analyst Remarks to Narrative
CAAM-HP is the official entity responsible for conducting in-depth evaluations of any medical schools in Barbados. CAAM-HP uses general procedures and standards that cover the basics needed for the proper functioning of a medical school. CAAM-HP conducts the evaluation process and shares its findings and decisions with the government of Barbados.
 
Accreditation of Medical Schools, Question 2
 
Country Narrative
In order for a medical school to operate in Barbados, it must submit to the accreditation processes and procedures of the CAAM-HP as set out in the document, Accreditation Guidelines for New and Developing Schools (Exhibit 10). CAAM-HP will advise the Minister of Education whether or not the school has met the minimum requirements for establishing the school. In addition, the Caribbean Accreditation Authority (Education in Medicine and Other Health Professions) (Incorporation) Act, 2016 (Exhibit 5) formally authorizes the CAAM-HP to accredit programmes of study in medicine and other health professions offered by institutions in Barbados.
 
Analyst Remarks to Narrative
As presented in the supporting documentation provided by the country in response to this section, CAAM-HP is the only entity in Barbados for the establishment, accreditation and monitoring of medical schools. CAAM-HP uses its published guidelines and standards for that purpose. The government of Barbados has committed itself through legislation to accept the accreditation decisions made by CAAM-HP. (Questions regarding any decision to close a medical school have been raised earlier.)
 
Part 2: Accreditation/Approval Standards
 
Mission and Objectives, Question 1
 
Country Narrative
Yes, the CAAM-HP requires medical schools to have an educational mission that serves the public interest. As the CAAM-HP has set out in its Revised Standards for the Accreditation of Medical Schools in the Caribbean Community, Exhibit 11, doctors who have graduated from medical schools accredited by CAAM-HP in accordance with its Standards,

“Should be capable of serving patients in resource poor conditions as well as in the modern hospital or clinical setting. Graduates should be skilled in making clinical diagnoses and undertaking basic treatment of those conditions that do not require specialist skills, but must know how to access specialist skills and facilities when required. The graduate doctor must also be capable of absorbing postgraduate training and after a period of supervised practice to enter independent practice in CARICOM countries. Graduates must have the capacity and desire for life-long learning so they can practice in circumstances where knowledge, health conditions and cultures are different or change over time.”

The Standards expect that a doctor “should be a promoter of health for the individual as well as the community, and must have the clinical competencies to be able to diagnose and treat illness in resource constrained circumstances. They must be aware of modern techniques of diagnosis and care and how they may be accessed when not available in the setting in which they practice. They must be aligned with international codes of conduct for health professionals and practice within the law and ethical code of conduct of the country or jurisdiction in which they practice. They should be an advocate for the patient, particularly those disadvantaged by age, or economic circumstance and to do so irrespective of ethnic, racial, religious, political or other circumstances.” See Standards, Section III, Educational Programme, Exhibit 11.

Standard ED-18 requires that faculty and students demonstrate an understanding of the manner in which people of diverse culture and belief systems perceive health and illness and respond to various symptoms, diseases and treatments. Medical school instruction should stress the need for students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on their health. To demonstrate compliance with Standard ED-18, medical schools should be able to document objectives relating to the development of skills in cultural competence and international human righrs, to indicate where in the curriculum students are exposed to such material and to demonstrate the extent to which the objectives are being achieved.

Standard ED-19 requires medical schools to recognize and address appropriately gender, cultural and religious biases in themselves and others. A medical school’s objectives for clinical instruction should include student understanding of demographic influences on health care quality and effectiveness, such as racial and ethnic disparities in the diagnosis and treatment of diseases. The objectives should also address the need for self-awareness among medical students of any personal biases in their approach to health care delivery.

Standard ED-20 requires a medical school to teach medical ethics with respect for religious and other human values and their relationship to law and governance of medical practice. Students must be required to exhibit scrupulous ethical principles in caring for patients and in relating to patients’ families and others involved in patient care, strive to encompass community concerns.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical
Education Database, Section III: Educational Programme, Exhibit 12, at Part B.

The CAAM-HP has a process through which it develops and approves new or revised standards and procedures. See Procedures of the CAAM-HP, Exhibit 9, Appendix E. As part of the process of standards revision, consideration will be given to standards related to how the CAAM-HP evaluates a medical school’s mission in relation to managing health problems of the individual and the community, taking charge of health promotion and prevention of disease and maintaining acceptable scientific and ethical standards of the profession.

As part of the standards revision process this topic will be addressed in the Database, Institutional Setting, Part B (a) and reads as follows:

A medical school must develop a mission statement to drive the development of educational objectives that support the school’s mission and provide the basis for evaluating the effectiveness of the educational programme. Such a mission statement should include a component related to serving the public.

The revised standards will be discussed at the Annual General Meeting of the CAAM-HP, July 27-30, 2016. Following the meeting documentary evidence will be provided as to the decision taken to adopt this and other new standards.
 
Analyst Remarks to Narrative
CAAM-HP’s “Standards for the Accreditation of Medical Schools” (hereafter, Standards) cover the public service aspect of the medical school’s mission under the section on the educational program. That section insists that every doctor “should be an advocate for the patient, particularly those disadvantaged by age or economic circumstance, and do so irrespective of ethnic, racial, religious, political or other considerations.”

Among the foundational documents provided by the country are the “Procedures of the CAAM-HP” (Exhibit 9); CAAM-HP’s “Standards for the Accreditation of Medical Schools” (revised in 2011) (Exhibit 11); CAAM-HP’s “Guide to the Institutional Self-Study for Programs of Education in Medicine” (Exhibit 14); the reports from the last two site visits to Barbados, including the most recent one in 2012 (Exhibit 19); a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28); and a completed Medical School Questionnaire (numerical data) for academic year 2013-2014 (Exhibit 29).

However, since the country is revising the relevant section of the Medical Education Database, the NCFMEA may wish to request a completed example of the revised version. (If one will not be available until later in 2016, it could be provided with a periodic report to the NCFMEA, if comparability has been determined.)
 
Country Response
The process followed by the Advisory Committee charged with the revision of CAAM-HP’s accreditation standards for medicine was as follows:

• Maintenance of the current format
• Consideration of the existing standards in the light of the recently revised LCME standards, identified discrepancies which resulted in new standards being added to the current CAAM-HP standards
• Change some standards which were “should” to “must”
• Amalgamation of some standards where they overlapped substantially
• Renumbering the standards in the various sections to take account of the additions and amalgamations
• Awareness that the standards must be applicable both to regional and ‘offshore’ schools

With respect to quantitative standards, the Committee, in keeping with the international trend, agreed that it would be important to capture a small number of key, robust and verifiable numbers rather than data that would be hard to collect, difficult to verify and impossible to manage effectively. The decision was to use only objective quantitative standards such as exam pass rates, attrition, placement in postgraduate training etc.

The Committee recommended that standards related to Internship and Continued Medical Education be eliminated.

To Section I, Institutional Setting, were added the following:

a. Provide a brief statement of the mission and goals of the medical school.
A medical school must develop a mission statement to drive the development of educational objectives that support the school's mission and provide the basis for evaluating the effectiveness of the educational programme. Such a mission statement should include a component related to serving the public.

IS-1 (new standard)
• An institution that offers a medical education programme must engage in a planning process that sets the direction for its programme and results in measurable outcomes.

Explanatory Note:
To ensure the ongoing vitality and successful adaptation of its medical education programme to the rapidly changing environment of academic medicine, the institution needs to establish periodic or cyclical institutional planning processes and activities. Planning efforts that have proven successful typically involve the definition and periodic reassessment of both short-term and long-term goals for the successful accomplishment of institutional missions. By framing goals in terms of measurable outcomes wherever circumstances permit, the institution can more readily track progress toward their achievement. The manner in which the institution engages in planning will vary according to available resources and local circumstances, but it should be able to document its vision, mission and goals; evidence indicating their achievement; strategies for periodic or ongoing reassessment of successes and unmet challenges.

a. Please provide a copy of the school’s strategic plan.
b. What are the school’s mission, vision and goals?
c. How does the school monitor the delivery of its strategic plan?

IS-3
The governing body responsible for oversight of an institution that offers a medical education programme must have and follow formal policies and procedures to avoid the impact of conflicts of interest of members in the operation of the institution and its associated clinical facilities and any related enterprises. At legally constituted meetings of an institution’s board, ex-officio members of the institution’s governing board, such as Directors of the Corporation owning the school and academic and administrative officers, must constitute less than half of the representatives participating in the meeting. There must be an appropriate accountability of the management of the medical school to an ultimate responsible authority external to and independent of the school’s administration. This external authority must have sufficient understanding of the medical programme to develop policies in the interest of both the medical school and the public.

The revised standards were presented to the CAAM-HP annual general meeting held July 27-29, 2016.

The following is an extract from the draft Minutes of the meeting (see Exhibit 38):

There was general agreement in principle with the revised accreditation standards for medicine. The meeting agreed that the revised standards would be circulated to members with a request for any comments within two weeks. The amended standards would then be circulated to all stakeholders for comment. It was noted that the intention was to have the revised standards become effective in July 2018.

The meeting also discussed the issue of including measures for student performance outcomes in the revised standards. The NCFMEA had suggested that the Authority should base its accreditation decisions, in part, on the effective use of data in evaluating the performance of students after graduation from the medical school. CAAM-HP should, therefore establish student performance outcome standards such as, acceptable numbers of graduates from the school passing a licensing examination and an acceptable percentage of all students graduated during the preceding year that obtained placement in an accredited US postgraduate medical training programme (residency) to determine whether to grant accreditation.

While acknowledging that such data would be useful, the meeting expressed concern about including performance outcome data in the standards and noted that this was not a requirement for the LCME. The meeting agreed that this matter should be considered carefully.

See Exhibit 39A: Revised Standards, Section I: Institutional Setting
 
Analyst Remarks to Response
The draft staff analysis noted that the country was revising the relevant section of the Medical Education Database, and that the NCFMEA may wish to request a completed example of the revised version. In response, the country provided a revised section that does include the expectation that the public interest will be served by the medical school.

In addition, the country response touched on questions that were raised in conjunction with other NCFMEA guidelines. Those other concerns, such as CAAM-HP’s continued reluctance to include performance outcome data in its standards will be discussed under the appropriate sections.
 
Staff Conclusion: Comprehensive response provided
 
Mission and Objectives, Question 2
 
Country Narrative
Standard ED-1 states that “the medical school faculty must define the objectives of its educational programme.” For purposes of the Standard, educational objectives are defined as, “statements of the items of knowledge, skills, behaviours and attitudes that students are expected to exhibit as evidence of their achievement. They are not statements of mission or broad institutional purposes such as, education, research, health care or community service. Educational objectives state what students are expected to learn not what is to be taught.” The Standard continues, “student achievement of these objectives must be documented by specific and measurable outcomes (e.g. measures of basic science grounding in the clinical years, examination results, performance of graduates in residency training, performance in licensure examinations, etc)”.

Standard FA-14 requires a medical school to have mechanisms for direct faculty involvement in decisions related to the educational programme, including curriculum development and evaluation. The Standard notes that the “quality of an educational programme may be enhanced by the participation of volunteer faculty in faculty governance, especially in defining educational goals and objectives.”

Standard ED-29 requires that the faculty must be responsible for the detailed design and implementation of the components of a coherent and coordinated curriculum that is designed to achieve the school’s overall educational objectives. In accordance with Standard ED-30, the curriculum should include:

• Logical sequencing of the various segments of the curriculum;
• Content that is coordinated and integrated within and across the academic periods of study;
• The development of specific course or clerkship objectives;
• Methods of pedagogy and student evaluation that are appropriate for the achievement of the school’s educational objectives.

Faculty engaged in curriculum management are expected to evaluate programme effectiveness through outcome analysis. See Standard ED-31. Curriculum management also includes review of the stated objectives of individual courses and clerkships as well as methods of pedagogy and student evaluation to assure congruence with institutional educational objectives. See also Standard ED-33, which requires the faculty committee responsible for the curriculum to monitor the content provided in each discipline so that the medical school’s educational objectives will be achieved.

With regard to clinical education, Standard ED-2 requires that educational objectives include quantified criteria for the types of patients, the level of student responsibility and the appropriate clinical settings needed for the objectives to be met. Courses and clerkships that require physical or simulated patient interactions should specifically monitor and verify by appropriate means, the number and variety of patient encounters in which students participate so that adjustments in the criteria can be made if necessary without sacrificing educational quality.

Standard ED-3 requires that the objectives of the educational programme be made known to all medical students and to the faculty, residents/junior staff and others with direct responsibility for medical student education. The dean and the academic leadership of any clinical affiliates where the education programme takes place are also expected to exhibit familiarity with the overall objectives for the education of medical students. See also Standard ED-22 which requires that faculty, residents/junior staff, graduate students and postdoctoral fellows serving as teacher or teaching assistants are familiar with the educational objectives of the course or clerkship and should be prepared or received training for their roles in teaching and evaluation.

Standard ED-26 requires that a medical school conduct ongoing assessments that assures students have acquired and can demonstrate on direct observation the core clinical skills, behaviours and attitudes that have been specified in the school’s educational objectives. Such assessment should include evaluation of problem solving, clinical reasoning and communication skills all in relation to both individuals and communities.

To guide programme improvement, Standard ED-42 requires medical schools to evaluate the effectiveness of the educational programme by documenting the extent to which its objectives have been met. Medical schools must consider student evaluations of their courses and professor, acceptancs and an appropriate variety of outcome measures in assessing programme quality. Appropriate outcome measures for evaluating the effectiveness of the educational programme include data on student performance, academic progress, programme completion rates, acceptance into residency/postgraduate performance and practice characteristics of the medical school’s graduates. Medical schools must evaluate the performance of students and graduates in the framework of national and international norm of accomplishment and performance within the wider health care system.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12 at Part B and Medical Education Database, Section IV: Faculty, Exhibit 13 at Part B. The CAAM-HP also asks a school to address this topic in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14 at Questions III. A.1; III.D.11 and III.D.12; IV.C.8 and IV.C.9.
 
Analyst Remarks to Narrative
CAAM-HP's standards require that a medical school's faculty define the objectives of the educational program, and that the faculty be involved in decisions regarding the curriculum and the development of the educational program.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28). However, NCFMEA may wish to request a completed Section IV: “Faculty” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section IV: “Faculty” in order to see the responses to those questions.

In response, the country provided a completed Section IV: “Faculty,” as requested.

(Note: the country response referred to Exhibit 40A – Section 1, which is incorrect for this guideline. However, the country did provide the correct materials, Exhibit 40D – Section IV, which can be found in the table of contents and under the next guideline.)

 
Staff Conclusion: Comprehensive response provided
 
Mission and Objectives, Question 3
 
Country Narrative
Standard ED-1 requires that the medical school faculty must define the objectives of its educational programme.

It further explains that “educational objectives are statements of the items of knowledge, skills and behaviours and attitudes that students are expected to exhibit as evidence of their achievement. They are not statements of mission or broad institutional purpose, such as education, research, health care or community service. Educational objectives state what students are expected to learn not what is to be taught.

Student achievement of these objectives must be documented by specific and measurable outcomes such as measures of basic science grounding in the clinical years, examination results, performance of graduates in residency/internship training, performance in licensing examinations etc.

Standard ED-29 requires that the faculty must be responsible for the detailed design and implementation of the components of a coherent and coordinated curriculum that is designed to achieve the school’s overall educational objectives.

Standard ED-5 requires that “faculty approve a curriculum that provides a general professional education and fosters in students the ability to learn through self-directed, independent study throughout their professional lives.”

Standard FA-14 requires a medical school to have mechanisms for direct faculty involvement in decisions related to the educational programme, including curriculum development and evaluation. The Standard notes that the “quality of an educational programme may be enhanced by the participation of volunteer faculty in faculty governance, especially, in defining educational goals and objectives.”

An institutional body (commonly called a curriculum committee) must oversee the educational programme. Standard ED-29 notes that an “effective central curriculum authority will exhibit…faculty, student and administrative participation.”

The faculty committee responsible for the curriculum must monitor the content provided in each discipline so that the school’s educational objectives will be achieved. See Standard ED-33. The curriculum committee is tasked making sure that each academic period maintains common standards for content, which address the depth and breadth of knowledge required.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12 at Part B and Medical Education Database, Section IV: Faculty, Exhibit 13 at Part B. The CAAM-HP also asks a school to address this topic in its self-study report. See Guide to the Institutional Self-Study for Programmes of Education in Medicine, Exhibit 14, at Question IV. C.8 and IV.C.9.
 
Analyst Remarks to Narrative
The Standards require faculty involvement in the development of the objectives of the education program at each medical school. In addition, the Standards expect that the faculty committee responsible for the curriculum must monitor the content provided in the medical school so that the school’s educational objectives will be achieved.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28). However, NCFMEA may wish to request a completed Section IV: “Faculty” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40D: UWI Medical Education Database: Faculty.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section IV: “Faculty” in order to see the responses to those questions.

In response, the country provided a completed Section IV: “Faculty,” as requested.
 
Staff Conclusion: Comprehensive response provided
 
Mission and Objectives, Question 4
 
Country Narrative
Standard ED-1 defines educational objectives as “statements of the items of knowledge, skills, behaviors, and attitudes that students are expected to exhibit as evidence of their achievement.” The Standard cautions that educational objectives “are not statements of mission or broad institutional purpose, such as education, research, health care, or community service. Educational objectives state what students are expected to learn, not what is to be taught.”

Standard ED-1 further requires that student achievement of educational objectives be documented by specific and measurable outcomes (e.g., measures of basic science grounding in the clinical years, examination results, performance of graduates in residency training, performance in licensure examinations, etc.).

To guide programme improvement, Standard ED-42 requires medical schools to evaluate the effectiveness of the educational programme by documenting the extent to which its objectives have been met. Medical schools must consider student evaluations of their courses and professors and an appropriate variety of outcome measures in assessing programme quality. Appropriate outcome measures for evaluating the effectiveness of the educational programme include data on student performance, academic progress, programme completion rates, acceptance into residency/postgraduate programmes, postgraduate performance, and practice characteristics of the medical school’s graduates. Medical schools must evaluate the performance of students and graduates in the framework of national and international norms of accomplishment and performance within the wider health care system. See also Standard ED-31, which requires medical schools to engage in curriculum management, to include the evaluation of programme effectiveness by outcomes analysis.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards define what an educational objective is and also specify that achievement of educational objectives be demonstrated via measurable outcomes measures. In relation to those expectations, “Appropriate outcome measures for evaluating the effectiveness of the educational program include data on student performance, academic progress, program completion rates, acceptance into residency/postgraduate programs, postgraduate performance, and practice characteristics of the medical school’s graduates. Medical schools must evaluate the performance of students and graduates in the framework of national and international norms of accomplishment and performance within the wider health care system.”

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).

 
Mission and Objectives, Question 5
 
Country Narrative
Student achievement of the medical school’s educational objectives must be documented by specific and measurable outcomes (e.g., examination results, performance of graduates in residency training, performance on licensure examinations, etc.). See Standard ED-1.

Standard ED-5 requires a medical school to design and its faculty to approve a curriculum that provides a general professional education and fosters in students the ability to continue to learn through self-directed, independent study throughout their professional lives.

Standard ED-24 requires the medical school faculty to establish a system for the evaluation of student achievement throughout medical school that employs a variety of measures of knowledge, skills, behaviors, and attitudes. Such evaluation should “measure not only retention of factual knowledge, but also development of the skills, behaviors, and attitudes needed in subsequent medical training.” The students’ ability to use data for solving problems commonly encountered in medical practice should also be evaluated. The Standard specifies that the “sole use of frequent tests which condition students to memorize details for short-term retention only is not considered a good system of evaluation to foster self-initiated learning,” which is an essential objective of a programme of medical education.

A medical school’s faculty committee responsible for the curriculum must monitor the content provided in each discipline so that the school’s educational objectives must be achieved. See Standard ED-33. The final year of the educational programme should complement and supplement the curriculum so that each student will acquire appropriate competence in general medical care regardless of their subsequent career specialty.

Standard ED-42 requires medical schools to evaluate the effectiveness of the educational programme by determining the extent to which its objectives have been met. Among the kind of outcome measures that serve this purpose are acceptance into residency/post-graduate programmes, post-graduate performance, and practice characteristics of graduates.

Standard ED-43 requires medical schools to evaluate the performance of their students and graduates from within a framework of national and international norms of accomplishment and performance within the wider health care system.

The Standards related to Continuing Professional Education (“CPE”) address the continued learning needs of medical graduates. A medical school should provide programmes for the CPE of its graduates; when appropriate, such programmes should be offered in consultation with and with the cooperation of national and regional authorities. See Standard CE-1. Such CPE programmes should be of acceptable educational quality and promote quality of care through self-evaluation. See Standard CE-2.

