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Staff Analysis of the Report Submitted by the Cayman Islands

 
Prepared October 2015
 
Background
 
In September 2002, the National Committee on Foreign Medical Education and Accreditation (NCFMEA) first determined that the Cayman Islands' standards and processes to evaluate medical education programs leading to the M.D. (or equivalent) degree are comparable to the standards of accreditation used to evaluate medical education programs in the United States. The NCFMEA most recently affirmed the country's comparability in March 2009 and recieved a special report from the Cayman Islands on its accrediting activities in 2013.

The Accreditation Commission on Colleges of Medicine (ACCM) is the entity responsible for evaluating the quality of medical education in the Cayman Islands.

In Spring 2015, a redetermination of the Cayman Islands comparability was scheduled. Cayman Islands was asked to submit the following narrative for review. The report provided in response to those requests is the subject of this analysis.This analysis provides a review of the Cayman Islands' report of its accreditation activities for redetermination for NCFMEA's review.
 
Summary of Findings
 
Based on the information submitted by the Cayman Islands, it appears that the country's standards and processes are robust and similar to standards and processes of accreditation used to evaluate medical education in the United States. The Accreditation Commission on Colleges of Medicine (ACCM) carries out the Cayman Islands' quality assurance function and relies on its published standards in evaluating medical programs as well as its established 2014 Elements of Accreditation.

The country has provided significant information regarding the country’s standards for medical education, however there are a few remaining questions. The NCFMEA may wish to request that country is provide clarification and/or additional information and documentation related to administrative personnel and authority, the conflict of interest policies related to its faculty members, documentation related to student service learning, and data related to the collection of MCAT attempts for its students.
 
Staff Analysis
 
PART 1: Entity Responsible for the Accreditation/Approval of Medical Schools
 
Approval of Medical Schools, Question 1
 
Country Narrative
The Accreditation Commission on Colleges of Medicine, ACCM has the authority and responsibility to certify or license different types of medical schools, private or for-profit, together with an agreement with the government of Cayman Islands. Founded in 1995 by Professor Conor Ward, the ACCM is an independent, not for profit organisation based in the Republic of Ireland. ACCM is invited by Governments of countries which do not have a national medical accreditation body, to act on their behalf in relation to the inspection and accreditation of a specified medical school / university / college* in their jurisdiction (* medical school, medical university or medical college are terms used interchangeably to indicate an institution where a medical education programme is offered which leads to the degree of M.D. (Exhibit 5 & 6).

The Educational Council (Cayman Island Government) granted its approval for St. Matthew’s University School of Medicine to be registered in the Cayman Islands in accordance with Section 32 of Education Law (1999) in 2002 (Exhibit10). The Department of Education regulates the certificate and licensure for medical practice within Cayman Islands .There is a University Charter, May 29, 2003 (Exhibit 11) and a Memorandum of Understanding between the Government of the Cayman Islands and St. Matthew’s University School of Medicine Limited. Governing Law and Jurisdiction: This Memorandum of Understanding shall be governed by the Laws of the Cayman Islands and any and all disputes and or differences arising hereunder shall be subject to the exclusive jurisdiction of the Court of the Cayman Islands.

There is one medical school in the jurisdiction of the Cayman Islands Government: St. Matthew’s University School of Medicine. ACCM is the organization which conducts an in depth on-site inspection to confirm compliance with the minimum standards for its operation. The Heads of Agreement was signed between the Hon. Roy Bodden, Minister Responsible for Education, Human Resource and Culture and Professor Ward Chairman of the ACCM, in June 2002 (Exhibit 5). In its declaration of June, 2002, the Government of the Cayman Islands states that it officially recognizes ACCM for “the sole purpose of (a) ensuring that St. Matthew’s University School of Medicine of Grand Cayman meets standards comparable to those in the United States Department of Education and (b) that St. Matthew’s University School of Medicine is providing a quality and meaningful medical education”. It also states that the ACCM “is authorised to work with and to receive reports and information on behalf of the Cayman Island Government”. The resolution is in effect no longer than the duration of the operation of St. Matthew’s University School of Medicine (SMU) in the Cayman Islands.