CE-2. They should also be conducted according to relevant standards and criteria developed by the medical school, in keeping with those standards and criteria of relevant national and regional authorities.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B and Medical Education Database, Section VII: Continuing Professional Education, Exhibit 15, at Part B.
 
Analyst Remarks to Narrative
As previously noted, CAAM-HP standards require the ongoing evaluation of medical students throughout their educational program. Student achievement is required to be evaluated through a variety of means, but schools must consider outcomes-related data, including acceptance into residency/post-graduate programs, post-graduate performance, and practice characteristics of graduates.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28). However, NCFMEA may wish to request a completed Section VII: “Continuing Professional Education” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40F: UWI Medical Education Database: Continuing Professional Education.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section VII: “Continuing Professional Education” in order to see the responses to those questions.

In response, the country provided the completed database section, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Governance, Question 1
 
Country Narrative
Standard IS-1 provides that accreditation will be conferred only on those programmes that are legally authorized under applicable law to provide the programme(s) of education for which accreditation is sought. The Standard also requires that an educational institution be registered by the government of the jurisdiction in which it operates. The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part B. As part of the accreditation process, a medical education programme provides the CAAM-HP a copy of its charter or other legal instrument in order to demonstrate that the programme has legal authority to operate.

In the case of the University of the West Indies, Cave Hill Campus, the medical school is legally authorized to provide a programme of medical education under Ordinance 44- School of Clinical Medicine and Research, Cave Hill, Exhibit 3 and Exhibit 2, Plans for Upgrading and Expanding School of Clinical Medicine and Research (SCMR), Cave Hill, 2008.

Please note the addition of a specific requirement to provide a copy of the charter or any other documentation evidencing a school’s legal authority to operate. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part B, IS-1 (c).

Private/for-profit institutions will be required to obtain a charter from the government of the territory in which the school is located following advice from CAAM-HP that such institutions have met the minimum requirements to operate and been given Initial Provisional Accreditation. See Procedures of the CAAM-HP, Appendix A, Exhibit X. In addition, local, regional and foreign based institutions offering educational courses in Barbados must be registered by the Barbados Accreditation Council (BAC), BAC Act 2004-11 Cap 41, page 4, paragraph 4 (a), Exhibit 17.
 
Analyst Remarks to Narrative
CAAM-HP requires that there be a legal authorization to operate in the country in which it is located. However, the only medical school in Barbados at Cave Hill is a branch campus of the University of the West Indies, which is headquartered on Jamaica.

Furthermore, the country application has introduced the fact that a Barbados Accreditation Council (BAC) was established to register schools. However, no evidence was presented to document that the Cave Hill campus was ever registered with the BAC. (It may be that the government of Barbados only requires the approval or registration of a medical school by BAC if it is a private for-profit enterprise, but that distinction is not documented.)

Therefore, it is not clear if Barbados requires a special authorization to operate from any official government entity, such as the Barbados Accreditation Council, or if it just accepts the fact that the school is a branch of Jamaica’s University of the West Indies. In addition, it is unclear if the BAC’s authority would allow it to remove any registration that may have been granted to the Cave Hill campus.

[These matters were introduced above under the very first NCFMEA Guideline.]

The NCFMEA may wish to inquire further regarding these matters.
 
Country Response
All schools are required to be registered by the Barbados Accreditation Council (BAC) including the Cave Hill Campus of the University of the West Indies which was registered up to 2013 and subsequently granted institutional accreditation valid up to 2019.

See Exhibit 37A: UWI Cave Hill Certificate of Registration, 2010 and Exhibit 37B: UWI Cave Hill Certificate of Institutional Accreditation, 2013.
 
Analyst Remarks to Response
The draft staff analysis noted that it was not clear if Barbados requires a special authorization from any official government entity, such as the Barbados Accreditation Council (BAC), or if it just accepts the fact that Cave Hill is a branch of Jamaica’s University of the West Indies. In addition, it is unclear if the BAC’s authority would allow it to remove any registration that may have been granted to the Cave Hill campus.

In response, the country did provide the BAC registration for the Cave Hill campus of the University of the West Indies. (In response to the very first guideline, the country indicated that that Barbados cannot revoke that registration unless the decision to close the campus is made by the countries in the region. Any further questions regarding this matter can be asked in conjunction with the first NCFMEA guideline.)
 
Staff Conclusion: Comprehensive response provided
 
Governance, Question 2
 
Country Narrative
The Medical School in Barbados is part of the University of the West Indies. The governing bodies of the Cave Hill Campus are the Senate, the Council of the University and the Campus Council. Statutes 18 and 19 of The Charter (Exhibit 1) describe in detail the broad membership of the Council of the University and the Campus Council which ranges from Officers of the University to representatives of the governments of the contributing countries, industry, commerce, the professions, representatives of tertiary level institutions in the Caribbean, alumni, non-academic staff. The Government of Barbados accepts that these bodies are external to and independent of the medical school’s administration. Statute 24 of The Charter describes the membership of the Senate and Statute 25 of The Charter the Powers of the Senate.

At present, CAAM-HP does not have a policy requiring that a school’s governing board be external to or independent of the medical school. However, the Advisory Committee charged with the responsibility to revise the current standards has included a new standard which reads as follows:

The governing body responsible for oversight of an institution that offers a medical education programme must have and follow formal policies and procedures to avoid the impact of conflicts of interest of members in the operation of the institution and its associated clinical facilities and any related enterprises. At legally constituted meetings of an institution’s board, ex-officio members of the institution’s governing board, such as Directors of the Corporation owning the school and academic and administrative officers, must constitute less than half of the representatives participating in the meeting. There must be an appropriate accountability of the management of the medical school to an ultimate responsibility authority external to and independent of the school’s administration. This external authority must have sufficient understanding of the medical programme to develop policies in the interest of both the medical school and the public.

This new standard will, inter alia, be discussed at the CAAM-HP Annual General meeting, July 27-30, 2016. The decision will be communicated to all stakeholders following the meeting.

The CAAM-HP asks a school to evaluate its governance structure, including as related to the school’s governing board, in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions I.A.2 and 1.A.3. Also, the CAAM-HP asks a school to report on its governance structure in its Database responses. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part B.
 
Analyst Remarks to Narrative
As previously noted, there is a lack of clarity as to where the ultimate responsibility for a medical school in Barbados rests. The country application has noted that CAAM-HP is considering the adoption of a new standard that would require the establishment of a governing board, independent of the school’s administration, to be responsible for the school. However, the language of the suggested new standard implies that it is only a requirement for a private for-profit enterprise. (That standard had not yet been adopted.)

Therefore, it is unclear as to whether the administrators of medical schools in Barbados are held accountable for the operation and success of their school by an authority that is independent of the medical school, and that is sufficiently knowledgeable about medical education. If yes, the name of that authority and its relationship to the school and to the government of Barbados are unclear. Furthermore, the country needs to clarify if the proposed new standard requiring a governing board has been adopted as written or has been revised, and whether it applies to the medical school at Cave Hill.

The NCFMEA may wish to inquire further regarding this matter.
 
Country Response
The new standard requiring appropriate responsibility of the management of the medical school to an ultimate responsible authority external to and independent of the school’s administration is among the new standards discussed at the recent Annual General Meeting of the CAAM-HP and accepted in principle.

It reads as follows:

IS-3
The governing body responsible for oversight of an institution that offers a medical education programme must have and follow formal policies and procedures to avoid the impact of conflicts of interest of members in the operation of the institution and its associated clinical facilities and any related enterprises. At legally constituted meetings of an institution’s board, ex-officio members of the institution’s governing board, such as Directors of the Corporation owning the school and academic and administrative officers, must constitute less than half of the representatives participating in the meeting. There must be an appropriate accountability of the management of the medical school to an ultimate responsible authority external to and independent of the school’s administration. This external authority must have sufficient understanding of the medical programme to develop policies in the interest of both the medical school and the public.

See Exhibit 39A: Revised Standards, Section I: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis indicated that it was unclear as to whether the administrators of medical schools in Barbados are held accountable for the operation and success of their school by an authority that is independent of the medical school, and that is sufficiently knowledgeable about medical education. If yes, the name of that authority and its relationship to the school and to the government of Barbados are unclear. Furthermore, the country needs to clarify if the proposed new standard requiring a governing board has been adopted as written or has been revised, and whether it applies to the medical school at Cave Hill.

In response, the country indicated that the school’s board is expected to be knowledgeable regarding medical education and independent of the school, and that the board’s role is to hold the administrators accountable.

Regarding the adoption of the proposed new standard and its application to the Cave Hill campus, the country responded that the new standard was recently discussed and “accepted in principle.” How and when the new standard on a medical school’s external authority will be implemented, and if it will be applied to the Cave Hill campus, are still unclear.

The NCFMEA may wish to inquire further regarding these matters.
 
Staff Conclusion: Additional Information requested
 
Administrative Personnel and Authority, Question 1
 
Country Narrative
The standards and requirements regarding how medical schools are to be administered in Barbados are set forth in the Standards under the heading “Institutional Setting, A. Governance and Administration.”

Pursuant to Standard IS-2, the manner in which a medical school is organized, including the responsibilities and privileges of administrative officers, faculty, students, and committees must be promulgated in medical school or university by-laws.

Pursuant to Standard IS-3, the governing body responsible for oversight of the medical school should be composed of persons who have the education needs of the institution as their first priority and have no clear conflict of interest in the operation of the school, its associated hospitals, or any related enterprises.

Pursuant to Standard IS-4, the terms of the governing body members should be sufficiently long to permit them to gain an understanding of the programme(s) of the medical school.

Pursuant to Standard IS-5, administrative officers and members of the medical school faculty must be appointed by, or on the authority of, the governing body of the medical school or its parent university.

Pursuant to Standard IS-9, the medical school administration should include such associate and assistant deans, department chairs, leaders of other organizational units, and staff as are necessary to accomplish the missions of the medical school. The Standard also notes that there should not be excessive turnover or long-standing vacancies in medical school leadership. Medical school leadership is defined to include the dean, vice/associate deans, department chairs, and other positions where a vacancy could negatively impact institutional stability, especially with regard to planning or implementing the educational programme. Areas that commonly require administrative support include admissions, student affairs, academic affairs, faculty affairs, postgraduate education, continuing education, hospital relationships, research, business and planning, and fundraising.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part B.

The CAAM-HP asks a school to assess the organizational stability of the medical school administration in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Question I.A.4.
 
Analyst Remarks to Narrative
The CAAM-HP standards address medical school organization, governing body oversight and members, and a requirement that medical school administrators and faculty be appointed under the authority of the university or its governing board. The standards also specify that the medical school administration should include enough deans, department chairs, unit leaders, and support staff to accomplish the school's mission.

NCFMEA may wish to request a completed Section I: “Institutional Setting” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section I: “Institutional Setting” in order to see the responses to those questions.

In response, the country provided the completed database section, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Administrative Personnel and Authority, Question 2
 
Country Narrative
Under Standard IS-6, the dean or chief medical officer of the medical school must have ready access to the administrative head of the school or other school official charged with final responsibility for the school, and to other school officials as are necessary to fulfill the responsibilities of the dean’s office.

Standard ER-2 requires that an accredited programme have current and anticipated financial resources adequate to sustain a sound programme of medical education and to accomplish other institutional goals. Under the Standard, the cost of conducting an accredited programme should be supported by diverse sources, including tuition, endowments, support from the parent university, covenants, grants from organizations and individuals, and appropriations by the government. Evidence of compliance with Standard ER-2 includes documentation of adequate financial reserves to maintain the programme in the event of unexpected revenue loss along with demonstrated effective fiscal management of the medical school budget. Such information may be submitted to the CAAM-HP under confidential cover. Standard ER-3 states that pressure for institutional self-financing must not compromise the educational mission of the institution nor cause it to enroll more students than its resources can accommodate.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part B and Medical Education Database, Section V: Educational Resources, Exhibit 18, at Part B. A school is also asked to address this topic in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions V.A.1 through V.A.4.
 
Analyst Remarks to Narrative
The CAAM-HP standards require that the dean of the medical school must have access to the institution's administrative head, or another school official with the final responsibility for the school, as well as to other school officials who are necessary for the dean to fulfill the responsibilities associated with the dean's office.

NCFMEA may wish to request a completed Section I: “Institutional Setting” and completed Section V: “Educational Resources” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education databases are attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting; Exhibit 40E: UWI Medical Education Database: Educational Resources.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section I: “Institutional Setting” and completed Section V: “Educational Resources” in order to see the responses to those questions.

In response, the country provided the completed database sections, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Administrative Personnel and Authority, Question 3
 
Country Narrative
Under Standard IS-7, there must be a clear understanding of the authority and responsibilities for medical school matters among the administrative officials of the school, the dean of the school, the faculty, and the administrative officials of other components of the medical teaching complex of the university.

Standards ER-2 and ER-3 require that the medical school have financial resources adequate to sustain a sound programme of medical education while accomplishing other institutional goals. Standards ER-4 and ER-5 require that a medical school have adequate buildings and equipment appropriate to achieve its educational and other goals. Standards ER-6 through ER-11 require sufficient access to resources and authority needed to carry out clinical teaching activities. Standards ER-12 and ER-13 require that adequate information resources and library services be provided.

CAAM-HP Standard ER-11 identifies the role that department heads and clinical faculty must have with respect to the medical programme and clinical affiliates. The Standard requires:

"In the relationship between the medical school and its clinical affiliates, the educational programme for medical students must remain under the control of the school's faculty.

"Regardless of the location where clinical instruction occurs, department heads and faculty must have authority consistent with their responsibility for the instruction and evaluation of medical students.

"The responsibility of the clinical facility for patient care should not diminish or preclude opportunities for medical students to undertake patient care duties under the appropriate supervision of medical school faculty and junior staff / residents."

With regard to the UWI Cave Hill, the following sites were visited (See 2012 Site Visit Report, Exhibit 19B and The UWI’s Medical Education Database, Section V: Educational Resources, Exhibit 20):

• The Queen Elizabeth Hospital (QEH) (See Exhibit 21, Memorandum of Understanding between the University of the West Indies Cave Hill Campus and the Ministry of Health and Government of Barbados)
• Psychiatric Hospital
• Polyclinics
• Chronic Disease Research Centre (CDRC)

Please note that the 2016 site visit report will be available for submission following CAAM-HP’s Annual General Meeting in July 2016.

CAAM-HP assesses compliance with Standard ER-11 through discussions with clinical faculty during site visits to clinical teaching sites. Furthermore, the CAAM-HP self-study document asks medical schools to “describe and evaluate the interaction between the administrators of the hospitals/clinics used for teaching and the medical school administration.” It also asks medical schools to “describe and evaluate the level of interaction/cooperation between the staff members of the hospitals/clinics used for teaching and medical school faculty members and department heads.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part B and Medical Education Database, Section V: Educational Resources, Exhibit 18, at Part B. A school is also asked to address this topic in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions V.A.1 through V.A.4.
 
Analyst Remarks to Narrative
The CAAM-HP standards require that there be clear lines of administrative authority in a medical school, that the medical school program must remain under the control of the medical school faculty, and that department heads and faculty must have the authority for the instruction and evaluation of the medical school students. The standards require that the medical school must have sufficient resources to sustain the medical school program and support institutional goals.

NCFMEA may wish to request a completed Section I: “Institutional Setting” and completed Section V: “Educational Resources” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education databases are attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting; Exhibit 40E: UWI Medical Education Database: Educational Resources.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section I: “Institutional Setting” and completed Section V: “Educational Resources” in order to see the responses to those questions.

In response, the country provided the completed database sections, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Chief Academic Official, Question 1
 
Country Narrative
As set forth in Standard IS-5, the Chief Academic Officer, administrative officers, and members of a medical school faculty must be appointed by or on the authority of the governing body of the medical school or its parent university.

Under Standard IS-8, the dean or chief academic officer must be qualified by education and experience to provide leadership in medical education, in scholarly activity, and in the care of patients.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part B.

In addition, the site visit team determines the adequacy of the chief academic officer’s qualifications and experience. Determinations are based on information solicited through the database document (e.g., curriculum vitae), the team members’ professional expertise, and the team’s interactions with the chief academic officer during the site visit. Criteria such as the individual’s medical qualifications, experience in teaching, patient care experience, research and publications, and professional affiliations are taken into account.
 
Analyst Remarks to Narrative
The Standards contain requirements related to the dean or chief academic officer's qualifications and also require that the person be appointed by the school's governing board or its parent university. The dean's qualifications are evaluated during on-site reviews.

NCFMEA may wish to request a completed Section I: “Institutional Setting” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section I: “Institutional Setting” in order to see the responses to those questions.

In response, the country provided the completed database section, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Chief Academic Official, Question 2
 
Country Narrative
The CAAM-HP does not prescribe the manner in which a medical education programme must select a chief academic official. However, such process must result in a chief academic official who meets the CAAM-HP’s standards, meaning the person must be “qualified by education and experience to provide leadership in medical education, scholarly activity, and he/she or his/her deputy in the care of patients” as set forth in the Standards (i.e., IS-8).

The CAAM-HP asks a school to address the chief academic official’s qualifications in its Database responses. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part B. Site visit teams are able to assess whether the chief academic official is qualified to occupy his or her position based in part on a medical education programme’s Database responses about the experience and qualifications of its chief academic official.

Under Standard IS-5, the chief academic officer must be appointed by or on the authority of the governing body of the medical school or its parent university. The process to select the chief academic official must result in a chief academic official who meets CAAM-HP standards, particularly IS-8, which requires the chief academic official to be “qualified by education and experience to provide leadership in medical education, scholarly activity, and he/she or his/her deputy in the care of patients” as set forth in the Standards. If a site visit team finds deficiencies with respect to a medical school’s compliance with IS-8, the team would evaluate the factors that contributed to selection of an unqualified chief academic official, including the selection process.

With respect to the UWI Deans of Faculties are appointed by the University Council, on the recommendation of the Campus Principal through the Vice-Chancellor after the Campus Principal has consulted with the Faculty. The term of Office of a Dean is four years and may be extended for up to an additional four years. A person may be eligible for re-appointment as Dean once an intervening term of office of another person as Dean has expired, Statute 12, Exhibit 3.
 
Analyst Remarks to Narrative
Although they do not specify the hiring process for the chief academic official, the CAAM-HP standards require that the chief must be appointed by either the school's governing body or the parent university and must be qualified for the position by both education and experience. Site visit teams review the chief's qualifications while conducting the on-site review.
 
Faculty
 
Country Narrative
Standard FA-7 requires that medical school faculty must make decisions regarding student admissions, promotion, and graduation.

Standard FA-13 requires that the dean and a committee of faculty should determine medical school policies. The committee, which should consist of the heads of major departments, may be organized in any manner that brings reasonable and appropriate faculty influence into the governance and policy-making processes of the medical school.

Standard FA-8 requires that a medical school possess clear policies for faculty appointment, renewal of appointment, promotion, granting of tenure, and dismissal that involve the faculty, the appropriate department heads, and the dean/Chief Academic Officer.

Standard FA-14 requires that a medical school must have mechanisms for direct faculty involvement and decision-making relating to its educational programme(s). Important areas where direct faculty involvement is expected include admissions, curriculum development and evaluation, and student promotions. This Standard also requires that faculty should be involved in decisions about any other mission-critical areas specific to the schools. Strategies for assuring direct faculty participation may include peer selection or other mechanisms that bring a broad faculty perspective to the decision-making process, independent of departmental or central administration points of view. The quality of an educational programme may be enhanced by the participation of volunteer faculty and faculty governance, especially in defining educational goals and objectives.

Standard ED-1 requires that medical school faculty define the objectives of the educational programme. Such objectives should state what students are expected to learn, not what is to be taught. Objectives for clinical education, including quantified criteria for the types of patients, the level of student responsibility, and the appropriate clinical settings needed for the objectives to be met are also required. See Standard ED-2.

Pursuant to Standard ED-5, the faculty must approve a curriculum that provides a general professional education and fosters in students the ability to learn through self-directed, independent study throughout their professional lives.

Pursuant to Standard ED-29, the faculty must be responsible for the detailed design and implementation of the components of the curriculum. The educational programme as a whole must be overseen by an institutional body such as a curriculum committee consisting of faculty, students, and administrative representatives. The curriculum committee is expected to lead, direct, coordinate, control, plan, evaluate, and report on the programme. See Standard ED-31. The faculty committee responsible for the curriculum must monitor the content provided in each discipline, giving careful attention to the impact on students of the amount of work required. See Standards ED-33 and ED-34.

Standard FA-15 requires that faculty should meet often enough for all faculty members to have the opportunity to participate in the discussion and establishment of medical school policies and practices.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B and Medical Education Database, Section IV: Faculty, Exhibit 13, at Part B.

The CAAM-HP also asks a school to address these topics in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions III.A.1; III.D.11 and III. D.12; IV.B.4 through IV.B.7; IV.C.8.
 
Analyst Remarks to Narrative
CAAM-HP has numerous standards that contain appropriate requirements related to admissions, the hiring, retention, promotion, and discipline of faculty and all phases of the curriculum, including the clinical education portion. Faculty members participate in decisions either by virtue of their job assignments or descriptions or by participation on decision-making committees, such as curriculum committees.

NCFMEA may wish to request a completed Section IV: “Faculty” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40D: UWI Medical Education Database: Faculty.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section IV: “Faculty” in order to see the responses to those questions.

In response, the country provided the completed database section, as requested.

 
Staff Conclusion: Comprehensive response provided
 
Remote Sites, Question 1
 
Country Narrative
The CAAM-HP’s accreditation process encompasses complete education programmes (basic sciences and clinical sciences) regardless of the distance to remote sites. As explained in the CAAM-HP’s accreditation guidelines:

“The ‘scope of recognition’ for the CAAM-HP, as recognised by the participating countries of the region, is the accreditation of medical, dental, veterinary and degree nursing education programmes that are provided in the participating countries.

Several schools offer multiple parallel segments of their education programmes, sometimes by way of separate campuses where students may complete portions of their study, or through distinct 'tracks' within educational programmes where students at a single location may learn similar content using varying educational methods. Schools may also offer programmes or parts of programmes in countries outside of the participating countries, that is, in the case of offshore schools, clinical clerkships may be offered outside of the country in which the school is located. The basic sciences portion of the programme cannot be taken outside the country in which the medical school is located.

By restricting the scope of recognition to complete education programmes, the CAAM-HP is able to focus its assessment activities on comprehensive and comparable units of analysis, independent of the administrative structures of the schools that provide them. Thus, it does not confer accreditation on programmes of one or two-year duration, except as elements of a complete educational programme. Nor does it normally accredit programmes provided outside the participating countries even if the school responsible for the programme operates in the region.” See Exhibit 10, Accreditation Guidelines for New and Developing Schools.

In the case of the medical school in Barbados, the medical education programme is conducted entirely in the host country.
 
Analyst Remarks to Narrative
CAAM-HP accredits a medical school's entire program, including both the basic sciences component and the clinical sciences component. The Standards require that the basic sciences component be taken inside the country in which the school is located, but the clinical sciences component could be offered in other countries. However, as noted in the country’s application, the medical education program in Barbados is conducted entirely in that country.

As documentation, the country provided "Accreditation Guidelines for New and Developing Schools" (Exhibit 10).

 
Remote Sites, Question 2
 
Country Narrative
As set forth in the Standards, when a medical school offers all or part of its medical education programme at geographically separate locations, there must be comparable educational experience and equivalent methods of evaluation across all alternative instructional sites within a given discipline.

Standard ED-7 sets forth in detail the requirements to be applied to the evaluation of the medical school to ensure that the quality of its education programme at geographically separate sites is comparable to that at the main campus and that students are evaluated in a comparable manner at all sites. For example, Standard ED-7 sets forth:

-- Course duration or clerkship length should be identical, unless a compelling reason exists for varying the length of the experience;
-- The instruments and criteria used for student evaluation, as well as policies for the determination of grades, should be the same for all alternative sites;
-- Faculty at each site should be sufficiently knowledgeable in the subject matter to provide effective instruction and should possess a clear understanding of the objectives of the educational programme and the evaluation methods used to determine achievement of those objectives;
-- Opportunities to enhance teaching and evaluation skills should be available for faculty at all instructional sites;
-- While the types and frequency of problems or clinical conditions seen at alternate sites may vary, each course or clerkship must identify any core experiences needed to achieve its objectives and ensure that students receive sufficient exposure to such experiences;
-- The proportion of time spent in inpatient and ambulatory settings may vary according to local circumstance, but in such cases the course or clerkship director must ensure that limitations in learning environments do not impede the accomplishment of objectives;
-- The course or clerkship director should orient all participants, both teachers and learners, about the educational objectives and the assessment system used;
-- Course or clerkship directors should review student evaluations of their experiences at alternative sites to identify any persistent variations in educational experiences or evaluation methods.

Several other Standards provide additional detail to operationalize the effective administration of the requirements set forth in Standard ED-7. For example:

Standard ED-35 requires the medical school’s academic officers to be responsible for the conduct and quality of the educational programme and for assuring the adequacy of faculty at all educational sites.

Standard ED-36 states that the academic officer in charge of each geographically separate site must be administratively responsible to the Chief Academic Officer of the medical school.

Standard ED-37 requires the faculty in each discipline at all sites to be functionally integrated through appropriate administrative mechanisms. Medical schools should demonstrate the means by which faculty participate in student education consistent with the objectives and performance expectations established by course or clerkship leadership. Mechanisms to achieve appropriate functional integration may include regular meetings, electronic communication, periodic visits to all sites by course or clerkship leadership, and sharing of course or clerkship evaluation data and other types of feedback regarding faculty performance of their educational responsibilities.

Standard ED-38 requires that there be a single standard for promotion and graduation of students across all geographically separate sites.

Standard ED-39 requires the “parent” school to assume ultimate responsibility for the selection and assignment of all medical students in the case when geographically separated campuses are operated.

Standard ED-40 states that students assigned to all campuses should receive the same rights and support services.

Standard ED-41 states that students should have the opportunity to move among the component programmes of the school.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B. The CAAM-HP also asks a school to assess its practices in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions III.B.5 and III.D.13.
 
Analyst Remarks to Narrative
CAAM-HP has numerous standards that address requirements that require a school to offer comparable programs sites that are geographically apart from the main medical school campus. Students must be held to the same standards at all sites, and the programs, faculty, facilities, support services, etc. must be comparable. The branch locations must be administratively responsible to the chief administrator at the main campus. Course duration and evaluation instruments must be the same. Acceptance, promotion, and graduation requirements must be the same.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Program Length, Question 1
 
Country Narrative
Pursuant to Standard ED-4, the degree programme of medical education leading to the M.D. (or equivalent) degree must include at least 130 weeks of instruction, scheduled over a minimum of four calendar years.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part A, item (a), p. 1 and Part B.
 
Analyst Remarks to Narrative
The Standards expect a program leading to the M.D. degree must be a minimum of 130 weeks of instruction that take place over a minimum of four calendar years.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Curriculum, Question 1
 
Country Narrative
Standard ED-6 states that the “curriculum must incorporate the fundamental principles of medicine and its underlying scientific concepts; allow students to acquire skills of critical judgment based on evidence and experience; and develop students' ability to use principles and skills wisely in solving problems of health and disease.” The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
For this section and the following curriculum-related sections, the CAAM-HP requirements closely overlap with the NCFMEA curriculum-related expectations. Each school must address CAAM-HP’s curriculum-related requirements within the school’s responses to the corresponding sections of the CAAM-HP database.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Curriculum, Question 2
 
Country Narrative
Under Standard ED-6, the curriculum must incorporate the fundamental principles of medicine and its underlying scientific concepts; allow students to acquire skills of critical judgment based on evidence and experience; and develop students’ ability to use principles and skills wisely in solving problems of health and disease. The curriculum must include current concepts in the basic and clinical sciences, including therapy and technology, changes in the understanding of disease, and the effect of social needs and demands on care.

The curriculum must include behavioral and socio-economic subjects, in addition to the basic sciences and clinical disciplines. See Standard ED-9. Pursuant to this Standard, subjects widely recognized as important components of the general professional education of a physician should be included in the medical education curriculum. The depth of coverage of the individual topics will depend on the school’s educational goals and objectives.

Pursuant to Standard ED-10, the curriculum must include the contemporary content of those disciplines that have been traditionally titled among anatomy, biochemistry, genetics, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, community and preventative medicine, as well as ethics, law, and international codes of conduct.

Pursuant to Standard ED-11, instruction within the basic sciences should include laboratory or other practical exercises that entail accurate observations of biomedical phenomena.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
The country application presents selections from the CAAM-HP Standards that concise address the country’s approach to the basic sciences. In summary, the Standards require that the basic sciences must include anatomy, biochemistry, genetics, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, community and preventative medicine, as well as ethics, law, and international codes of conduct.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Curriculum, Question 3
 
Country Narrative
Pursuant to Standard IS-12, students should have the opportunity to participate in research and other scholarly activities of the faculty.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part A, item (d). The CAAM-HP also asks a school to address this topic in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions I.B.3 through I.B.5.
 
Analyst Remarks to Narrative
In keeping with its closely tracking of NCFMEA expectations, the CAAM-HP Standards include the requirement that medical students have the opportunity to participate in research and other scholarly activities with the medical school faculty.

NCFMEA may wish to request a completed Section I: “Institutional Setting” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section I: “Institutional Setting” in order to see the responses to those questions.

In response, the country provided the completed database section, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 4
 
Country Narrative
Pursuant to Standard IS-11, the programme of medical education should be conducted in an environment that fosters the intellectual challenge and spirit of inquiry appropriate to a community of scholars.

Pursuant to Standard ED-11, instruction within the basic sciences should include laboratory or other practical exercises that entail accurate observations of biomedical phenomena.

Pursuant to Standard ED-15, critical analyses of data must be a component of all segments of the curriculum.

Pursuant to Standard ED-21, the curriculum must include elective courses to supplement required courses. While electives permit students to gain exposure to and deepen their understanding of medical specialties reflecting their career interests, they should also provide opportunities for students to pursue individual academic interests.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section I: Institutional Setting, Exhibit 16, at Part B, and Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B. The CAAM-HP also asks a school to assess the structure of its educational programme in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions III.B.3 and III.B.4.
 
Analyst Remarks to Narrative
The Standards include requirements that the medical program be offered in an intellectually challenging environment, include labs and other practical experiences that will include accurate biomedical observations, require students to undertake critical analyses of data, and include electives that will allow students to deepen their understanding of medical specialties that reflect their career interests.

NCFMEA may wish to request a completed Section I: “Institutional Setting” of the Medical Education Database in order to see the responses to those questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section I: “Institutional Setting” in order to see the responses to those questions.

In response, the country provided the completed database section, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 5
 
Country Narrative
While the term “service-learning” is not used in the region the concept is being applied.

Students have the opportunity to study in practical ways the health care delivery system and social services of the country in which their medical school is located. Clerkship students are able to apply what they have learned about community-based care, rehabilitation of patients, and the role of the practicing physician in community health care and promotion. They also develop their ability to collect relevant information through observation and practical participation in health activities in the community and are encouraged to reflect upon their experiences. Please refer to Standard ED-13.

The service is addressed in ED-10 (Exhibit 11) as a basic science to be introduced in the early years of the curriculum; in ED-12 (Exhibit 11) exposure to family medicine takes the student into a primary care setting which in the Caribbean may be in community clinics in both rural and urban settings. In ED-13 (Exhibit 11) primary care is listed on a par with the traditional major disciplines of Medicine and Surgery.

CAAM-HP’s Advisory Committee, charged with the responsibility of revising the current standards, has included a new standard to be included in the Education Programme, which reads as follows:

The medical school should ensure that the medical education programme provides sufficient opportunities, encourages and supports medical students’ participation in service-learning and community service activities. Service-learning is defined as a structured learning experience that combines community service with preparation and reflection.
 
Analyst Remarks to Narrative
The country application indicates that a new standard will be adopted that expects medical schools to “ensure that the medical education program provides sufficient opportunities, encourages and supports medical students’ participation in service-learning and community service activities. Service-learning is defined as a structured learning experience that combines community service with preparation and reflection.”

However, it is unclear if the new standard regarding service learning has been adopted and implemented, and if so, where it can be found in the CAAM-HP Standards.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
The new standard regarding service learning has been included in Section III, Educational Programme as ED-13 and reads as follows:

The medical school should ensure that the medical education programme provides sufficient opportunities, encourages and supports medical students’ participation in service learning and community service activities. Service learning is defined as a structured learning experience that combines community service with preparation and reflection.

See Exhibit 39C: Revised Standards, Section III: Educational Programme.

As regards the UWI medical education programmes, service learning is most evident in years 3-5 where students rotate through health centres/clinics/doctors’ offices and are supervised by University-appointed faculty and participate in community-based health activities in both urban and rural settings.

 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if the new standard regarding service learning had been adopted and implemented, and if so, where it could be found in the CAAM-HP Standards.

In response, the country indicated that the new standard had been adopted and included in the revised materials as ED-13 (cf. Exhibit 39C, bottom of p. 7).
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 6
 
Country Narrative
Pursuant to Standard ED-10, the curriculum must include the contemporary content of those disciplines that have been traditionally titled among anatomy, biochemistry, genetics, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, community and preventative medicine, as well as ethics, law, and international codes of conduct.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
Regarding the basic sciences, the CAAM-HP Standards list the same subject titles as mentioned in the NCFMEA guidelines. However, there was no elaboration regarding the actual content covered in the treatment of those subject areas.

Therefore, it is unclear how CAAM-HP consistently ensures that each medical school is providing its students with up-to-date content in its basic sciences curriculum.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
In general, the traditional disciplines are taught in an integrated manner throughout a curriculum which is system-based as opposed to discipline-based.

Anatomy and Physiology are taught together as ‘Structure & Function’ in a series of system-based courses.

The principles of drug actions and interactions (Pharmacology) and basic Pathology and Immunology are taught in a first year course - Fundamentals of Disease and Treatment.

Biochemistry is dealt with slightly differently in two courses – Cell Biology and An Introduction to Molecular Medicine. Some basic microbiology and Immunology are included.

Example of a system-based course:
In the Cardiovascular system course, the gross anatomy of the heart and circulatory system is taught along with the Physiology of circulation. The embryology (development) and histology (microscopic tissue structure) are included. Clinical relevance is provided by a series of problem-oriented cases which students work through in groups illustrating common or important clinical/pathological conditions affecting the cardiovascular system. Drugs treatment (Therapeutics), of conditions of the Cardiovascular system are included including drugs used to treat infectious diseases (Microbiology)

At the end of each system-based course students are tested using a multidisciplinary/ integrated examination.

The hours devoted to each of the traditional disciplines can be gleaned from a breakdown of the timetables in each semester and the proportions are reflected in the blue-printing of the examinations.

In such cases of integrated delivery, the CAAM-HP site visit team examines the curricular presented and determines if the hours of exposure to each of the traditional disciplines meets the minimum standards prescribed by CAAM-HP.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear how CAAM-HP consistently ensures that each medical school is providing its students with up-to-date content in its basic sciences curriculum.

In response, the country indicated that the traditional disciplines are taught in an integrated manner throughout a curriculum which is system-based as opposed to discipline-based, and the narrative proceeded to provide some elucidation. In addition, the narrative indicated that the CAAM-HP site visit team examines the curriculum presented and determines if the hours of exposure to each of the traditional disciplines meets the minimum standards prescribed by CAAM-HP.
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 7
 
Country Narrative
Introductory education within the basic sciences should include laboratory or other practical exercises that entail accurate observations of biomedical phenomena. See Standard ED-11. Critical analyses of data must be a component of all segments of the curriculum, pursuant to Standard ED-15.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
The CAAM-HP Standards include an overall expectation that each medical school will include the appropriate laboratory or other practical exercises in the basic sciences curriculum (using language similar to the NCFMEA guidelines).

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).

 
Clinical Experience, Question 1
 
Country Narrative
Pursuant to Standard ED-13, clinical experience in primary care, internal medicine, obstetrics and gynecology, child health/pediatrics, psychiatry, and surgery must be included as part of the curriculum. Student clinical experience must be based on out-patient, in-patient, and emergency settings.

Standard ED-2 requires that the objectives of a medical school for clinical education include quantified criteria for the types of patients, the level of student responsibility, and the appropriate clinical settings needed for the objectives to be met. The Standard further requires that each course or clerkship that requires physical or simulated patient interactions should specify the number and kinds of patients that students must see in order to achieve the objectives of the learning experience. They should also specify the extent of student interaction with the patients and the venue(s) in which the interactions will occur, irrespective of the student’s religious beliefs and with full respect for the autonomy of the patient. A corollary requirement of the Standard is that courses and clerkships will monitor and verify, by appropriate means, the number and variety of patient encounters in which patients participate so that adjustments in the criteria can be made if necessary without sacrificing educational quality.

The clinical sciences component must cover all organ systems and include the important aspects of preventative, emergency, acute, chronic, continuing, rehabilitative, family medicine and end-of-life care. See Standard ED-12.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
The Standards require that the clinical component of the medical school program include experience in primary care, internal medicine, obstetrics and gynecology, child health/pediatrics, psychiatry, and surgery. Student clinical experience must be based on out-patient, in-patient, and emergency settings. The standards also require the clinical sciences component to cover all organ systems and include aspects of preventative, emergency, acute, chronic, continuing, rehabilitative, family medicine and end-of-life care.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Clinical Experience, Question 2
 
Country Narrative
The Standards state: “[Graduates] should be capable of serving patients in resource poor conditions as well as in the modern hospital or clinic setting. Graduates should be skilled in making clinical diagnoses and undertaking basic treatment of those conditions that do not require specialist skills, but must know how to access specialist skills and facilities when required. The graduate doctor must also be capable of absorbing postgraduate training and after a period of supervised practise to enter independent practise in CARICOM countries. Graduates must have the capacity and desire for life-long learning so they can practise in circumstances where knowledge, health conditions and cultures are different or change over time. Since the further professional education of graduate doctors, before they are accepted to practise independently, varies from country to country, CAAM-HP may make recommendations as to the licensing requirements for graduate doctors who wish to practise in CARICOM countries. This acknowledges that most of the doctors currently being trained in the CARICOM region are being trained to enter countries where the professional requirements for further training towards independent practise may not be the same as those within CARICOM countries. For example, the assessment examination (USMLE 1 and 2) used by the USA to determine whether a graduate from a school in a CARICOM country, or other foreign locations, is capable of entering residency programmes in the USA is not considered by the competent CARICOM body, the Caribbean Association of Medical Councils (CAMC), to be a sufficiently thorough process to assess a doctor who wishes to enter independent practise in CARICOM countries. The standards are therefore written to assure governments, students and the public that graduates of medical schools in CARICOM countries attain educational standards that allow them to adapt to practise anywhere in the world.” See Revised Standards, Introduction, Exhibit 11.

Standard ED-5 requires that “[t]he medical school must design and the faculty approve a curriculum that provides a general professional education, and fosters in students the ability to learn through self-directed, independent study throughout their professional lives.” Standards ED-2, ED-10, ED-12, ED-13, ED-14, and ED-16 also address matters related to this topic.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
The narrative describes some basic CAAM-HP Standards that ensure that the medical school equips its students with the necessary skills and experiences. Overall the Standards require medical schools to have a curriculum that provides a professional education, and also fosters the student's ability to learn through independent study throughout their careers.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Clinical Experience, Question 3
 
Country Narrative
Standard ED-2 requires that the objectives of a medical school for clinical education include quantified criteria for the types of patients, the level of student responsibility, and the appropriate clinical settings needed for the objectives to be met. The Standard further requires that each course or clerkship that requires physical or simulated patient interactions should specify the number and kinds of patients that students must see in order to achieve the objectives of the learning experience. They should also specify the extent of student interaction with the patients and the venue(s) in which the interactions will occur, irrespective of the student’s religious beliefs and with full respect for the autonomy of the patient. A corollary requirement of the Standard is that courses and clerkships will monitor and verify, by appropriate means, the number and variety of patient encounters in which patients participate so that adjustments in the criteria can be made if necessary without sacrificing educational quality.

Standard ED-13 requires a medical education programme to give students clinical experience in primary care, internal medicine, obstetrics and gynecology, child health/pediatrics, psychiatry, and surgery.

Standard ED-14 requires that educational opportunities be available in multi-disciplinary content areas, such as emergency medicine and geriatrics.

Standard ER-6 requires that the medical school have, or be assured use of, appropriate resources for the instruction of its medical students. Clinical resources should be sufficient to ensure breadth and quality of both ambulatory and bedside teaching. Such resources include adequate numbers and types of patients (acuity, case mix, age, gender, etc.) as well as physician resources for the treatment of illness, the prevention of disease, and the promotion of health.

When national and regional examinations are given at the request of government authorities (in order to license graduates), Standard CE-5 requires that such “examinations should cover the diagnosis, prevention and treatment of conditions which occur in the region and may include the diagnosis of transmissible disorders that occur internationally.”

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B; Medical Education Database, Section V: Educational Resources, Exhibit 18; and Medical Education Database, Section VII: Continuing Professional Education, Exhibit 15, at Part B.
 