ACCM confirms compliance by ensuring that standards of operation meet those required by the Elements of Accreditation of ACCM (Exhibit 1). ACCM Elements were reconfigured in 2007 to meet with LCME Guidelines as most students in medical schools currently under ACCM accreditation are North American. The Liaison Committee on Medical Education (LCME) is the recognised accreditation authority for the accreditation of medical education programmes leading to the degree of M.D.in the United States and Canada. ACCM's standards and processes are therefore aligned with the Guidelines of the LCME. The medical schools have been accredited, subject to their continuing compliance with ACCM required standards. All are subject to regular interim site inspections of the basic medical science campus as well as inspection of all affiliated clinical training sites. Each medical school must also report annually to ACCM utilising ACCM's detailed Institutional Self Study (Exhibit 15) and the Annual Database Report (Exhibit 4).

ACCM requires an accreditation agreement with each government served, designating the roles, responsibilities and expectations of both parties in the accreditation process. ACCM reports annually to the Governments it serves including an outline of accreditation activities during the previous year and a review of the Annual Database which each medical school annually submits to ACCM (Exhibit 7 & 24). The report also addresses any changes that may have occurred in the medical school or the programme of medical education which may have positively or negatively affected the educational programme (Exhibit 9 & 25). The accreditation status of the school is either confirmed, or a change of status is notified (Exhibit 1, Element 12 p.22). When an inspection visit has occurred at a medical school’s campus, an inspection report is made to the relevant government, detailing all aspects of the inspection and the level of the medical school's compliance with accreditation standards. Accreditation status of the medical school is reviewed by ACCM in the light of this report with ACCM’s accreditation decisions notified to governments in these inspection reports. The ACCM reports formally each year to: The Government of the Cayman Islands, The NCFMEA, US Department of Education and St. Matthew’s University School of Medicine.
 
Analyst Remarks to Narrative
Based on agreement with the government, the country states in its narrative that the Accreditation Commission on Colleges of Medicine (ACCM) has the authority and responsibility to certify or license medical schools within the country. Additionally, it is noted that the only operating medical school in the Cayman Islands is St. Matthews University School of Medicine (SMU), which has currently been granted a six-year term of accreditation effective July 1, 2013 - June 30, 2019.

The Educational Council granted its approval for St. Matthew’s University School of Medicine to be registered in the Cayman Islands in accordance with Section 32 of Education Law. The country has provided documentation of the authority by including exhibits that include agreements between the Educational Council and ACCM, a signed MOU outlining respective party responsibilities, and signed Heads of Agreement by the Government of the Cayman Islands and ACCM. However, as a note, the Accreditation Certificate provided as (Exhibit 6) has not been signed by both.

The Accreditation Certificate (Exhibit 6) for SMU is included, but only signed by one party. NCFMEA may wish to ask for a copy that has both parties signatures.
 
Country Response
ACCM have attached an electronic copy (Exhibit 6) with both parties signatures.

For convenience, ACCM has also attached an updated Exhibits List (Exhibit 28)
 
Analyst Remarks to Response
Additional documentation provided shows a certificate that displays an image that is not clear. NCFMEA may wish to ask for a copy of the certificate that includes the original signature, similar to the one that is displayed in the second line of the document.
 
Staff Conclusion: Additional Information requested
 
Approval of Medical Schools, Question 2
 
Country Narrative
In brief, the preliminary steps are: The Government gives approval for the establishment of a medical school. This must be by formal Resolution of that Government. The Government reviews the standards and procedures (Elements & Protocol) of ACCM and finds such standards and procedures appropriate (Exhibit 1 & 2). The Government approves ACCM as the accreditation agency for the particular medical school concerned and issues an invitation to ACCM to undertake the evaluation of the medical school. ACCM examines Profile documentation from the medical school which may be submitted in advance of or concurrently with the Government’s invitation (Exhibit 12 & 20). If on the basis of the information contained in the Self-Profile Database (Exhibit 26) ACCM finds that the school is operating a programme which appears to satisfy the Elements of Accreditation, the ACCM arranges for the medical school to submit a more in-depth Self Study, after which a preliminary inspection visit is made to the medical school's campus. During this visit the ACCM inspection team expects to meet with the appropriate Minister and/or Head of Government. After the visit, the inspection team reports to the next meeting of ACCM and a decision is then made as to whether ACCM will undertake the work of accrediting the medical school or whether it recommends actions on the part of the school before accreditation work will be undertaken. If ACCM decides to undertake accreditation of a medical school further steps are required in order to formalise the arrangement.