Analyst Remarks to Narrative
The Standards include a number of requirements related to the medical school's clinical education component. They require clinical experience in primary care, internal medicine, obstetrics and gynecology, child health/pediatrics, psychiatry, and surgery, as well as in multi-disciplinary content areas such as emergency medicine and geriatrics. The clinical component is expected to include experience in both ambulatory (outpatient) and bedside (inpatient) settings.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28). However, NCFMEA may wish to request a completed Section V: “Educational Resources” and completed Section VII: “Continuing Professional Education” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education databases are attached as follows: Exhibit 40E: UWI Medical Education Database: Educational Resources; Exhibit 40F: UWI Medical Education Database: Continuing Professional Education.
 
Analyst Remarks to Response
The draft staff analysis indicated that the NCFMEA may wish to request a completed copy of Section V: “Educational Resources” and Section VII: “Continuing Professional Education.”

In response, the country provided the completed documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Supporting Disciplines
 
Country Narrative
Standard ED-14 requires that educational opportunities be available in multidisciplinary content areas, such as emergency medicine and geriatrics, and in the disciplines that support the practice of medicine, such as diagnostic imaging and clinical pathology.

The clinical curriculum of a medical school must include elective courses to supplement required courses. See Standard ED-21.
The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
When it comes to the supporting disciplines, the CAAM-HP Standards require educational opportunities in a variety of content areas, including diagnostic imaging and clinical pathology. The curriculum must also include electives to supplement the requirements covered in this area.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Ethics, Question 1
 
Country Narrative
Required curricular content includes instruction on ethics, law, and international codes of conduct. See Standard ED-10.

Standard ED-20 mandates that a medical school must teach medical ethics with respect for religion and other human values and their relationship to law and governance of medical practice. Under the Standard, students must be required to exhibit scrupulous ethical principles in caring for patients and, in relating to patients’ families and others involved in patient care, students must strive to encompass community concerns. Each school must ensure that students receive instruction in medical ethics, human values, and communication skills before engaging in patient care activities. As students take on increasingly more active roles in patient care during their progression through the curriculum, adherence to ethical principles must be observed, evaluated, and reinforced through formal instructional efforts. Scrupulous ethical principles imply the characteristics of honesty, integrity, maintenance of confidentiality, and respect for patients, patients’ families, other students, and other health professionals. Standard ED-20 also requires that in student-patient interactions there should be a system for identifying possible breaches of ethics in patient care through such means as faculty/resident observation of the encounter, patient reporting, or some other appropriate method.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
The Standards require instruction in medical ethics, law, and international codes of conduct. The standards also require that student patient interactions include a system for identifying ethical breaches in patient care through faculty/resident observations, patient reporting, or some other appropriate method.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Communication Skills, Question 1
 
Country Narrative
As set forth in Standard ED-16, a medical school must provide specific instruction in communication skills as they relate to physician responsibilities, including communication with patients, families, colleagues, other health professionals, team work, and resolution of conflict.

Standard ED-20 requires that each school ensure that students receive instruction in communication skills before engaging in patient care activities.

Standard ED-26 requires that a medical school demonstrate that it engages in ongoing assessment of students to ensure that they have acquired and can demonstrate on direct observation the core clinical skills, behaviors, and attitudes that have been specified in the school’s additional objectives, including assessment of students’ problem solving, clinical reasoning, and communication skills in relation to both individuals and communities.

As set forth in Standard ED-27, the directors of all courses and clerkships of a medical school seeking accreditation must have designed and implemented a system of formative and summative evaluation of student achievement in each course and clerkship. Adherence to this Standard ensures that students have sufficiently developed communication skills.

Standard ED-28 states that narrative descriptions of student performance including personal qualities and interactions should be included as part of evaluations in all required courses and clerkships where teacher-student interaction permits this form of assessment.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
The CAAM-HP standards include requirements for instruction in communication skills related to physician responsibilities, including communication with patients, families, colleagues, other health professionals, team work and resolution of conflict. The standards also require ongoing evaluation of students' communication skills throughout the course of the medical education program.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Design, Implementation, and Evaluation, Question 1
 
Country Narrative
Pursuant to Standard FA-14, a medical school should have mechanisms for direct faculty involvement in decisions related to the educational programme, including curriculum development and evaluation.

As set forth in Standard ED-29, within a medical school, there must be an integrated institutional responsibility for the overall design, management, and evaluation of a coherent and coordinated curriculum. The faculty must be responsible for the detailed design and implementation of the components of the curriculum. An institutional body (commonly, a curriculum committee) must oversee the educational programme as a whole. An effective central curriculum authority will exhibit: faculty, student, and administrative participation; expertise in curriculum design, pedagogy, and evaluation methods; and empowerment to work in the best interest of the institutional programmes without regard for parochial or departmental pressures.

Standard ED-32 requires that the academic faculty of a medical school must have sufficient resources and authority to fulfill the responsibilities for the management and evaluation of the curriculum. The Standard provides that the kind of resources needed by the Chief Academic Officer to ensure effective delivery of the educational programme include: adequate numbers of teachers who have the time and training necessary to achieve the programme’s objectives; appropriate and adequate teaching space for the methods of pedagogy employed; appropriate educational infrastructure (e.g., computers, audio-visual aids, laboratories, etc.); educational support services such as examination grading, classroom scheduling, and faculty training; and support services for the efforts of the curriculum management body and for any interdisciplinary teaching efforts that are not supported at a departmental level.

Pursuant to Standard ED-32, the Chief Academic Officer must have explicit authority to ensure the implementation and management of the educational programme and to facilitate change when modifications to the curriculum are deemed to be necessary.

Standard ED-33 requires that the faculty committee responsible for the curriculum must monitor the content provided in each discipline so that the school’s educational objectives will be achieved. The committee working in conjunction with the Chief Academic Officer of the school should assure that each academic period of the curriculum maintains common standards for content. Such standards should address the depth and breadth of knowledge required for a general professional education in medicine, currency and relevance of content, and the extent of redundancy needed to reinforce learning of complex topics. The final year should complement and supplement the curriculum so that each student will acquire appropriate competence in general medical care regardless of their subsequent career specialty.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B and Medical Education Database, Section IV: Faculty, Exhibit 13, at Part B. The CAAM-HP also asks a school to assess its curriculum management practices in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions III.D.11 and III.D.12.
 
Analyst Remarks to Narrative
There are several CAAM-HP standards related to curriculum development and ongoing evaluation of the medical education program. The standards require that the faculty be involved in the development of the curriculum, and that a curriculum committee oversee the educational program as a whole. The committee must include faculty, staff, and student representatives.

The chief academic officer, working in conjunction with the committee, has the responsibility for implementing the educational program that is developed by the faculty and for facilitating changes to the program when evaluation shows that modifications are needed.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28). However, NCFMEA may wish to request a completed Section IV: “Faculty” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40D: UWI Medical Education Database: Faculty.
 
Analyst Remarks to Response
The draft staff analysis indicated that the NCFMEA may wish to request a completed copy of Section IV: “Faculty” from the medical school database.

In response, the country provided the appropriate documentation, as requested.

 
Staff Conclusion: Comprehensive response provided
 
Design, Implementation, and Evaluation, Question 2
 
Country Narrative
As set forth in Standard ED-29, within a medical school, there must be an integrated institutional responsibility for the overall design, management, and evaluation of a coherent and coordinated curriculum.

Pursuant to Standard ED-30, a medical school’s curriculum must be designed to achieve the school’s overall educational objectives. The Standard specifies that to do so, a curriculum should include: logical sequencing of the various segments of the curriculum; content that is coordinated and integrated within and across the academic periods of study (horizontal and vertical integration); the development of specific course or clerkship objectives; and methods of pedagogy and student evaluation that are appropriate for the achievement of the school’s educational objectives.

Standard ED-31 sets forth that curriculum management should involve leading, directing, coordinating, controlling, planning, evaluating, and reporting and that evidence of effective curriculum management should include: evaluation of programme effectiveness by outcomes analysis; monitoring of contents and workload in each discipline, including the identification of omissions and unwanted redundancies; and review of the stated objectives of individual courses and clerkships as well as methods of pedagogy and student evaluation to assure congruence with institutional educational objectives and ongoing review and updating of content and assessment of course and teacher quality.

Pursuant to Standard ED-32, the Chief Academic Officer must have explicit authority to ensure the implementation and management of the educational programme and to facilitate change when modifications to the curriculum are deemed to be necessary.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B. The CAAM-HP also asks a school to evaluate the effectiveness of its educational programme in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions III.C.9 and III.C.10; III.E.14 and III.E.15.
 
Analyst Remarks to Narrative
The CAAM-HP standards require each medical school to have its own ongoing process of program evaluation. The curriculum must be driven by stated objectives and evaluated on a regular basis to ensure that the objectives are being met, including the sequencing of curriculum segments, coordination of content, and the review of the stated objectives, including updating of curriculum content as necessary.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Design, Implementation, and Evaluation, Question 3
 
Country Narrative
ED-24 states that “A medical school faculty must establish a system for the evaluation of student achievement throughout medical school that employs a variety of measures of knowledge, skills, behaviours and attitudes.

Evaluation of student performance should measure not only retention of factual knowledge, but also development of the skills, behaviours and attitudes needed in subsequent medical training and practice. The use of data for solving problems commonly encountered in medical practice should be evaluated.”

As set forth in Standard ED-29, within a medical school, there must be an integrated institutional responsibility for the overall design, management, and evaluation of a coherent and coordinated curriculum.

Pursuant to Standard ED-30, a medical school’s curriculum must be designed to achieve the school’s overall educational objectives. The Standard specifies that to do so, a curriculum should include: logical sequencing of the various segments of the curriculum; content that is coordinated and integrated within and across the academic periods of study (horizontal and vertical integration); the development of specific course or clerkship objectives; and methods of pedagogy and student evaluation that are appropriate for the achievement of the school’s educational objectives.

Standard ED-31 sets forth that curriculum management should involve leading, directing, coordinating, controlling, planning, evaluating, and reporting and that evidence of effective curriculum management should include: evaluation of programme effectiveness by outcomes analysis; monitoring of contents and workload in each discipline, including the identification of omissions and unwanted redundancies; review of the stated objectives of individual courses and clerkships as well as methods of pedagogy and student evaluation to assure congruence with institutional educational objectives and ongoing review and updating of content and assessment of course and teacher quality.

Pursuant to Standard ED-32, the Chief Academic Officer must have explicit authority to ensure the implementation and management of the educational programme and to facilitate change when modifications to the curriculum are deemed to be necessary.

Standard ED-31 states that evidence of effective curriculum management includes “[e]valuation of programme effectiveness by outcomes analysis.” See also Standards ED-42 and ED-43.

ED-42 reads as follows: To guide programme improvement, medical schools must evaluate the effectiveness of the educational programme by documenting the extent to which its objectives have been met.

In assessing programme quality, schools must consider student evaluations of their courses and teachers, and an appropriate variety of outcome measures.

Among the kinds of outcome measures that serve this purpose are data on student performance, academic progress and programme completion rates, acceptance into residency / postgraduate programmes, postgraduate performance, and practice characteristics of graduates.

CAAM-HP asks a school to address these in its Medical Education Database, Section III, ED-42 as follows:

a. Check all indicators used by the medical school to evaluate educational programme effectiveness.

-Student scores on internally developed examinations
-Performance-based assessment of clinical skills (e.g., OSCEs)
-Results of CAMC, USMLE, PLAB or other national examinations
-Student evaluation of courses and clerkships
-Student advancement and graduation rates
-Specialty choice of graduates
-Assessment of residency performance of graduates
-Licensure rates of graduates
-Specialty certification rates
-Practice location of graduates
-Practice type of graduates
-Other (specify)

b. For each checked item, indicate
1. How the data are collected (including response rates for questionnaires)
2. What groups or individuals review the data (e.g., curriculum committee, department chairs)
3. How the information is used for curriculum review and change

c. Provide evidence that the educational programme objectives in the domains of knowledge, skills, behaviours, and attitudes are being achieved.

In addition, ED-43 states that: Medical schools must evaluate the performance of their students and graduates in the framework of national and international norms of accomplishment and performance within the health care system.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B. The CAAM-HP also asks a school to evaluate the effectiveness of its educational programme in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions III.C.9 and III.C.10; III.E.14 and III.E.15.
 
Analyst Remarks to Narrative
CAAM-HP Standards ED-24 and ED-42 require schools to provide data to show that educational objectives have been met. This may be demonstrated through the use of a variety of types of data, including a number of types of outcomes data, including results of national examinations, retention and graduation rates, licensure and certification rates, and placement data such as the type of practice a graduate enters. This is evaluated as a part of the agency's on-site review process.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Admissions, Recruiting, and Publications, Question 1
 
Country Narrative
Standard MS-5 mandates that medical schools must select students who possess the intelligence, integrity, and personal and emotional characteristics necessary for them to become effective physicians in the social as well as the scientific sense. Standard MS-6 provides that the selection of individual students should not be influenced by political or personal financial reasons. Standard MS-7 provides that medical schools should have policies and practices ensuring the gender, cultural, racial, cultural, and economic diversity of their students.

The University of the West Indies (UWI) considers a student’s performance in regional examinations (Caribbean Advanced Proficiency Examinations (CAPE)) as part of its admissions process. Some medical schools accredited by the CAAM-HP consider a student’s performance on regional examinations as part of their admissions process. See Exhibit 22 for MBBS entry criteria (extract from Faculty Regulations). The CAAM-HP requests data from schools about the mean scores for all examinations taken by students in the entering first year class, which includes MCAT scores. See Medical Education Database 5.B.-2 – Section II. Medical Students Exhibit 23, at Part A, items (a), (b), (e), and (f) and Part B.

Admission requirements for the UWI MB BS programme apply to all its campuses including the Cave Hill Campus and is available in the university’s faculty regulations.
 
Analyst Remarks to Narrative
CAAM-HP standards parallel the expectations set forth by the NCFMEA. CAAM-HP requests data from schools about the mean scores for all examinations taken by students in the entering first year class, which includes MCAT scores.

NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.

(Note: the country response referred to Exhibit 40A – Section 1, which is incorrect for this guideline. However, the country did provide the correct materials, Exhibit 40B – Section II, which can be found in the table of contents.)
 
Staff Conclusion: Comprehensive response provided
 
Admissions, Recruiting, and Publications, Question 2
 
Country Narrative
As set forth in Standard MS-1, a medical school should require as conditions for admission an undergraduate degree or an adequate level of preparation in the sciences. Students granted admission into a medical school should have a general education that includes the social sciences, history, arts, and languages in order for development of physician competencies outside of the scientific knowledge domain.

Neither the CAAM-HP nor the government of Barbados mandates admissions standards. The CAAM-HP requires the faculty of a medical education programme to make decisions regarding admission, promotion, and graduation of its medical students. See Standard FA-7.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards require the medical school to set admissions standards. A student should have an undergraduate degree or an adequate level of preparation in the sciences and a general education that includes the social sciences, history, arts and languages. CAAM-HP agency requires the faculty of a medical school to make decisions regarding admission, promotion, and graduation of its medical students.

NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.

(Note: the country response referred to Exhibit 40A – Section 1, which is incorrect for this guideline. However, the country did provide the correct materials, Exhibit 40B – Section II, which can be found in the table of contents.)
 
Staff Conclusion: Comprehensive response provided
 
Admissions, Recruiting, and Publications, Question 3
 
Country Narrative
Standard MS-2 requires that the faculty of each school must develop criteria and procedures for the selection of students that are readily available to potential applicants and to their collegiate advisors.

Pursuant to Standard MS-3, the final responsibility for selecting students to be admitted for medical study should reside with a duly constituted faculty committee. Persons or groups external to the medical school may assist in the evaluation of applicants but should not have decision-making authority. The catalogue or informational materials must enumerate the school’s criteria for selecting students and describe the admissions process.

Pursuant to Standard MS-8, a medical school must develop and publish technical standards for the admission of handicapped applicants.
The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B. The CAAM-HP also asks a school to assess its admissions practices in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Question II.A.1.
 
Analyst Remarks to Narrative
CAAM-HP standards require the medical school faculty to develop selection criteria. Those criteria must be available to applicants, and include published standards for the admission of handicapped applicants.

A faculty admissions committee should have the final responsibility for selecting students to be admitted; external groups may not have decision-making authority regarding admissions. Finally, the school's catalog or other published materials must list the selection criteria and describe the admissions process.

NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.

(Note: the country response referred to Exhibit 40A – Section 1, which is incorrect for this guideline. However, the country did provide the correct materials, Exhibit 40B – Section II, which can be found in the table of contents.)
 
Staff Conclusion: Comprehensive response provided
 
Admissions, Recruiting, and Publications, Question 4
 
Country Narrative
As set forth in Standard MS-4, each medical school should have a pool of applicants sufficiently large and possessing the published qualifications to fill its entering class. The size of the entering class and of the medical student body as a whole should be determined not only by the number of qualified applicants but by the adequacy of critical resources, namely: finances; size of the faculty and the variety of academic fields they represent; library and informational systems resources; number and size of classrooms, student laboratories, and clinical training sites; patient numbers and varieties; student services; instructional equipment; and space for the faculty.

The same Standard requires that class size considerations should also include: any need to share resources to education graduate students or other students within the university; the size and variety of programmes of graduate medical education; and responsibilities for continuing education, patient care, research, the size of the community, and the sensibility of the individual patient.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B. The CAAM-HP also asks a school to assess its admissions practices in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions II.A.1 and II.A.2, p. 9.
 
Analyst Remarks to Narrative
CAAM-HP standards require that the school have a qualified pool of applicants that is large enough to fill its entering glass. The size of the entering class and the medical school student body as a whole should be determined by the adequacy of critical resources.

Those critical resources include finances, the size of the faculty and variety of academic fields they represent, library and informational systems resources, the number and size of classrooms, student laboratories and clinical training sites, the number of available patients, student services, instructional equipment and space for faculty.

NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.

(Note: the country response referred to Exhibit 40A – Section 1, which is incorrect for this guideline. However, the country did provide the correct materials, Exhibit 40B – Section II, which can be found in the table of contents.)
 
Staff Conclusion: Comprehensive response provided
 
Admissions, Recruiting, and Publications, Question 5
 
Country Narrative
As set forth in Standard MS-9, a medical school’s catalogue or equivalent informational material must describe the requirements for the M.D. (or equivalent) degree to be awarded by the school and all associated joint degree programmes. It must provide the most recent academic calendar for each curricular option and describe all required courses and clerkships offered by the school. The Standard requires that a medical school’s publications, advertising, and student recruitment material should present a balanced and accurate representation of the mission and objectives of the programme.

As per Standard MS-3, the school’s catalogue or informational materials must enumerate the school’s criteria for selecting students and describe the admissions process.

The following standards address the requirements for health insurance, student conduct and procedures for disciplinary action:

MS-22 Health services and disability insurance must be available to all students, with options to include dependents.

Students must have access to preventive and therapeutic health services.

MS-26 Each medical school / university must define and publicise the standards of conduct for the teacher-learner relationship, and develop written policies for preventing and addressing violations of those standards.

Mechanisms for reporting violations of these standards, such as incidents of harassment or abuse, should assure that complaints can be registered and investigated without fear of retaliation.

The policies also should specify mechanisms for the prompt handling of such complaints, preventing inappropriate behaviour, and the corrective measures to be employed where such behaviour occurs.

Standard MS-27 requires a medical school to publicize to all faculty and students its standards and procedures for the evaluation, advancement, and graduation of its students.
MS-28 There must be a fair and formal process for taking any action that adversely affects the status of a student.

The process should include timely notice of the impending action, disclosure of the evidence on which the action would be based, an opportunity for the student to respond, and an opportunity to appeal any adverse decision related to promotion, graduation, dismissal or other disciplinary action.

The University of the West Indies’ Code of Principles (Exhibit 24) and Sexual Harassment Policy (Exhibit 25) as well as Medical Sciences Faculty Handbook, 2014-2015 for the Cave Hill Campus (Exhibit 26), address these topics.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B.

The CAAM-HP has never considered it necessary to require medical schools to publish the language of instruction of all countries except Suriname over which CAAM-HP has jurisdiction are former British Colonies and English is their official language and there is no other language of instruction.

Information with respect to the estimated cost of attendance is available on the Cave Hill campus website at http://www.cavehill.uwi.edu/financial/fees/tuition-fees.aspx. See Exhibit 27, Cave Hill Fees, 2016-2017.

Also, CAAM-HP has not found it necessary to require a medical school’s catalogue or equivalent informational materials to include tuition and fees as all schools do provide this information on their websites and in catalogues.

However, in the revision of standards process the current Standard MS-9 has been expanded to include the following: Publications must include annual costs for attendance, including tuition and fees.
 
Analyst Remarks to Narrative
CAAM-HP standards address most of the requirements of this section, including the publication of information about the medical school's educational program, admissions requirements, advancing in the program, as well as evaluation, advancement and graduation requirements. CAAM-HP has no requirements related to language of instruction since English is the official language of instruction in the former British colonies where the agency operates.

Regarding the publication of annual costs for attendance, including tuition and fees, the country application indicates that CAAM-HP standards are being revised to specifically require that “Publications must include annual costs for attendance, including tuition and fees.”

However, it is unclear when the new standard requiring schools to publish the annual costs for attendance, including tuition and fees, will be incorporated into CAAM-HP’s published standards so that the new requirement will be consistently enforced.

The NCFMEA may wish to inquire further regarding this matter.
 
Country Response
The requirement for publication of tuition fees has been incorporated in standard MS-9 of the revised standards. See Exhibit 39B: Revised Standards, Section II: Students.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear when the new standard requiring schools to publish the annual costs for attendance, including tuition and fees, will be incorporated into CAAM-HP’s published standards so that the new requirement will be consistently enforced.

In response, the country indicated the necessary change has already been made. The following sentence has been added to Standard MS-9: “Publications must include annual costs for attendance, including tuition and fees.”
 
Staff Conclusion: Comprehensive response provided
 
Admissions, Recruiting, and Publications, Question 6
 
Country Narrative
Standard MS-30 requires that students must be allowed to review and challenge their academic records. Standard MS-29 requires that student records must otherwise be confidential and available only to members of the faculty and administration with the need to know, unless released by the student or as otherwise governed by laws concerning confidentiality in the jurisdiction in which the medical school operates. The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards require that students be allowed to view and challenge their academic records and that the records be confidential unless released by the student.

NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40A: UWI Medical Education Database: Institutional Setting.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.

(Note: the country response referred to Exhibit 40A – Section 1, which is incorrect for this guideline. However, the country did provide the correct materials, Exhibit 40B – Section II, which can be found in the table of contents.)
 
Staff Conclusion: Comprehensive response provided
 
Student Achievement, Question 1
 
Country Narrative
Pursuant to ED-24, the medical school faculty must establish a system for the evaluation of student achievement throughout medical school that employs a variety of measures of knowledge, skills, behaviors, and attitudes.

Evaluation of student performance should measure not only retention of factual knowledge, but also development of the skills, behaviours, and attitudes needed in subsequent medical training and practice.

The ability to use data for solving problems commonly encountered in medical practice should be evaluated.

The sole use of frequent tests which condition students to memorize details for short-term retention only, is not considered a good system of evaluation to foster self-initiated learning.

Pursuant to ED-27, the directors of all courses/clerkships must design/implement a system of formative and summative evaluation of student achievement in each course/clerkship.

Pursuant to MS-27, the medical school must publicize to all faculty and students its standard procedures for the evaluation, advancement, and graduation of its students and for disciplinary action.

Pursuant to ED-38, there must be a single standard for promotion and graduation of students across geographically separate campuses.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B; and Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards require that the medical school faculty establish a system for the evaluation of student achievement, and that the directors of all courses and clerkships must design and implement an evaluation system for student achievement in each course and clerkship. In addition, the Standards specify that the medical school must publicize to all faculty and students the school’s procedures for the evaluation, advancement, and graduation of its students.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28). However, NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40B: UWI Medical Education Database: Students.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Student Achievement, Question 2
 
Country Narrative
The Government of Barbados relies on the CAAM-HP to evaluate student achievement in the context of accreditation, continuing accreditation, and licensure processes, all in accord with published standards. Those are the national requirements with respect to evaluation of student achievement. Medical schools are free to establish their own methods of evaluating student achievement, so long as such methods satisfy relevant Standards, including those identified here.

Pursuant to Standard ED-1, educational objectives (i.e., statements of the items of knowledge, skill, behaviors, and aptitudes that students are expected to exhibit as evidence of their achievement) must be documented by specific and measurable outcomes—that is, measures of basic science grounding in the clinical years, examination results, performance of graduates in residency training, performance in licensure examinations, etc.

Standard ED-24 charges the medical school faculty with the responsibility to establish a system for the evaluation of student achievement that employs a variety of measures of knowledge, skills, behaviors, and attitudes. Under the Standard, evaluation of student performance should measure not only retention of factual knowledge but also development of skills, behaviors, and attitudes needed in subsequent medical training and practice. The ability to use data for solving problems commonly encountered in medical practice is to be evaluated. The Standard makes clear that the sole use of frequent tests which condition students to memorize details for short-term retention only is not considered an acceptable system of evaluation to foster self-initiated learning.

As per Standard ED-25, a school’s Chief Academic Officer, curriculum leaders, and faculty should understand or have access to individuals who are knowledgeable about methods for measuring student performance. Under this Standard, a medical school should provide opportunities for faculty members to develop their skills in such methods.

Likewise, pursuant to Standard ED-26, there must be ongoing assessment that assures that students have acquired and can demonstrate on direct observation the core clinical skills, behaviors, and attitudes that have been specified in the school’s educational objectives. There must be evaluation of problem solving, clinical reasoning, and communication skills in relation to both individuals and communities.

Under Standard ED-27, it is specified that directors of all courses and clerkships should design and implement a system of formative and summative evaluations of student achievement in each course or clerkship. Those directly responsible for the evaluation of student performance should understand the uses and limitations of various test formats, criterion-referenced versus norm-referenced grading, reliability and validity of issues, formative versus summative assessment, and objective versus subjective formats. Each student should be evaluated early enough during a unit of study to allow time for remedial work, if necessary. Courses or clerkships that are short in duration may not have sufficient time to provide structured activities for formative evaluation. In such cases, some alternative means, such as self-testing or teacher consultation, that will allow students to measure their progress in learning should be provided.

Standard ED-28 provides that narrative descriptions of student performance including personal qualities and interactions should be included as part of the evaluation in all required courses and clerkships where teacher/student interaction permits this form of assessment.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
The country application notes that Barbados has not set any special governmental requirements for the evaluation of student achievement, but relies upon the CAAM-HP requirements. CAAM-HP allows medical schools the freedom to establish their own requirements, as long as they do not conflict with the CAAM-HP standards.

The CAAM-HP standards require that medical schools establish educational objectives and that the achievement of those objectives must be demonstrated by measurable outcomes. Evaluations must employ a variety of methods, and apply to both courses and to clerkships.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Student Achievement, Question 3
 
Country Narrative
Pursuant to Standard ED-24, the medical school faculty must establish a system for the evaluation of student achievement throughout medical school that employs a variety of measures of knowledge, skills, behaviors, and attitudes. The CAAM-HP Standard states that the “sole use of frequent tests which condition students to memorize details for short-term retention only, is not considered a good system of evaluation to foster self- initiated learning.” See Standard ED-24.

Pursuant to Standard ED-26, there must be ongoing assessment that assures students have acquired and can demonstrate on direct observation the core clinical skills, behaviors, and attitudes that have been specified in the school's educational objectives; there must be evaluation of problem solving, clinical reasoning, and communication skills, in relation to both individuals and communities. See Standard ED-27.

Pursuant to Standard ED-37, each student should be evaluated early enough during a unit of study to allow time for remedial work. Courses or clerkships that are short in duration may not have sufficient time to provide structured activities for formative evaluation, but should provide some alternate means (such as self-testing or teacher consultation) that will allow students to measure their progress in learning.
Pursuant to Standard ED-38, there must be a single standard for promotion and graduation of students across geographically separate campuses.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards require the medical school to develop a system of student achievement that is used throughout the medical school program. It must include ongoing student assessment; the students must receive evaluation and feedback early enough in their studies to allow for any necessary remediation; and there must be a single, consistent standard for promotion and graduation across all the school's campuses.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Student Achievement, Question 4
 
Country Narrative
The CAAM-HP extensively monitors and appraises performance outcomes, although it has not set metric standards in that regard. Under the Standards, medical schools are free to establish their own methods of evaluating student achievement. Since Barbados has determined to adopt the Standards and Procedures of the CAAM-HP with respect to the accreditation of medical schools, Barbados does not set specific national requirements by which medical schools are to evaluate student achievement, nor has it established students’ performance outcomes measures, benchmarks, or requirements for schools to determine whether to grant accreditation or approval to that school.

CAAM-HP considers examination-results data as part of its assessment of whether a medical programme has evidence that its objectives are being met. Outcomes data of in-course examinations, both promotional and non-promotional and degree granting examinations must be documented in the Institutional Database and in the Annual Medical Schools Questionnaire of accredited institutions. See The UWI’s Medical Education Database Section III- Educational Programme and its Annual Medical School Questionnaire (AMSQ), 2013-2014, Exhibits 28 and 29, respectively.

The data on degree granting examinations will, where appropriate, be checked against international norms of accomplishment including USMLE Steps I and II and Caribbean Association of Medical Councils (CAMC) examinations. Such examination results and their patterns will be taken into account by CAAM-HP in coming to its accreditation decisions. Failure to progress in the course, to graduate, or to achieve international assessments at rates of 50% or less will be considered poor outcomes that can affect accreditation decisions and status.
 
Analyst Remarks to Narrative
Regarding the specific question concerning country-established benchmarks, the country’s application narrative indicates that Barbados does not use them. Barbados relies on CAAM-HP’s requirements, which allows medical schools to establish their own methods of evaluating student achievement. CAAM-HP requires the schools to report their various milestone examination results annually.

CAAM-HP checks the data on degree-granting exams against international norms for USMLE Steps I and II, and failure to achieve rates above 50% compared to the international assessments are considered a poor outcome that could affect the school’s accreditation status.

However, it is not clear how CAAM-HP decided to establish what appears to be a 50 percent failure rate as its acceptable benchmark for USMLE Steps I and II.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
This matter is still under consideration by CAAM-HP. However, the Authority has taken note that the 50% outcomes benchmark is wholly inadequate. In addition, the Authority notes that setting outcomes benchmark is not a requirement for the LCME.

With respect to the USMLE, the UWI has no benchmark because at present the UWI does not prepare its students to sit it and passing it does not affect the students’ ability to progress or graduate.

The UWI is pleased when its students perform well but the institution does not expect them to do as well as students from schools in the region which prepare their students specifically for these examinations and use the results to determine progression.

The UWI now receives aggregate reports from the ECFMG on USMLE results of their students. The most recent report (for the Mona campus) showed that UWI students performed marginally better than the average for all IMGs (78% first time pass rate). Considering that the UWI’s curriculum is not specifically geared for the USMLE this percentage might be considered satisfactory but in any event, it is not used as a benchmark.

MBBS pass rates for the Cave Hill campus for 2012 to 2014 are as follows:

Year Number examined % Passing
2012 32 84%
2013 43 93%
2014 64 95%
 
Analyst Remarks to Response
The draft staff analysis noted that it was not clear how CAAM-HP decided to establish what appears to be a 50 percent failure rate as its acceptable benchmark for USMLE Steps I and II.

In response, the country indicated that the 50 percent failure rate is inadequate, but that setting outcomes benchmark is not a requirement for the LCME. There seems to be much discussion about the use of benchmarks by Barbados and CAAM-HP. However, it is unclear if student performance outcomes measures or benchmarks are considered of genuine value and would serve a significant role in the country’s accreditation process.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Student Achievement, Question 5
 
Country Narrative
Pursuant to Standard ED-42, medical schools must evaluate the effectiveness of the educational programme by documenting the extent to which its objectives have been met. In assessing programme quality, schools must consider student evaluations of their courses and teachers, and an appropriate variety of outcome measures.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards require medical schools to evaluate the effectiveness of the program by documenting the extent to which the school's educational objectives have been met. In conducting this evaluation, the school must consider student evaluations and an appropriate variety of outcomes measures.

As was previously noted, CAAM-HP evaluates a medical school's entire program of study, including both the basic science portion and the clinical portion, thereby covering both courses and clerkships.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28).
 
Student Services, Question 1
 
Country Narrative
Standard MS-16 states: “There must be a system to assist students in career choice and application to internship, residency and postgraduate programmes, and to guide students in choosing elective courses.”

Standard MS-19 requires medical schools to provide students with effective financial aid and debt management counseling, which includes alerting students to the impact of their total indebtedness.

The CAAM-HP Standards address health-related policies in Standards MS-20 to MS-24.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards address student financial aid and debt counseling, medical program and career counseling, and the requirements related to mental and physical health services, as expected by this section of the NCFMEA Guidelines.

NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40B: UWI Medical Education Database: Students.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Student Services, Question 2
 
Country Narrative
Standard MS-30 requires that students must be allowed to review and challenge their academic records. Standard MS-29 requires that student records must otherwise be confidential and available only to members of the faculty and administration with the need to know, unless released by the student or as otherwise governed by laws concerning confidentiality in the jurisdiction in which the medical school operates. The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards include the requirement that students have access to their records, have the right to challenge their records, and that the records will be available for review by the faculty and administration, but will otherwise be maintained as confidential, unless released by the student.

NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40B: UWI Medical Education Database: Students.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Student Complaints, Question 1
 
Country Narrative
CAAM-HP does require a medical school to have a process for addressing student complaints at the school level as per standards MS-26 and MS-28 which read as follows:

MS-26 Each medical school / university must define and publicise the standards of conduct for the teacher-learner relationship, and develop written policies for preventing and addressing violations of those standards.

Mechanisms for reporting violations of these standards, such as incidents of harassment or abuse, should assure that complaints can be registered and investigated without fear of retaliation.

The policies also should specify mechanisms for the prompt handling of such complaints, preventing inappropriate behaviour, and the corrective measures to be employed where such behaviour occurs.

MS-28 There must be a fair and formal process for taking any action that adversely affects the status of a student.

The process should include timely notice of the impending action, disclosure of the evidence on which the action would be based, an opportunity for the student to respond, and an opportunity to appeal any adverse decision related to promotion, graduation, dismissal or other disciplinary action.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B. The CAAM-HP also asks a school to assess its practices in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions II.C.9 and II.C.10.

If students feel that their complaint has not been satisfactorily addressed by the school then CAAM-HP will accept and investigate complaints about programme quality that, if substantiated, may constitute non-compliance with accreditation standards as per the Procedures, Exhibit 9, page 21 and Appendix H.

As per the Procedures, Exhibit 9, p. 21 and Appendix H, the CAAM-HP will accept and investigate complaints about programme quality that, if substantiated, may constitute non-compliance with accreditation standards. Pursuant to the CAAM-HP Procedures: “Any person concerned about the quality of an undergraduate education programme accredited by the CAAM-HP may contact the CAAM-HP Secretariat to discuss lodging or lodge a complaint. Only those complaints will be investigated that, if substantiated, may constitute non-compliance with accreditation standards. The CAAM-HP will not intervene on behalf of an individual personal complaint regarding, for example, matters of admission, appointment, promotion, or dismissal of faculty or students unless the matter is deemed to represent a breach of accreditation standards.” See Procedures, Exhibit 9, Appendix H.

Pursuant to the Procedures, the “CAAM-HP Secretariat will make an initial determination of whether the complaint contains issues relating to the programme’s compliance with accreditation standards. If the CAAM-HP Secretariat determines that the complaint does raise such issues, the secretariat will contact the dean, including the letter of complaint and corroborating information, and citing the information that the dean should provide in response. A response from the dean will ordinarily be requested within four (4) weeks. The initial letter of complaint, including the corroborating materials, and the response from the dean will be reviewed by an ad hoc subcommittee on Complaints that is appointed by the secretariat in consultation with the Chair.” See Procedures, Exhibit 9, Appendix H. If the subcommittee determines that some areas of non-compliance with Standards exist, it will present its findings and recommendations to the CAAM-HP at the CAAM-HP’s next regularly scheduled meeting. See Procedures, Exhibit 9, Appendix H.

Barbados does not have a written procedure for addressing student complaints that is separate from the procedures set forth by each school and the CAAM-HP.
 
Analyst Remarks to Narrative
CAAM-HP standards require schools to have a process for addressing student complaints at the school level. The expectations are addressed under Standards MS-26 and MS-28, which specify that institutions must develop a code of conduct, develop written policies for addressing violations of conduct, and have a formal process for addressing adverse actions against students. Compliance with these requirements is evaluated during the course of the agency's on-site review process.

NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40B: UWI Medical Education Database: Students.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Student Complaints, Question 2
 
Country Narrative
CAAM-HP does require a medical school to have a process for addressing student complaints at the school level as per standards MS-26 and MS-28 which read as follows:

MS-26 Each medical school / university must define and publicise the standards of conduct for the teacher-learner relationship, and develop written policies for preventing and addressing violations of those standards.

Mechanisms for reporting violations of these standards, such as incidents of harassment or abuse, should assure that complaints can be registered and investigated without fear of retaliation.

The policies also should specify mechanisms for the prompt handling of such complaints, preventing inappropriate behaviour, and the corrective measures to be employed where such behaviour occurs.

MS-28 There must be a fair and formal process for taking any action that adversely affects the status of a student.

The process should include timely notice of the impending action, disclosure of the evidence on which the action would be based, an opportunity for the student to respond, and an opportunity to appeal any adverse decision related to promotion, graduation, dismissal or other disciplinary action.

CAAM-HP asks the schools to address these topics in the Medical Education Database Section II, Part B, Exhibit 23.

If students feel that their complaint has not been satisfactorily addressed by the school then CAAM-HP will accept and investigate complaints about programme quality that, if substantiated, may constitute non-compliance with accreditation standards as per the Procedures, Exhibit 9, page 21 and Appendix H.

As per the Procedures, Exhibit 9, p. 21 and Appendix H, the CAAM-HP will accept and investigate complaints about programme quality that, if substantiated, may constitute non-compliance with accreditation standards. Pursuant to the CAAM-HP Procedures: “Any person concerned about the quality of an undergraduate education programme accredited by the CAAM-HP may contact the CAAM-HP Secretariat to discuss lodging or lodge a complaint. Only those complaints will be investigated that, if substantiated, may constitute non-compliance with accreditation standards. The CAAM-HP will not intervene on behalf of an individual personal complaint regarding, for example, matters of admission, appointment, promotion, or dismissal of faculty or students unless the matter is deemed to represent a breach of accreditation standards.” See Procedures, Exhibit 9, Appendix H.

Pursuant to the Procedures, the “CAAM-HP Secretariat will make an initial determination of whether the complaint contains issues relating to the programme’s compliance with accreditation standards. If the CAAM-HP Secretariat determines that the complaint does raise such issues, the secretariat will contact the dean, including the letter of complaint and corroborating information, and citing the information that the dean should provide in response. A response from the dean will ordinarily be requested within four (4) weeks. The initial letter of complaint, including the corroborating materials, and the response from the dean will be reviewed by an ad hoc subcommittee on Complaints that is appointed by the secretariat in consultation with the Chair.” See Procedures, Exhibit 9, Appendix H. If the subcommittee determines that some areas of non-compliance with Standards exist, it will present its findings and recommendations to the CAAM-HP at the CAAM-HP’s next regularly scheduled meeting. See Procedures, Exhibit 12, Appendix H.

To date, the CAAM-HP has received no formal complaints from any student from the UWI, Cave Hill. Also, Barbados does not have a written procedure for addressing student complaints that is separate from the procedures set forth by each school and the CAAM-HP.
 
Analyst Remarks to Narrative
The county application indicates that CAAM-HP Procedures allow a student who feels that their complaint has not been satisfactorily addressed by the school to contact CAAM-HP directly. The Procedures also indicate that CAAM-HP will accept and investigate complaints about program quality that, if substantiated, may constitute noncompliance with the accreditation standards.

However, it is unclear how medical students are notified of their right to submit complaints about program quality directly to CAAM-HP. As well, it is unclear if CAAM-HP requires school mechanisms for the handling of complaints to include the contact information for CAAM-HP, so that students can submit complaints not resolved at the institutional level.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
CAAM-HP has not required schools to have mechanisms in place for the handling of student complaints. However, this has not been an obstacle as students have accessed contact information from the CAAM-HP website.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear how medical students were notified of their right to submit complaints about program quality directly to CAAM-HP. As well, it was unclear if CAAM-HP required school mechanisms for the handling of complaints to include the contact information for CAAM-HP, so that students could submit complaints not resolved at the institutional level.

In response, the country indicated that CAAM-HP has not required schools to have mechanisms in place for the handling of student complaints. The country believes that students who may wish to contact CAAM-HP regarding a complaint can find the necessary information themselves on the CAAM-HP website.

However, the country’s response to a previous guideline on student complaints (Question 1) indicates that CAAM-HP does require a complaint processing mechanism at its medical schools.

Therefore, it is unclear if the required complaint mechanism will be revised to incorporate the name and contact information of CAAM-HP. In addition, it is unclear if the required complaint mechanism will be revised to clearly inform students that they may submit complaints to CAAM-HP that are not resolved at the institutional level.

The NCFMEA may wish to inquire further regarding these matters.
 