ACCM has the authority and responsibility, together with an agreement with the government of Cayman Islands, for the monitoring and continued certification of different types of medical schools, private or for-profit (Exhibit 6). ACCM requires an accreditation agreement with each government served, designating the roles, responsibilities and expectations of both parties in the accreditation process (Exhibit 5). ACCM reports annually to the Government it serves. The report includes an outline of accreditation activities during the previous year and a review of the Annual Database which each medical school must submit annually to ACCM. The report also addresses any changes that may have occurred in the medical school or the programme of medical education which may have positively or negatively affected the educational programme. The accreditation status of the school is either confirmed, or a change of status is notified.

When an inspection visit has been made to a medical school’s campus, a report on the inspection is made to the relevant government, detailing all aspects of the inspection and the level of the medical school's compliance with accreditation standards. Accreditation status of the medical school is reviewed by ACCM in the light of this report. ACCM’s accreditation decisions are notified to governments in these inspection reports (Exhibit 7 & 9, 24 & 25).
 
Analyst Remarks to Narrative
The country has provided documentation of ACCM’s monitoring and continued accreditation role in ensuring quality in academic programs. The Government reviews ACCM to ensure adequate standards and procedures. Once approved, ACCM conducts preliminary activities (such as a review of the institutions self-profile database, a preliminary visit, etc.) to determine appropriateness of the institution. If deemed sufficient, the institution is asked to submit an in-depth self-study. Next, an official on site inspection visit is conducted by a team that involves representatives from the Ministry of Education and/or Head of Government. The review of all stages of the accreditation process allows ACCM to make determination of compliance and in turn, an accreditation decision about the institution. The government is notified regarding final decisions.
 
Approval of Medical Schools, Question 3
 
Country Narrative
In the Cayman Islands, the Educational Council has the authority to register tertiary educational institutions, as evidenced by the 2002 certification of SMU’s registration application to open a medical school (Exhibit 10).

Other documents indicate that the office of the Minister of Education, Human Resources and Culture has the authority to open and close institutions, and to regulate certification and licensure of medical practice within the country. Teachers do not need to seek licensure from the Education Council, but do need to pursue the requirements established by the country’s Immigration Department.

ACCM reports formally each year to: The Government of the Cayman Islands, the NCFMEA, U.S. Department of Education and St. Matthew’s University School of Medicine.
 
Analyst Remarks to Narrative
The country has provided documentation from the Educational Council Certification that showcases SMU’s application approval for the medical school. In the country’s narrative, they indicate that the office of the Minister of Education, Human Resources, and Culture has the authority to open and close institutions, and to regulate certification.
 
Accreditation of Medical Schools
 
Country Narrative
ACCM has the authority and responsibility (documented by an agreement with the government of Cayman Islands) for evaluating the quality of medical education in different types of medical schools - private or for-profit. ACCM reports to the Cayman Islands government. The medical schools have been accredited, subject to their continuing compliance with required standards set down in the ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2).

The ACCM defines its standards of educational quality as Elements (Exhibit 1). Element 1 establishes requirements for institutional goals that include the educational mission and teaching objectives. ACCM requires the institution to publish and distribute its goals among its students, faculty and the public, generally through an institutional catalogue or other publishing media. ACCM requires the medical school to engage in a planning process that sets the direction for the institution and identifies measurable outcomes that identify accomplishment of the goals or areas in need of improvement. Among other things, minimum institutional goals require the offering of a degree programme that fulfills or exceeds the provisions summarized in the Elements of Accreditation:
1. A graduate’s acquisition of a critical amount of knowledge and development of adequate skill to advance to and complete post-graduate training;
2. A graduate’s acquisition of the professional attributes expected by the academic community and physicians;
3. A graduates’ obtainment of licensure to provide quality health care, continuance of a life-long habit of learning as a way of keeping abreast of current medical advances; and
4. Assurance to students, parents, patients, postgraduate training directors, licensing authorities, government regulators and society that accredited programmes have met commonly accepted standards for quality education.