Staff Conclusion: Additional Information requested
 
Finances, Question 1
 
Country Narrative
As set forth in Standard ER-2, the current and anticipated financial resources of the medical school must be adequate to sustain a sound programme of medical education and to accomplish other institutional goals. The costs of conducting an accredited programme leading to an MB BS (or equivalent) degree should be supported from diverse sources, including tuition, endowments, support from the parent university, covenants, grants from organizations and individuals, and appropriations by government. Evidence for compliance with this Standard will include documentation of adequate financial reserves to maintain the educational programme in the event of unexpected revenue losses and demonstration of the effective fiscal management of the medical school budget. This information may be submitted to the CAAM-HP under confidential cover. The UWI Cave Hill campus did provide audited financial statements as per Exhibits 30A, 30B and 30C, Financial Statements July 2013, July 2014 and July 2015.

Pursuant to Standard ER-3, pressure for institutional self-financing must not compromise the educational mission of the medical school nor cause it to enroll more students than its resources can accommodate. Reliance on student tuition should not be so great that the quality of the programme is compromised by the need to enroll or retain inappropriate numbers of students or students who qualifications are substandard.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section V: Educational Resources, Exhibit 18, at Part B. The CAAM-HP also asks a school to address this topic in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions V.A.1 through V.A.4.

Pursuant to Standard MS-4, the size of the entering class and of the medical student body as a whole should be determined not only by the number of qualified applicants but also by the adequacy of critical resources (e.g., finances, size of the faculty, library and information systems resources, number and size of classrooms, patient numbers and variety, student services, instructional equipment, etc.). After conducting a site visit of a new school, the CAAM-HP will determine if the school must reduce the number of students that they plan to enroll owing to any deficiencies in their resources. If needed, the CAAM-HP may impose an enrollment cap on a school that is currently operating in order to ensure there are sufficient resources for its operation. The CAAM-HP can evaluate the adequacy of critical resources through unannounced visits as well.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section II: Medical Students, Exhibit 23, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards require a medical school to have adequate financial resources to support the educational program. Financial pressures should not cause a school to enroll more students than it can accommodate, or to enroll students with substandard qualifications. The size of the student body should be determined not only by the students' qualifications, but also on the adequacy of the school's critical resources. CAAM-HP reviews the size of the student body relative to the school's resources and may cap the size of the student body if it feels that the school does not have the necessary resources to support the program.

NCFMEA may wish to request a completed Section II: “Medical Students” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40B: UWI Medical Education Database: Students.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section II: “Medical Students” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Facilities, Question 1
 
Country Narrative
As per Standard ER-4, a medical school must have, or be assured use of, buildings and equipment appropriate to achieve its educational and other goals. These include: offices for faculty, administrators, and support staff; teaching laboratories and other space appropriate for conduct of research and space for humane care of animals when animals are used in teaching or research; student classrooms and laboratories; lecture halls sufficiently large to accommodate a full year’s class and any other students taking the same courses; space for student use, including student study space; and space for library and information access.

As per Standard ER-6, a medical school must have, or be assured use of, appropriate resources for the clinical instruction of its medical students. Clinical resources should be sufficient to ensure breadth and quality of ambulatory and bedside teaching, including adequate numbers and types of patients as well as physical resources for treatment of illness, prevention of disease, and promotion of health.

As per Standard ER-7, a hospital or other clinical facility that serves as a major site for medical student education must have appropriate instructional facilities and information resources, including areas for individual student study, for conferences, and for large group presentations such as lectures. Library holdings and access to other library systems must either be present or readily available in the immediate vicinity. Sufficient computers, call rooms, and lockers should be available for student use.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section V: Educational Resources, Exhibit 18, at Part B. The CAAM-HP also asks a school to address this topic in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions II.C.11; III.A.2; V.B.5 through V.B.6 and V.C.7.

Determinations as to whether the above Standards are satisfied are made by site visits to the facilities of each medical school to be evaluated for accreditation by the CAAM-HP, as set forth in the Guidelines for Accreditation Survey Visits on behalf of the CAAM-HP, Exhibit 31.
 
Analyst Remarks to Narrative
CAAM-HP standards include requirements that address the medical school's facilities, including classrooms and lecture halls, study space, laboratory and research space, libraries, humane research animal care, office space for faculty, staff and administration, as well as hospitals and other clinical facilities. The adequacy of the school's facilities is verified during the course of the on-site review.

NCFMEA may wish to request a completed Section V: “Educational Resources” of the Medical Education Database in order to see the responses to the questions.

 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40E: UWI Medical Education Database: Educational Resources.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section V: “Educational Resources” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Facilities, Question 2
 
Country Narrative
Pursuant to Standard ER-4, a medical school must have, or be assured use of, buildings and equipment appropriate to achieve its educational and other goals. These include: offices for faculty, administrators, and support staff; teaching laboratories and other space appropriate for conduct of research and space for humane care of animals when animals are used in teaching or research; student classrooms and laboratories; lecture halls sufficiently large to accommodate a full year’s class and any other students taking the same courses; space for student use, including student study space; and space for library and information access.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section V: Educational Resources, Exhibit 18, at Part B.
 
Analyst Remarks to Narrative
As noted under the previous section, the CAAM-HP Standards reflect the expectations of the NCFMEA Guidelines regarding the adequacy of facilities. The medical school’s facilities are reviewed by CAAM-HP’s visiting team as part of its on-site evaluation.

NCFMEA may wish to request a completed Section V: “Educational Resources” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40E: UWI Medical Education Database: Educational Resources.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section V: “Educational Resources” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Faculty, Question 1
 
Country Narrative
Standard ED-23 states, Supervision of student learning experiences must be provided throughout required courses / clerkships by members of the medical school's faculty.

The requirements for accreditation of medical schools related to the size of the faculty and the qualifications for appointment to the faculty are set forth in Standards FA-1 through FA-12. These Standards provide that recruitment and development of the medical school’s faculty should take into account its mission, the diversity of its student body, and the population that it serves. See Standard FA-1. The Standards further provide that there must be a sufficient number of faculty members in the subjects basic to medicine and in the clinical disciplines to meet the needs of the educational programme and the other missions of the medical school. See Standard FA-2. In this regard, the Standards provide that in determining the number of faculty needed for the educational programme, medical schools should consider that faculty may have educational and other responsibilities in academic programmes other than medicine. In the clinical sciences, the number and kind of faculty appointed should also relate to the amount of patient care, health promotion, and prevention activities required to conduct meaningful clinical teaching across the continuum of medical education.

The Standards also provide that persons appointed to faculty positions must have demonstrated achievement commensurate with their academic rank, see Standard FA-3, and that members of the faculty should have the capability and continuing commitment to be effective teachers. See Standard FA-4. Effective teaching requires knowledge of the discipline and understanding of curriculum design and development, curriculum evaluation, and methods of instruction. Faculty members involved in teaching, course planning, and curriculum evaluation should possess or have ready access to expertise in teaching methods, curriculum development, programme evaluation, and student evaluation. Such expertise may be supplied by an office of medical education or by faculty/staff members with background in educational science. Faculty involved in the development and implementation of a course, clerkship, or other large curricular unit should be able to design the learning activities and corresponding evaluation methods (student and programme) in a manner consistent with the school’s stated objectives and sound educational principles. Among the lines of evidence indicating compliance with this Standard are the following: documented participation of the faculty in professional development activities related specifically to teaching and evaluation; attendance at international, regional, or national meetings on educational affairs; and evidence that the faculty members’ knowledge of their discipline is current. See Standard FA-4.

As per Standard FA-5, physicians appointed to the faculty from outside of the school on a part-time basis or as volunteers should be effective teachers, serve as role models for students, and provide insight into contemporary methods of providing patient care, prevention of illness, and promotion of health in the community.

Standard FA-6 requires that faculty members should have a commitment to continuing with scholarly productivity characteristic of an institution of higher learning.

The CAAM-HP asks a school to address these topics in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B. Also, see Medical Education Database, Section IV: Faculty, Exhibit 13, at Part B. The CAAM-HP also asks a school to assess and evaluate itself with regard to these topics in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions IV.A.1 through IV.B.7.
 
Analyst Remarks to Narrative
CAAM-HP standards include numerous requirements related to the medical school's faculty. They include: a sufficient number of basic science and clinical faculty are present to meet the needs of the program; they should have demonstrated achievements appropriate to their rank; they should be appropriately qualified and capable of curriculum development and implementation; they should demonstrate a commitment to ongoing scholarly development; and they should be capable of making decisions regarding student admissions, promotion and graduation, as well as providing academic and career counseling. In addition, CAAM-HP Standards require that clerkships be supervised by members of the school's faculty. Compliance with all of these requirements is evaluated during the course of the on-site review process.

Among the documentation, the country provided a completed Section III: “Educational Program” of the 2015 Medical Education Database (Exhibit 28). However, NCFMEA may wish to request a completed Section IV: “Faculty” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40D: UWI Medical Education Database: Faculty.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section IV: “Faculty” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Faculty, Question 2
 
Country Narrative
Standard FA-9 requires that a medical school should have policies that deal with circumstances in which the private interests of faculty members or staff may be in conflict with their official responsibilities. Standard FA-8 requires that there be clear policies for faculty appointment, renewal of appointment, promotion, granting of tenure, and dismissal that involve the faculty, the appropriate department heads, and the dean/Chief Academic Officer.

For the University of the West Indies, the appointment, renewal of appointments, promotion, granting of tenure and dismissal of all categories of academic staff members are guided by the Rules and Regulations for Academic, Senior Administrative and Professional Staff (Ordinance 8 of the ‘Blue Book’ which can be accessed at: http://www.uwi.edu/staff/other_docs/bluebooknov05.pdf.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section IV: Faculty, Exhibit 13, at Part B. The CAAM-HP also asks a school to address this topic in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Question IV.B.5.
 
Analyst Remarks to Narrative
CAAM-HP Standards expect that a medical school will have policies that deal with circumstances in which the private interests of its faculty or the staff may conflict with their official responsibilities.

Other than that stated expectation, it is unclear how CAAM-HP visiting teams consistently evaluate the effectiveness of a medical school’s conflict of interest policies.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
During the site visit team members hold discussions with senior administrative staff such as the Registrar, dean, department heads, to determine whether it has ever been necessary to apply sanctions for breaches of the institution’s conflict of interest policies.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear how CAAM-HP visiting teams consistently evaluated the effectiveness of a medical school’s conflict of interest policies.

In response, the country indicated that the CAAM-HP site visitors ask senior administrative staff whether it has ever been necessary to apply sanctions for breaches of the institution’s conflict of interest policies. Section IV: “Faculty” of the Medical Education Database serves a consistent reminder to the site visitors to review each medical school’s conflict of interest policies.
 
Staff Conclusion: Comprehensive response provided
 
Library
 
Country Narrative
The Standards relating to the quality of a medical school’s library are set forth in Standards ER-12 through ER-13. Standard ER-12 provides that a medical school must have access to a well-maintained library and information facility sufficient in size, breadth of holdings, and information technology to support its education and other missions. This Standard also provides that there should be physical or electronic access to leading biomedical, clinical, and other relevant periodicals, the current numbers of which should be readily available. The library and other learning resource centers must be equipped to allow students to access information electronically, as well as to use self-instructional materials.

Standard ER-13 requires that the medical school’s library and information service staff must be responsive to the needs of the faculty, junior staff/residents, and students of the medical school. Professional staff should supervise the library and informational services and provide instruction in their use. The library and information services staff should be familiar with current international, regional, and national information resources and data systems and with contemporary information technology. Both school officials and library/information services staff should facilitate access of faculty, residents, and medical students to information resources, addressing their needs for information during extended hours and at dispersed sites.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section V: Educational Resources, Exhibit 18, at Part B. The CAAM-HP also asks a school to address this topic in its self-study report. See Guide to the Institutional Self-study for Programmes of Education in Medicine, Exhibit 14, at Questions V.D.10 through V.D.13.
 
Analyst Remarks to Narrative
CAAM-HP standards address both the library facility itself, and the qualifications of the library staff. The library facility must be well-maintained and have sufficient print and electronic holdings to support the educational program. The library staff should be professionally qualified, responsive to the needs of the medical school's faculty, staff and students, and available to address their needs during extended hours and at various sites.

NCFMEA may wish to request a completed Section V: “Educational Resources” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40E: UWI Medical Education Database: Educational Resources.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section V: “Educational Resources” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Clinical Teaching Facilities, Question 1
 
Country Narrative
As set forth in Standard ER-9, there must be a written and signed affiliation agreement between the medical school and its clinical affiliates that defines, at a minimum, the responsibilities of each party related to the educational programme for medical students. Under the Standard, written agreements are necessary between the medical school and hospitals or clinics that are used regularly as in-patient care sites for core clinical clerkships. Additionally, affiliation agreements may be warranted with other clinical sites that have a significant role in the clinical education programme.

The Standard also requires that affiliation agreements address, at a minimum, the following areas: the assurance of student and faculty access to appropriate resources for medical school education; the primacy of the medical school over academic affairs and the education/evaluation of students; the role of the medical school in appointment/assignment of faculty members with responsibility for medical student teaching; and specification of responsibility for treatment and follow-up when students are exposed to infectious or environmental hazards or other occupational injuries.

Under Standard ER-10, if the department heads of the school are not the clinical service chiefs, the affiliation agreements must confirm the authority of the department head to assure faculty and student access to appropriate resources for medical student education. Pursuant to Standard ER-10, the CAAM-HP should be advised of anticipated changes in affiliation status of a programme’s clinical facilities.

Likewise, under Standard ER-11, in the relationship between the medical school and its clinical affiliates, the educational programme for medical students must remain under control of the school’s faculty. Regardless of the location where the clinical instruction occurs, department heads and faculty must have authority consistent with their responsibility for the education and evaluation of medical students. The responsibility of the clinical faculty for patient care should not diminish or preclude opportunity for medical students to undertake patient care duties under the appropriate supervision of medical school faculty and junior staff/residents.

The CAAM-HP reviews affiliation agreements executed by each school to ensure such agreements are consistent with the Standards; it does not formally approve affiliation agreements.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section V: Educational Resources, Exhibit 18, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP standards specify that there must be a signed affiliation agreement for each clinical site that the medical school uses. The agreements must specify the responsibilities of each party for the clinical education program and address several matters. Those matters include appropriate resources, acknowledgement of the medical school's primary authority over academic affairs including the education and evaluation of students. The agreement must also address the role of the school in the appointment and assignment of clinical faculty, as well as the treatment of students who are exposed to hazards or are injured. CAAM-HP reviews the affiliation agreements, and requires that it be notified of anticipated changes in the affiliation status of a medical program’s clinical facilities.

NCFMEA may wish to request a completed Section V: “Educational Resources” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40E: UWI Medical Education Database: Educational Resources.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section V: “Educational Resources” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Part 3: Accreditation/Approval Processes and Procedures
Onsite Review, Question 1
 
Country Narrative
The CAAM-HP conducts an on-site review at a medical school prior to granting it accreditation. The on-site review includes a review of the school’s admissions process, its curriculum, its faculty, the achievement of its students and graduates, and the facilities and academic support services available to students. See the Guide to the Institutional Self-Study for Programmes of Education in Medicine, Exhibit 14 and the Procedures, Exhibit 9.

Exhibit 32 is an Overview of the CAAM-HP Surveyors’ Orientation (most recent version).

Exhibits 33 and 33A are CAAM-HP’s Schedules for a Full Accreditation Survey of the UWI which include the visit to the Cave Hill Campus. These visits were carried out in 2006, 2012 and 2016.

Exhibits 19A and 19B are the reports of the 2006 and 2012 visits. The report of the 2016 visit will be available after the CAAM-HP’s Annual Meeting in July 2016.

The CAAM-HP’s on-site reviews encompass the main campus of the medical school, any branch campus or campuses, and any other additional location or locations operated by the medical school as well as (required) clinical clerkship sites affiliated with the medical school. Exhibit 31 is the CAAM-HP’s Guidelines for Accreditation Survey Visits on behalf of the Caribbean Accreditation Authority for Education in Medicine and other Health Professions. See p. 12, which describes how the site visit schedule should be determined if geographically remote sites will be visited. Please see also the CAAM-HP’s Procedures, Exhibit 9. See p. 14, which requires a medical school to notify the CAAM-HP when a new geographically remote programme or campus is to be established; in such cases, a limited survey visit may be conducted.
 
Analyst Remarks to Narrative
CAAM-HP conducts on-site reviews that encompass the medical school and all branch campuses, other locations and clinical clerkship sites prior to granting accreditation. Based on the CAAM-HP self-study guide, the procedures manual, and the sample site visit reports provided as documentation, the CAAM-HP site visit covers the basic elements required by this section.

It must be noted that more than one campus of UWI was visited by CAAM-HP during each site visit. As a result, the final report is a compilation of the findings from all of the campuses with highlights devoted to each campus, as appropriate. For example, the summary report included the information that there were almost 70 medical students on the Cave Hill campus at that time.

In addition to the overall summary report, there were several appendices listed at the conclusion of the report that included additional data specific to the individual campuses. However, the 2012 site visit report appendices specifically referencing the Cave Hill campus were not part of the application's documentation. Therefore, they should be provided by the country with their response to this draft staff analysis.

If the appendices are not available with the country’s response, the NCFMEA may wish to enquire further regarding this matter.
 
Country Response
In support of this question, the reports of the site visits of 2012 and 2016 are attached as follows: Exhibit 19B: UWI Site Visit Report 2012, Exhibit 19B.1: Appendices to the 2012 Site Visit Report; Exhibit 19C: UWI Site Visit Report 2016; Exhibit 19C.1: Appendix 3 to the 2016 Site Visit Report.
 
Analyst Remarks to Response
The draft staff analysis found that the 2012 site visit report for the University of the West Indies did not contain all of the appendices that pertained directly to the Cave Hill campus. Therefore, the missing 2012 appendices were requested. No materials from the April 2016 site visit, except the overall schedule, were included in the country’s original application documentation, possibly because they not yet ready for release.

The country’s current response provided one of the missing appendices (no. 3) from the 2012 site visit that pertained directly to the Cave Hill campus. More importantly, however, the country provided the overall 2016 site visit report for the University of the West Indies (Exhibit 19C), plus the completed appendix template (Exhibit 19C.1) that covered all of the campuses referenced in the overall site visit report.

As previously noted, the accreditation process is somewhat unusual in one particular aspect. Barbados is focused on the accreditation of the Cave Hill campus, while CAAM-HP is focused on the accreditation of the entire University of the West Indies of which the Cave Hill campus is just one of the many pieces.

As a result, one must sift through the entire report and appendices to find the specific information that applies only to the Cave Hill campus. As one would expect, issues and problems at each campus receive the greatest attention. As a result, it is difficult to verify, based on the overall site visit report and the template appendix, the extent of the site visitors’ observations and investigations at Cave Hill. It is difficult because CAAM-HP’s checklist covers the entire University and all of its campuses, and contains sporadic observations only when a significant problem is found.

Therefore, it is unclear if Barbados would consider requesting a site visit report from CAAM-HP that would provide a comprehensive and concentrated focus on all of the aspects of the medical education taking place at the Cave Hill campus.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Onsite Review, Question 2
 
Country Narrative
The CAAM-HP’s on-site reviews encompass the main campus of the medical school, any branch campus or campuses, and any other additional location or locations operated by the medical school as well as (required) clinical clerkship sites affiliated with the medical school. Exhibit 31 is the CAAM-HP’s Guidelines for Accreditation Survey Visits on behalf of the Caribbean Accreditation Authority for Education in Medicine and other Health Professions. See p. 12, which describes how the site visit schedule should be determined if geographically remote sites will be visited.

With respect to the quality of teaching sites, the Standards by which the quality of the sites are evaluated, and who is responsible for ensuring that quality, Standards ER-6 through ER-8 provide that a medical school must have, or be assured use of, appropriate resources for the clinical instruction of its medical students. See Standard ER-6. Under that Standard, clinical resources should be sufficient to ensure breadth and quality of both ambulatory and bedside teaching. Such resources include adequate numbers and types of patients (acuity, case mix, age, gender, etc.) as well as physical resources for the treatment of illness, the prevention of disease, and the promotion of health.

Standard ER-7 requires that a hospital or other clinical facility that serves as a major site for medical student education must have appropriate instructional facilities and information resources. Appropriate instructional facilities include areas for individual student study, conferences, and large group presentations such as lectures. Sufficient information resources, including library holdings and access to other library systems, must either be present in the facility or readily available in the immediate vicinity. A sufficient number of computers are needed that allow access to the internet and to other educational software, and call rooms and lockers or other secure spaces to store personal belongings should be available for student use.

Pursuant to Standard ER-8, required clerkships should be conducted in healthcare settings where staff in accredited programmes of graduate medical education, under faculty guidance, participate in teaching the medical students.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section V: Educational Resources, Exhibit 18, at Part B.
 
Analyst Remarks to Narrative
CAAM-HP reviews encompass the entire medical education program, including all clinical clerkship sites. The agency's procedures address how remote sites will be scheduled for review. The sites are evaluated against the CAAM-HP standards and must address the quality of the sites and who is responsible for quality assurance. The standards also include requirements related to the quality of the quality and types of instruction provided, as well as the need for appropriate facilities and other resources, such as instruction space and library facilities. The staff in clinical settings must be a part of accredited graduate medical education programs.

NCFMEA may wish to request a completed Section V: “Educational Resources” of the Medical Education Database in order to see the responses to the questions.
 
Country Response
In support of this question, the UWI School of Medicine’s completed medical education database is attached as follows: Exhibit 40E: UWI Medical Education Database: Educational Resources.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to request a completed copy of Section V: “Educational Resources” in order to see the responses to those questions.

In response, the country provided the appropriate documentation, as requested.
 
Staff Conclusion: Comprehensive response provided
 
Onsite Review, Question 3
 
Country Narrative
The CAAM-HP’s on-site reviews encompass the main campus of the medical school, any branch campus or campuses, and any other additional location or locations operated by the medical school as well as (required) clinical clerkship sites affiliated with the medical school. Exhibit 31 is the CAAM-HP’s Guidelines for Accreditation Survey Visits on behalf of the Caribbean Accreditation Authority for Education in Medicine and other Health Professions. See p. 12, which describes how the site visit schedule should be determined if geographically remote sites will be visited. Exhibit 10 contains the CAAM-HP’s Accreditation Guidelines for New and Developing schools, which requires—as an essential prerequisite for obtaining initial or provisional accreditation—schools to identify their clinical teaching sites. Clinical site visits occur during every accreditation and reaccreditation review, and may be scheduled during the period of accreditation. See CAAM-HP’s Schedules for a Full Accreditation Survey of the UWI, Exhibits 33 and 33A.

CAAM-HP will review core programmes at all sites. A representative sample of teaching sites will be reviewed at the time of a major survey visit, and all other sites will be reviewed within the period of accreditation granted. A core programme site is defined as one where students are assigned on a year round basis and is provided with faculty and administrative support.

While CAAM-HP appreciates that written procedures establishing specific time frames for review would facilitate timely review of clinical sites, CAAM-HP is also of the view that since accreditation is given for a specific time frame, this does suggest that there is a time frame for review. CAAM-HP’s Procedures also provide for a limited site review at a specified time if circumstances so warrant.

As was reported at the NCFMEA’s Fall meeting 2015, and supported by extracts from the Minutes of the CAAM-HP’s Meeting held July 23-25, 2015, CAAM-HP considered and agreed to adopt as policy with immediate effect, the NCFMEA requirement that all clinical sites receive on-site visits. Sites not visited during the full accreditation exercise will be visited during the period of accreditation granted to the school. CAAM-HP has published this new policy on its web site, written to all schools advising of the new policy and requested schools to provide a list of all clinical affiliates to facilitate tracking.

The policy explains that “CAAM-HP at its meeting held July 23-25, 2015 discussed the requirement of the US Department’s National Committee on Foreign Medical Education and Accreditation (NCFMEA) for visits to clinical sites, The NCFMEA requires that all clinical sites for a school under review be visited during the accreditation period, irrespective of the number of students at any given site.

The meeting discussed the need for a full database of clinical sites for each school and acknowledged that there would be cost implications for the schools. In addition, the meeting noted that it would be a resource intensive activity for CAAM-HP, given the number of clinical sites for some schools.

CAAM-HP has formally adopted as policy, the requirement that all clinical sites receive on-site visits, with immediate effect.”

It is important to point out however, that in the Caribbean region there are medical schools at varying stages of development, for example, large, long established medical schools as well as small new and developing medical schools. In the CAAM-HP experience the larger and older medical schools have to date been accredited for four to five years and the smaller schools accredited for two years. This therefore makes it difficult to specify a time frame applicable to all schools. Furthermore, the small schools use fewer clinical affiliates thus making it possible to carry out visits to the clinical affiliates within two years.

Additionally, it must be borne in mind that the off-shore schools have more than one intake of students per year thus it is unlikely that students will not be present at a core clinical site during the period of accreditation.
 
Analyst Remarks to Narrative
During its July 2015 meeting, CAAM-HP adopted a policy that all clinical sites will receive on-site visits, and that sites not visited during the full accreditation exercise will be visited during the period of accreditation granted to the school. The country application indicates that CAAM-HP wrote to all its schools advising them of this new policy and requesting that the schools provide a list of all their clinical affiliates.

In addition, the application noted that CAAM-HP finds it difficult to specify a time frame for visits to clinical sites that is applicable to all schools. The reasons given include the fact that the more established schools can receive a maximum five-year accreditation, whereas developing schools usually only receive two years. Related to this reality is that more established schools typically have more clinical sites to cover, but the newer schools have few, so they could be readily visited within two years.

The discussion above indicates that CAAM-HP finds itself unable to establish a policy, in writing, that always mandates visits to the specified clinical sites with the 12-month period expected by the NCFMEA. However, it does appear that CAAM-HP may be meeting that NCFMEA expectation, in practice, a majority of the time because CAAM-HP recognizes its benefits and would like to comply with that NCFMEA expectation.

Aside from CAAM-HP’s universal policies, Department staff understands that at present, the only clinical sites used by the Cave Hill campus are in Barbados, and that they are all visited at the same time as the site visit to the Cave Hill campus.
However, it is still unclear what the CAAM-HP written policy on site visits would require should the medical school on Barbados establish a new clinical site after the periodic site visit team had finished its work, and especially if that new clinical site was outside of the country.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
Should the Cave Hill campus decide to establish a new clinical site outside of or within Barbados after the periodic site visit had finished CAAM-HP would visit this site inviting at least two members of the original site visit team to conduct a visit to the new site.

According to CAAM-HP’s Procedures any major change must be communicated to the CAAM-HP. The Procedures, also being revised, states that information must be communicated in writing to CAAM-HP one year in advance and reads as follows:

“School officials must notify CAAM-HP in writing at least one year in advance, that a change in programme ownership or governance is planned, (e.g. the programme is to be transferred to the auspices of another university or institution) providing details of the change and a transition plan as set out in Appendix I of the Procedures.

CAAM-HP may also conduct a Secretariat visit. The report and the visit allow CAAM-HP to determine whether reasonable compliance with accreditation standards can be assured and the current status and term of accreditation continued under the new ownership or governance. The same procedures apply when a new geographically remote programme/campus is to be established. Failure to comply could have negative consequences for the programme’s accreditation status.”

At its July 2016 meeting, the Authority reviewed the revised Procedures of the CAAM-HP. The revised document was accepted in principle with a few amendments. The meeting agreed that the amended Procedures should be circulated to members and then to CARICOM’s Council for Human and Social Development (COHSOD).

See Exhibit 41: Draft Revised Procedures of the CAAM-HP

In addition, standard ED-8 states:

“Accredited programmes must notify CAAM-HP of plans for any major modification of the curriculum.

Notification should include the explicitly-defined goals of the change, the plans for implementation and the methods that will be used to evaluate the results. Planning for curriculum change should consider the incremental resources that will be required, including physical facilities and space, faculty/resident support, demands on library facilities and operations, information management needs and computer hardware.

In view of the increasing pace of discovery of new knowledge and technology in medicine, the CAAM-HP encourages experimentation that aims at increasing the efficiency and effectiveness of medical education.”

It is to be noted that in 2008 with a track record of 41 years of clinical teaching, established professional postgraduate programmes and internationally recognized research at what was the School of Clinical Medicine and Research (SCMR) in Barbados, it was upgraded to the Faculty of Medical Sciences. CAAM-HP did visit the campus to evaluate the incremental resources required such as the physical facilities and space, faculty support, demands on library facilities and operations, information management needs and computer hardware with a focus on the basic sciences part of the medical education programme.
 
Analyst Remarks to Response
The draft staff analysis noted that it was still unclear what the CAAM-HP written policy on site visits would require should the medical school on Barbados establish a new clinical site after the periodic site visit team had finished its work, and especially if that new clinical site was outside of the country.

In response, the country indicated that if the Cave Hill campus decided to establish a new clinical site outside of or within Barbados after the periodic site visit had finished, CAAM-HP would visit this site. However, the question about when that visit would actually take place still remains unanswered.

Therefore, it remains unclear whether CAAM-HP will conduct an on-site review at new clinical sites inside or outside of Barbados within 12 months of the placement of Cave Hill students at those sites.

The NCFMEA may wish to inquire further about this matter.
 
Staff Conclusion: Additional Information requested
 
Onsite Review, Question 4
 
Country Narrative
Pursuant to Standard ER-6, a medical school must have, or be assured use of, appropriate resources for clinical instruction. A hospital or other clinical facility that serves as a major site for medical student education must have appropriate instructional facilities and information resources. See Standard ER-7. Pursuant to Standard ER-9, there must be a written and signed affiliation agreement between the medical school and its clinical affiliate that defines, at a minimum, the responsibilities of each party related to the educational programme for medical students, and the following areas:

- The assurance of student and faculty access to appropriate resources for medical student education.
- The primacy of the medical school over academic affairs and the education / evaluation of students.
- The role of the medical school in appointment / assignment of faculty members with responsibility for medical student teaching.
- Specification of the responsibility for treatment and follow-up when students are exposed to infectious or environmental hazards or other occupational injuries.

CAAM-HP reviews affiliation agreements during an accreditation site visit to assess whether they comply with CAAM-HP standards. CAAM-HP will make findings regarding affiliation agreements if it has concerns regarding any such agreements’ compliance with relevant standards, and it will take appropriate action based on such findings, as it would any finding.

During a site visit, CAAM-HP site visitors also interview medical students and staff and review the independent student analysis to determine the total number of students at individual teaching sites, regardless of the medical school of origin, and to assess whether the site has facilities and resources sufficient for that total number of students. Please see response to Clinical Teaching Facilities, Question 1 for additional information regarding review of affiliation agreements. Reference is also made to the signed Memorandum of Understanding between the University of the West Indies Cave Hill Campus and the Ministry of Health and Government of Barbados, Exhibit 21.
 
Analyst Remarks to Narrative
CAAM-HP standards require that the medical school have a signed affiliation agreement with each clinical site, and the standards specify what should be covered in the affiliation agreement. CAAM-HP reviews all affiliation agreements for compliance with its standards during the course of the on-site review visits.

Among the documentation, the country provided the reports from the last two site visits, including 2012 (Exhibit 19).
 
Onsite Review, Question 5
 
Country Narrative
CAAM-HP has standard operating procedures to address matters pertinent to the NCFMEA Guideline, Part 3 Accreditation/Approval Processes and Procedures, Section 1(e). Specifically, CAAM-HP does not accredit multiple schools or their operations at a single clinical site at one time. Each school is accredited individually, and a site visit team interviews only the students of the school under review when it visits a school and its clinical affiliates. For example, during the first half of 2013 CAAM-HP paid two visits to one hospital in Chicago that has a single coordinator responsible for the educational experience of students from multiple schools; the site visit team conducted interviews with students of the school under review and not with students from all schools that use the location. Site visitors do not evaluate a clinical site with regard to students of medical schools that are not within the jurisdiction of CAAM-HP.

This very broad, general requirement and its implications will need to be examined carefully by CAAM-HP at its next meeting in July 2016 in the light of the Caribbean context where there are medical schools which do not need to use for clinical affiliates in the USA or anywhere else and off-shore, for profit schools which do have clinical affiliates in the USA.

CAAM-HP will need to consider the implications of such a policy such as, requirement for the student learning experience to be under the supervision of the medical school’s faculty; whose curriculum is to be followed, sufficiency of information resources and instructional facilities.

CAAM-HP also needs to be careful that other medical schools in the region to which this policy is not applicable, are not compromised by such a policy/standard. If “approved foreign country” refers to countries “friendly” to the USA, then it is to be noted that CARICOM member countries have been traditionally friendly to the USA.

It is worthy of note that offshore medical schools in order to attract international students often claim that the school provides the opportunity to pursue their clinical training in the United States.

CAAM-HP recognises that with a number of schools within its jurisdiction using the same facilities for clinical training and in the light of the requirement that all clinical sites be visited, it may become necessary to make simultaneous assessments on behalf of more than one school. Consideration will be given to this during the revision of the standards and procedures in 2016.
 
Analyst Remarks to Narrative
Generally speaking, CAAM-HP currently conducts reviews of clinical sites for only one accredited medical school at a time, even if more than one school has clinical students at the site. In the particular case of Barbados, Department staff understands that at present, the only clinical sites used by the Cave Hill campus are in Barbados, and that there are no other medical schools using those clinical sites. Nevertheless, the current situation always has the potential to change.

As a result, CAAM-HP recognizes that it may need to change its general written policies to cover all potential situations. Those situations could be undertaking multi-school reviews of clinical sites in the future, based upon workload. It could also include working with a single clinical education coordinator responsible for overseeing the clinical program at sites that serve more than one school.

As well, CAAM-HP does not currently have a written policy specifying that clinical programs must be offered in conjunction with the education programs offered to students enrolled in medical schools in the approved foreign country or in the United States. [The application showed some confusion regarding the phrase “approved foreign country.” In the NCFMEA Guidelines that phrase refers to countries who have been specifically listed by the NCFMEA as having standards for the accreditation of medical schools that are comparable to those used in the United States.]

Therefore, it is unclear if CAAM-HP will be adopting a written policy specifying that if the clinical program is located in the United States or in a comparable third country, the medical accreditor must have conducted an on-site visit and approved the clinical training program. In addition, CAAM-HP policy should specify that those approved clinical training programs must be offered in conjunction with the education programs offered to students enrolled in medical schools in the approved foreign country or in the United States.

The NCFMEA may wish to inquire further regarding these matters.
 
Country Response
This is an issue which requires more consideration by CAAM-HP.

CAAM-HP appreciates the importance of adopting a written policy specifying that if the clinical programme located in the United States or in a comparable third country, the medical school accreditor must have conducted an on-site visit and approved the clinical training programme.

However, the difficulty arises regarding a requirement that the policy should specify that those approved clinical training programmes must be offered in conjunction with the education programmes offered to students enrolled in medical schools in the approved foreign country or in the United States as this seems to suggest a non-compliance with Standard ED-23 which states:

“Supervision of student learning experiences must be provided throughout required courses/clerkships by members of the medical school’s faculty.”
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if CAAM-HP will be adopting a written policy specifying that if the clinical program is located in the United States or in a comparable third country, the medical accreditor must have conducted an on-site visit and approved the clinical training program. In addition, CAAM-HP policy should specify that those approved clinical training programs must be offered in conjunction with the education programs offered to students enrolled in medical schools in the approved foreign country or in the United States.

In response, the country indicated that CAAM-HP will be considering this issue more fully. Since it appears that Cave Hill students are not currently using clinical sites outside of Barbados, the country may not have had occasion to consider the ramifications of whatever policy it may adopt to cover possible future contingencies. More importantly, there still appears to be some misunderstanding concerning NCFMEA requirements with regard to clinical programs located in countries that are approved (listed) by the NCFMEA outside of Barbados.

As a result, it is still unclear if CAAM-HP will be adopting a written policy specifying that if a clinical program is located in the United States, or in an approved (NCFMEA-listed) third country, that CAAM-HP must have conducted an on-site visit and approved that clinical training program.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Qualifications of Evaluators, Decision-makers, Policy-makers
 
Country Narrative
As set forth in the Procedures, Exhibit 9, the CAAM-HP Secretariat recruits and trains a suitable group of surveyors who are knowledgeable about medical education. The Secretariat maintains an updated roster of experienced and competent educators and practitioners in the respective disciplines from which to select appropriate ad hoc team members. Deans of schools are given particular consideration for team membership.

The Procedures also set forth (p. 15) that the Secretariat staff conducts accreditation orientation sessions for surveyors at times that will be publicized well in advance. See Overview of the CAAM-HP Surveyors’ Orientation, Exhibit 32. In addition, interactive workshops are offered as required for in-depth training of prospective surveyors, focusing on the interpretation of standards and the assessment of compliance. The survey team must include experienced surveyors as well as other qualified professionals who would have participated in a CAAM-HP training workshop.

The CAAM-HP Secretariat is responsible for appointing survey teams. Each survey team is appointed on an ad hoc basis. The composition of a survey team is determined by the characteristics of the school to be visited. The CAAM-HP’s Secretariat includes a representative cross-section of basic science and clinical educators and practitioners in each ad hoc survey team. Survey teams include one member of the CAAM-HP or of the Secretariat. Survey team appointments are in keeping with the CAAM-HP’s Conflict of Interest Guidelines. See Procedures, Exhibit 9. To avoid potential conflicts of interest, the dean of a school to be visited is asked to review the composition of the proposed survey team and to inform the Secretariat of any potential problems.

A full survey visit typically involves five persons, including a chair; a secretary; two or more members, one of whom should be a basic scientist faculty member or educational scientist and one of whom should be a clinician/practitioner; and a CAAM-HP member who is an educational administrator/senior faculty member and has not previously participated in a site visit. A limited or focused visit will be conducted by experienced surveyors, typically including three team members.

As stated in Article 1, Use of Terms, of the Agreement Establishing The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (“Agreement”), “Contracting Party” means a Member State or an Associate Member State of the Community for which this Agreement is in force. “Community” means the Caribbean Community (CARICOM), including the CARICOM Single market and Economy established by the Revised Treaty of Chaguaramas signed at Nassau, the Bahamas, on July 5, 2001. Member States that to date have signed the Agreement are Antigua & Barbuda, The Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Jamaica, St Kitts & Nevis, St Lucia, St Vincent and the Grenadines, Suriname, and Trinidad & Tobago. Since the establishment of CAAM-HP in 2004, the persons whom the Contracting Parties have appointed to the CAAM-HP have been the Chief Medical Officers of the Member States that have signed the Agreement. Chief Medical Officers are the most senior medical professionals in the Member States’ ministries of health.
 
Analyst Remarks to Narrative
CAAM-HP maintains a roster of qualified on-site evaluators for use in conducting on-site reviews in its behalf. The evaluators are educators and practitioners, with many serving as the deans of medical education programs. Team members are chosen on an as-needed basis depending on the reviews that are to be conducted.

CAAM-HP also conducts orientation training to familiarize the evaluators with the agency's requirements. Site review teams also include one CAAM-HP representative in addition to the educators and practitioners. Teams are usually comprised of a team chair, a team secretary, two additional reviewers, and the CAAM-HP representative.

In the particular case of Cave Hill, the 2012 site visit was started by the full team at the main UWI campus in Jamaica, while two of the evaluators were assigned to visit the Cave Hill campus on Barbados. An examination of the reports composed by these individuals demonstrates that they are well-prepared for their tasks, and very thorough in their evaluations of medical schools, and eminently qualified. (The chair of the CAAM-HP 2012 visit was also the chair of the General Medical Council of the United Kingdom.)

Appointments to CAAM-HP, the decision-maker itself, include “representatives from the universities in the region, students, civil society, professional associations and external professionals with expertise and knowledge in the accreditation of training programs in medicine and other health professions.” An examination of the current membership (cf. http://www.caam-hp.org/overview.html#membership) confirms that highly qualified individuals are selected to serve.

NCFMEA may wish to ask additional questions about the training for those who serve on the decision and policy making bodies.
 
Country Response
CAAM-HP has been fortunate to have highly qualified and experienced persons serving as members of the Authority and as evaluators from the Caribbean, the UK and Canada.

CAAM-HP has held training workshops for new members and potential surveyors from the Caribbean for whom participation in the accreditation process was a new experience.

Where it has not been possible to hold workshops CAAM-HP has prepared a Powerpoint presentation, updated frequently, outlining the aims, objectives, standards, processes and procedures of CAAM-HP in advance of meetings and/or site visits. Persons are requested to submit any need for clarifications to the Secretariat. Furthermore, with respect to site visits, team members meet informally before meeting with the school which provides an opportunity for discussion of the accreditation process and interpretation of the standards.

With respect to visits to the UWI, CAAM-HP has tended to invite UK-based surveyors who have wide experience as General Medical Council (GMC) surveyors in the accreditation of five-year medical education programmes such as that of the UWI.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to ask additional questions about the training for those who serve on the accreditor’s decision and policy making bodies.

In response, the country indicated that training workshops are held for new members, but that when they cannot personally attend a workshop, a Powerpoint presentation has been prepared for their use before decision meetings and site visits.
 