ACCM Protocol (Exhibit 2) (or procedures) requires on-site inspection teams to meet with the Chief Executive Officer of the medical school to review the institution’s educational goals for compliance and to summarize in a written report the educational goals of the medical school. The report comments on whether the institution has met its goals and these goals are familiar to faculty and students, and the extent to which the institution makes an effort to enhance its ability to reach its goals. Through testing, ACCM requires the institution to ensure that students pass the USMLE step 1 examination before beginning the 3rd year clinical science coursework. In addition, ACCM recommends that before graduation, students should also pass the USMLE Step 2 examination.

ACCM protocol specifically charges the on-site inspection team with determining if the education goals: are properly stated, are publicized and distributed among its students, faculty and the public, seek to sponsor a programme that fulfills or exceeds requirement to achieve accreditation, graduates only individuals who have acquired a critical amount of knowledge and skills to advance and complete postgraduate training, seeks to graduate only individuals who are able to secure licensure, provide quality patient care, and who have the capacity to keep medical knowledge current through self-learning and after completing the training.

Element 1 establishes ACCM’s requirements for the educational mission, goal and objectives of a medical school: “The institution shall develop educational goals which define its mission. The goals shall be adopted by the Board of Trustees of the institution and shall be re-evaluated periodically to reflect external and demographic changes in its constituencies…As a minimum the institution goals shall ensure graduates:
(1) Sponsor a Doctor of Medicine (M.D.) degree programme which fulfils or exceed the provisions summarized in the Elements of Accreditation
(2) have acquired a critical amount of knowledge and have developed adequate skill to advance to and complete post-graduate training.
(3) have acquired the professional attributes (knowledge, skills, attitudes and behaviour) expected by the academic community and society of a physician.
(4) be able to secure licensure, to provide quality health care and to continue a life-long habit of learning as a way to remain abreast of current medical advances,
(5) assure students, parents, patients, post-graduate training directors, licensing authorities, government regulators and society that accredited programmes have met commonly accepted standards for quality education.

ACCM Protocol requires on-site inspection team to meet with the Chief Executive Officer of the medical school to review the educational goals of the institution for compliance with Element 1. Specifically the team is charged with determining “if the educational goals statement:

(1) Is properly stated

(2) Is publicized and distributed among its student, faculty and the public.

(3) Seeks to sponsor a programme that fulfils or exceeds requirements to achieve accreditation

(4) Graduates only individuals who have acquired a critical amount of knowledge and skills to advance and complete postgraduate training

(5) Seeks to graduate only individuals who are able to secure licensure, provide quality patient care, and who have the capacity to keep his medical knowledge current through self-learning and after he completes his training”

ACCM Protocol requires ACCM team to summarize in its report the educational goals of the medical school, to comment on whether they are appropriate for the school, whether they have been achieved, whether the faculty and students are familiar with the goals and whether the college is contemplating any major effort to enhance its ability to reach its goals. Due, inter alia, to the insistence of the ACCM the student is required to pass USMLE step 1 examination before s/he can continue to participate in the core subjects associated with 3rd year clinical science (Exhibit 4 p.p. 8 -11). ACCM recommends that USMLE Step 2 examination should be passed before the student is graduated. St. Matthew’s University School of Medicine has a 75% residency placement for July 1, 2013 through to June 30, 2014 (Exhibit 4: p.31).
 
Analyst Remarks to Narrative
In the country’s narrative they indicate that ACCM has the authority and responsibility for conducting an in depth evaluation of the quality of medical education at SMU. They have included documentation standards for educational quality in the Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012. The country relies on a defined set of standards when it conducts its accreditation reviews of medical schools.
 
Accreditation of Medical Schools, Question 2
 
Country Narrative
ACCM has the authority and responsibility, with an agreement from the government of Cayman Islands, (Exhibit 5) for the monitoring and continued certification of different types of medical schools, private or for-profit. ACCM requires an accreditation agreement with each government served, designating the roles, responsibilities and expectations of both parties in the accreditation process. ACCM reports annually to the Governments it serves. The ACCM Report (Exhibit 7 & 9, 24 & 25) includes an outline of accreditation activities during the previous year and a review of the Annual Database which each medical school annually submits to ACCM (Exhibit 4). The report also addresses any changes that may have occurred in the medical school or the programme of medical education which may have positively or negatively affected the educational programme. The accreditation status of the school is either confirmed, or a change of status is notified.