Staff Conclusion: Comprehensive response provided
 
Re-evaluation and Monitoring, Question 1
 
Country Narrative
As per the CAAM-HP’s Procedures, Exhibit 9, an education programme once accredited remains accredited until the CAAM-HP terminates the programme formally or the programme itself terminates its accreditation status. Notwithstanding the foregoing, accreditation by the CAAM-HP does not end merely because a certain period of time has passed. Programmes typically are subject to review on a six-year cycle. The CAAM-HP may determine that an earlier review is necessary; in that case, the accreditation status does not change until a formal action is taken by the CAAM-HP.

As described in the Procedures, Appendix A, there are several “states of accreditation”; although six years is the maximum period for accreditation, the CAAM-HP may decide that a school must be monitored during shorter intervals. See Procedures, Exhibit 9. For example, a school with provisional accreditation will be accredited for a period of two years up to a maximum of the length of the academic programme. See Procedures, Exhibit 9.

All schools are expected to submit to the CAAM-HP Annual Progress Reports demonstrating that areas of concern/weaknesses are being addressed. In the event such reports are not submitted or submitted outside of the time stipulated, CAAM-HP may determine that a sanction should be imposed.
 
Analyst Remarks to Narrative
CAAM-HP's typical grant of accreditation lasts six years, but lasts until the agency takes formal action to either grant reaccreditation, or deny reaccreditation, to the school. The agency may specify shorter periods of accreditation as needed, such as for schools on provisional accreditation, which may be granted for only two years. The country notes that, in addition to periodic reaccreditation reviews, all accredited schools must also submit annual reports for review by CAAM-HP.
 
Re-evaluation and Monitoring, Question 2
 
Country Narrative
As set forth in the Procedures, each accredited medical school is required to complete annual questionnaire surveys that are carried out under the auspices of the CAAM-HP. The Annual Medical School Questionnaire collects academic and enrollment data and is the administrative responsibility of the Secretariat staff who will review the questionnaires to keep the content consistent with other CAAM-HP survey documents and bring any significant changes to the notice of the Chair of the CAAM-HP. Data received from the CAAM-HP annual questionnaires are compiled into a statistical summary report for the CAAM-HP members and otherwise made available to relevant schools and the public. A copy of the CAAM-HP Annual Medical School Questionnaire is attached as Exhibit 34.

As per the Procedures, Exhibit 9, p. 21 and Appendix H, the CAAM-HP will accept and investigate complaints about programme quality that, if substantiated, may constitute non-compliance with accreditation standards.

Site visitors are made aware of any complaints before their visit. A site visit team will need to discuss in their site visit report any complaints raised by students during their review, including those that rise to the level of breaching Standards.

The following CAAM-HP accreditation standards require medical schools to have a student complaint process at the school level:

MS-26 Each medical school / university must define and publicise the standards of conduct for the teacher-learner relationship, and develop written policies for preventing and addressing violations of those standards.

Mechanisms for reporting violations of these standards, such as incidents of harassment or abuse, should assure that complaints can be registered and investigated without fear of retaliation.

The policies also should specify mechanisms for the prompt handling of such complaints, preventing inappropriate behaviour, and the corrective measures to be employed where such behaviour occurs.

MS-28 There must be a fair and formal process for taking any action that adversely affects the status of a student.

The process should include timely notice of the impending action, disclosure of the evidence on which the action would be based, an opportunity for the student to respond, and an opportunity to appeal any adverse decision related to promotion, graduation, dismissal or other disciplinary action.
 
Analyst Remarks to Narrative
As noted under the previous section, CAAM-HP requires its accredited schools to submit annual reports in order for the agency to evaluate the school for continued compliance with its standards throughout the accreditation period. The agency compiles the annual report form data into a summary report for each school.

Regarding complaints, CAAM-HP has established a process for students to submit complaints directly to the agency and CAAM-HP site visitors are made aware of any student complaints prior to conducting the on-site review. The on-site review team must also report any student complaints that arise during the course of the on-site review visit.

CAAM-HP also requires its accredited schools to develop student complaint procedures for implementation at the campus level. CAAM-HP standards require that accredited schools define and publicize standards of conduct, develop policies for dealing with violations of those standards, and specify how complaints will be promptly registered and evaluated. The agency's standards also require that there be a formal process for handling any actions that may negatively impact a student's status.
 
Substantive Change
 
Country Narrative
Pursuant to Standard ED-8, accredited programmes must notify the CAAM-HP of plans for any major modification of the curriculum. The notification should include the explicitly-defined goals of the change, the plans for implementation, and the methods that will be used to evaluate the results. Planning for curriculum change should consider the incremental resources that will be required, including physical facilities and space, faculty/resident support, demands on library facilities and operations, information management needs, and computer hardware. In view of the increasing pace of discovery of new knowledge and technology in medicine, the CAAM-HP encourages experimentation that aims at increasing the efficiency and effectiveness of medical education. As part of its planned standards revision process, described earlier, the CAAM-HP expects to consider the establishment of timeframes within which a medical education programme must notify the CAAM-HP of plans to undergo a substantive change.

Pursuant to Standard ER-1, the CAAM-HP must be notified of plans for or the implementation of any substantive change in the number of students enrolled or in the resources of the institution, including the faculty, physical facilities, or the budget.

As set forth in the Procedures, accreditation is awarded to a programme of medical education based on the judgment of the CAAM-HP that there is an appropriate balance between student enrollment and the total resources of the institution, including the faculty, physical facilities, and available funding. See Procedures, Exhibit 9, p.14. Plans to significantly alter the educational programme; a significant change in student enrollment; or a change in institutional resources, so that the balance between enrollment and resources is altered, may trigger a request for additional written information or an unplanned accreditation review or survey visit of a previously accredited medical school. See Procedures, Exhibit 9, p.14.

Accredited institutions are required to notify the CAAM-HP if there is a planned change in programme ownership or governance. See Procedures, Exhibit 9, p. 41. In such cases, the school is asked to supply a written report that will be reviewed by the CAAM-HP. A limited survey visit also may be conducted. The report and visit allow the CAAM-HP to determine whether reasonable compliance with accreditation standards can be assured and the current status and term of accreditation continued under the new ownership or governance. The same procedures apply whether a new geographically remote programme or campus is to be established.

The CAAM-HP asks a school to address this topic in its Database responses. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B and Medical Education Database, Section V: Educational Resources, Exhibit 18, at Part B.

CAAM-HP appreciates the benefit that specified deadlines may provide to medical education programmes and CAAM-HP to facilitate timely review and implementation of appropriately assessed substantive changes. It is proposed that Standard ER-1 be amended to read as follows:

CAAM-HP must be notified one year in advance of plans or the implementation of any substantial change in the number of students enrolled or in the resources of the institution, including the faculty, physical facilities or the budget.
 
Analyst Remarks to Narrative
CAAM-HP standards require medical schools to notify the agency of substantive changes. The standards specify the circumstances that constitute a substantive change, such as a change in the curriculum, the number of students to be enrolled, institutional resources such as faculty, facilities or budget, or a change in ownership or governance. The school must notify the agency through a report of planned changes, and the notification may trigger an on-site visit.

The country application indicated that CAAM-HP was proposing to amend its standards to specifically require a one-year advance notification of any substantial change in the number of students enrolled, or in the resources such as the faculty, physical facilities or budget.

However, it is unclear if CAAM-HP ever officially adopted the proposed amendment to its standards that would specifically require schools to provide a one-year advance notification of any substantial change in the number of students that it plans to enroll, or any anticipated substantial change to the medical school’s faculty, physical facilities or budget.

The NCFMEA may wish to inquire further regarding this matter.
 
Country Response
According to CAAM-HP’s Procedures any major change must be communicated to the CAAM-HP. The Procedures, also being revised, states that information must be communicated in writing to CAAM-HP one year in advance and reads as follows:

“School officials must notify CAAM-HP in writing at least one year in advance, that a change in programme ownership or governance is planned, (e.g. the programme is to be transferred to the auspices of another university or institution) providing details of the change and a transition plan as set out in Appendix I of the Procedures.

CAAM-HP may also conduct a Secretariat visit. The report and the visit allow CAAM-HP to determine whether reasonable compliance with accreditation standards can be assured and the current status and term of accreditation continued under the new ownership or governance. The same procedures apply when a new geographically remote programme/campus is to be established. Failure to comply could have negative consequences for the programme’s accreditation status.”

At its July 2016 meeting, the Authority reviewed the revised Procedures of the CAAM-HP. The revised document was accepted in principle with a few amendments. The meeting agreed that the amended Procedures should be circulated to members and then to CARICOM’s Council for Human and Social Development (COHSOD).

In addition, standard ED-8 states:

“Accredited programmes must notify CAAM-HP of plans for any major modification of the curriculum.

Notification should include the explicitly-defined goals of the change, the plans for implementation and the methods that will be used to evaluate the results. Planning for curriculum change should consider the incremental resources that will be required, including physical facilities and space, faculty/resident support, demands on library facilities and operations, information management needs and computer hardware.”

See Exhibits 41 and 11: Draft Revised Procedures of the CAAM-HP and Revised Standards for the Accreditation of Medical Schools in the Caribbean Community, 2011.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if CAAM-HP ever officially adopted the proposed amendment to its standards that would specifically require schools to provide a one-year advance notification of any substantial change in the number of students that it plans to enroll, or any anticipated substantial change to the medical school’s faculty, physical facilities or budget.

In response, the country indicated that during its July 2016 meeting the proposed amendment to the CAAM-HP standards regarding the one-year advance notification was revised and adopted in principle. The revised version appears to limit the substantive changes that must be presented one year in advance to CAAM-HP to planned changes in ownership or governance.

Regarding all the other substantive changes, the original country submission indicated that CAAM-HP was expecting “to consider the establishment of timeframes within which a medical education program must notify the CAAM-HP of plans to undergo a substantive change.” However, it appears that those other substantive change deadlines may not have been adopted. Therefore, it is unclear what substantive changes must be reported to CAAM-HP one year in advance, and what deadlines are applied to other types of substantive changes.

The NCFMEA may wish to inquire about this matter.
 
Staff Conclusion: Additional Information requested
 
Conflicts of Interest, Inconsistent Application of Standards, Question 1
 
Country Narrative
Barbados’ policies regarding bias and conflict of interest by persons involved in the accreditation, evaluations, and decision-making processes are those established by the CAAM-HP for such purposes. Appendix C of the Procedures, Exhibit 9, sets forth the Conflict of Interest Guidelines and Statement for the CAAM-HP Members, Staff, and Surveyors.
 
Analyst Remarks to Narrative
CAAM-HP has a conflict of interest policy that covers those persons who are involved in the accreditation, evaluation and decision-making processes, including CAAM-HP members, staff and on-site reviewers. The CAAM-HP policy language is similar to that used in the accreditation process in the United States.

NCFMEA may wish to ask for documentation demonstrating the application of the conflict of interest policy.
 
Country Response
The extract below is taken from CAAM-HP’s document, Procedures of the Caribbean Accreditation Authority, Exhibit 9, which provides guidelines as follows:

CONFLICT OF INTEREST AND CONFIDENTIALITY POLICIES
Conflict of Interest Guidelines

Conflict of interest guidelines and procedures are described in Appendix C. CAAM-HP members, staff, and surveyors must sign the conflict of interest policy attesting that they will abide by its terms.

The secretariat notifies the deans of the schools being accredited of the composition of appointed survey teams approximately three months before a scheduled visit. Deans may challenge any team member appointment for perceived conflict of interest or other cause in writing to the secretariat within two (2) weeks of receiving the notification. Final decisions regarding such perceived conflict of interest or other cause for challenge remain at the sole discretion of the CAAM-HP Secretariat or, upon their determination, at the sole discretion of the CAAM-HP.

See Exhibit 9: Procedures of the CAAM-HP.
 
Analyst Remarks to Response
The draft staff analysis noted that the NCFMEA may wish to ask for documentation demonstrating the application of CAAM-HP’s conflict of interest policy.

In response, the country provided its written policy that requires CAAM-HP members, staff and surveyors to sign the conflict of interest policy attesting that they will abide by its terms. However, the country did not provide any documentation that the written policy was being implemented in practice. In other words, some evidence that demonstrates those conflict of interest documents are currently being signed, collected and maintained for all the appropriate persons.

Therefore, the NCMEA may still wish to ask for current documentation demonstrating the application of CAAM-HP’s conflict of interest policy.
 
Staff Conclusion: Additional Information requested
 
Conflicts of Interest, Inconsistent Application of Standards, Question 2
 
Country Narrative
In order to ensure that the standards for accreditation/approval of medical schools are applied consistently to all schools that seek accreditation/approval, survey teams include one member of the CAAM-HP and/or of the Secretariat.
 
Analyst Remarks to Narrative
Each CAAM-HP on-site review team includes one CAAM-HP representative to serve as a resource person. In addition, all on-site review team members must undergo orientation and training on the agency's policies and standards prior to participating as a member of an on-site review team. Furthermore, all decision-making, evaluations and site visits rely on common evaluation instruments, i.e., the published CAAM-HP standards and procedures, thereby helping maintain consistency.
 
Accrediting/Approval Decisions, Question 1
 
Country Narrative
The site visit team, following deliberations during their visit, will detail in their written report the medical education programme’s level of compliance with each individual accreditation standard. See Guide for Writing a Report on a Visit of a Survey Team, Exhibit 35; Procedures, Exhibit 9. Exhibit 36 provides evidence that site visit teams do consider carefully the programme’s compliance with the accreditation standards.
 
Analyst Remarks to Narrative
As the designated entity responsible for the evaluation and accreditation of medical education in Barbados, CAAM-HP’s accrediting decisions are required to be based upon its review of the report by an on-site evaluation team that has been trained in the CAAM-HP standards. The sample team reports demonstrate the thoroughness of the evaluations based on the CAAM-HP Standards.
 
Accrediting/Approval Decisions, Question 2
 
Country Narrative
At present, the CAAM-HP does not base any part of its accreditation on benchmarks, such as licensing rates or established minimum levels of performance of graduates of its accredited medical schools.

In CAAM-HP’s experience, data such as performance in postgraduate residency programmes, licensure exams, specialty exams/certifications or other forms of evaluation usually confirm deficiencies that are readily apparent from the accreditation process. Additionally, school supplied data are insufficiently consistent to serve as a determinative factor in accreditation decisions. CAAM-HP has asked schools to collect this data systematically. CAAM-HP recognizes and supports the importance of benchmarks as part of the quality assurance process and will give this further consideration during the July Annual General Meeting.
 
Analyst Remarks to Narrative
Although CAAM-HP asks medical schools to collect this data systematically, the country application notes that CAAM-HP does not base any part of its accreditation decision-making on benchmarks, such as licensing rates or established minimum levels of performance of graduates of its accredited medical schools.

Nevertheless, the country reports that “CAAM-HP recognizes and supports the importance of benchmarks as part of the quality assurance process and will give this further consideration during the July Annual General Meeting.”

Since that July 2016 meeting is finished, it is unclear what information on the performance of a medical school’s graduates will be used by CAAM-HP in reaching its decision on whether or not to grant accreditation to a medical school, as required by the NCFMEA.

The NCFMEA may wish to inquire further regarding this matter.
 
Country Response
On the matter of establishment of benchmarks, this was discussed at the July 2016 meeting of the Authority. The matter is still under careful consideration. Reference is made to Exhibit 38, Extract: Draft Minutes of CAAM-HP July 2016 Meeting.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear what information on the performance of a medical school’s graduates will be used by CAAM-HP in reaching its decision on whether or not to grant accreditation to a medical school, as required by the NCFMEA.

In response, the country indicated that CAAM-HP recently (July 2016) considered whether graduate performance data might have a more significant place in its accreditation process, but that no determinations were reached.

As noted elsewhere, it appears that data on the performance of medical school graduates is not considered of significant value to CAAM-HP at this time. Nevertheless, it is still unclear what future discussions CAAM-HP plans to hold on incorporating at least rudimentary graduate performance data into its accreditation decision-making process.

The NCFMEA may wish to inquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Accrediting/Approval Decisions, Question 3
 
Country Narrative
The CAAM-HP does not at present base any part of its accreditation on benchmarks, such as licensing rates or established minimum levels of performance of graduates of its accredited medical schools. Accredited schools are required to submit to the CAAM-HP an Annual Medical School Questionnaire, Exhibit 34, which requests data on the placement for residency of the last graduating class. CAAM-HP does comment on such data. CAAM-HP is considering steps to incorporate outcomes data analysis into its decision-making process.
 
Analyst Remarks to Narrative
As noted in the application narrative, CAAM-HP does not base any part of its accreditation on benchmarks. It only requests data from schools on the performance of its graduates in licensure examinations and their placement in postgraduate training programs. Other outcomes measures such as graduate performance in post graduate residency programs, specialty exams/certifications, or other forms of evaluation of school graduates are not requested. As a result, CAAM-HP collects minimal data and does not use it in its decision to accredit a medical school.

Therefore, it is unclear if CAAM-HP has any plans to establish a structured mechanism for collecting data regarding each medical school’s graduates, including the range of performance data suggested by the NCFMEA guidelines, and to begin using that data in its decision-making process.
 
Country Response
On the matter of the establishment of outcomes benchmarks, this was discussed at the July 2016 meeting of the Authority. The matter is still under careful consideration. Reference is made to Exhibit 38, Extract: Draft Minutes of CAAM-HP July 2016 Meeting.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear if CAAM-HP had any plans to establish a structured mechanism for collecting data regarding each medical school’s graduates, including the range of performance data suggested by the NCFMEA guidelines, and to begin using that data in its decision-making process.

In response, the country simply stated that as of July 2016 CAAM-HP was still thinking about what its response should be. Therefore, it is still unclear if CAAM-HP has any plans to establish a structured mechanism for collecting data regarding each medical school’s graduates, including the range of performance data suggested by the NCFMEA guidelines, and to begin using that data in its decision-making process.

The NCFMEA may wish to enquire further regarding this matter.
 
Staff Conclusion: Additional Information requested
 
Accrediting/Approval Decisions, Question 4
 
Country Narrative
In the CAAM-HP’s experience, data such as performance in post graduate residency programmes, licensure exams, specialtyexams/certifications, licensure or other forms of evaluation usually confirm deficiencies that are readily apparent from theaccreditation process. CAAM-HP has asked schools to collect this data systematically.

Standards ED-42 and ED-43, and their related Database requests, require schools to provide data on the performance of graduates in licensure examinations and placement in postgraduate training programmes. See Medical Education Database, Section III: Educational Programme, Exhibit 12, at Part B. The CAAM-HP is considering steps to incorporate more systematically and comprehensively outcomes-data analysis as part of the accreditation decision-making process.

CAAM-HP supports the general trend to assess outcomes data as part of the quality assurance process, while it also recognizes ongoing discourse regarding the specific role outcomes data should play in that process and the extent to which outcomes data should be part of a holistic quality assurance review or a determinative factor in final accreditation decisions.

CAAM-HP notes however, that specific measures such as residency placement in U.S. programmes over which a school has no control may not necessarily be the best tool for assessment.

Steps to incorporate more systematically and comprehensively outcomes-data analysis as part of the accreditation decision-making process will be included in the revised standards.

Steps to incorporate more systematically and comprehensively outcomes-data analysis as part of the accreditation decision-making process will be included in the discussion on the revised standards. Implementation of this new requirement is not likely before 2018.
 
Analyst Remarks to Narrative
As has been noted in previous sections, CAAM-HP has not established any performance benchmarks for its medical schools, and does not incorporate the limited data that it does collect into the CAAM-HP decision-making process.

The country application indicates that CAAM-HP is considering steps to incorporate outcomes data analysis as part of the accreditation decision-making process. However, in response to the requirements of this section of the NCFMEA Guidelines, the country application frankly admitted that “implementation is not likely before 2018.”

[The country application has referred to a number of revisions to the CAAM-HP standards that are not reflected in the 2012 standards that were submitted with the application as current documentation. It appears that CAAM-HP is holding them for a standards revision process that it plans to implement at some unspecified point in the future, perhaps around 2018.]

As a result, it is unclear when CAAM-HP will realistically incorporate outcomes data analysis into its accreditation decision-making process.

The NCFMEA may wish to enquire further regarding this matter.
 
Country Response
On the matter of the establishment of outcomes benchmarks, this was discussed at the July 2016 meeting of the Authority. The matter is still under careful consideration. Reference is made to Exhibit 38, Extract: Draft Minutes of CAAM-HP July 2016 Meeting.
 
Analyst Remarks to Response
The draft staff analysis noted that it was unclear when CAAM-HP will realistically incorporate outcomes data analysis into its accreditation decision-making process.

In response, the country repeated its response that as of July 2016 CAAM-HP was still thinking about what it is going to do regarding student achievement data. Therefore, it is still unclear when CAAM-HP will realistically incorporate outcomes data analysis into its accreditation decision-making process.

The NCFMEA may wish to enquire further regarding this matter.
 
Staff Conclusion: Additional Information requested