When an inspection visit has been made to a medical school’s campus, a report on the inspection is made to the relevant government, detailing all aspects of the inspection and the level of the medical school's compliance with accreditation standards. Accreditation status of the medical school is reviewed by ACCM in the light of this report. ACCM’s accreditation decisions are notified to governments in these inspection reports. Medical schools having been accredited are subject to their continuing compliance with the required standards which are set down in ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2).
 
Analyst Remarks to Narrative
In the country’s narrative, they indicate that ACCM has the authority and responsibility for monitoring the quality of medical education at SMU. ACCM operates under agreement with the Government of the Cayman Islands. The Government serves as the oversight authority of ACCM. In annual reporting requirements, ACCM sets standards for all aspects of the on site inspection and the level of the medical school's compliance with accreditation standards. Exhibits include documentation of an example report that the institution is required to submit on an annual basis and documentation of standards for quality education as outlined in the Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012.
 
Part 2: Accreditation/Approval Standards
 
Mission and Objectives, Question 1
 
Country Narrative
Yes, the medical school must adhere to standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2).

The Educational Council (Cayman Island Government) had granted its approval for St. Matthew’s University School of Medicine to be registered in the Cayman Islands in accordance with Section 32 of the Education Law (1999) in 2002 (Exhibit 10). The Executive Council, including government ministers, approved the application to offer a medical education programme at SMU on January 4, 2002. A more substantial University Charter in 2003 was established and signed by Hon. Roy Bodden, Minister of Education, Human Resources and Culture and by Michael A Harris, M.D. President and CEO (Exhibit 11).

Element 2 (Exhibit 1) establishes the Accreditation Commission on College of Medicine (ACCM) regarding the legal authorization of the medical school: “The institution shall be organized as a government-supported or a private independent entity which offers degree programmes beyond the baccalaureate level. The institution shall also be licensed by the appropriate governmental or regulatory authority to offer courses of instruction leading to the award of the M.D. degree”.
“The institution shall be governed by an independent and voluntary board of trustees as the highest authoritative body of the institution. The members shall be selected by the board itself and may represent the founders…..or the public who have an interest in the general welfare of the institution…….Furthermore, an individual shall be disqualified from serving on the board if s/he (or an organization s/he is/was affiliated with):
Has a financial interest in the medical school,
Has a business relationship with the medical school,
Is employed by the medical school,
Is a consultant to the medical school or
Has a family member or relative (by blood or marriage) who is connected to the medical school.

ACCM Protocol (Exhibit 2) requires that the inspection team ensures that Board members are free of conflicting interests. ACCM Protocol requires that the team reports whether the college is chartered, licensed and authorised to award the M.D. degree by the regulatory body that governs educational institutions in that jurisdiction. The college must annex all documents to demonstrate its authority to operate and to award the M.D. degree (Exhibit 5 &10).

Again in Element 2 (i.e. Corporate Organization) ACCM’s requirements for governance are as follows:
“In consultation with the Chief Academic Officer, divisional heads and representatives of the faculty the board shall govern the institution by:
Establishing broad institutional policies,
Providing institutional direction,
Securing financial resources,
Selecting the Chief Executive Officer, the Chief Academic Officer and their deputies and Overseeing the management’s performance of its duties and responsibilities.”

ACCM Protocol requires inspection team to ensure that the medical school complies with ACCM Elements (Exhibit 1). Element 2 requires that the institution’s by-laws and codes of regulation shall delineate the roles, duties and responsibilities of the key administrative and academic officers, the faculty committees as outlined in these documents. ACCM Protocol requires the team to report specifically on each of these areas of governance, in particular whether Board members serve without conflicts of interest with the medical school and are independent of the administration and whether the Board properly exercises its authority in overseeing the administration performance of its duties and responsibilities.
 
Analyst Remarks to Narrative
The country indicates in its narrative that ACCM has the authority and responsibility for evaluating the quality of medical education at SMU in the Cayman Islands and that ACCM does have a function that serves public interest.

Documentation was provided in the Elements of Accreditation 2014 that specifically includes Standard 1.1.4(e) that states: “Assuring students, parents, patients, postgraduate training directors, licensing authorities, government regulators and society that accredited programs have met commonly accepted standards for professional education and that they serve the public interest.” However, the country did not provide any examples or discuss how the public interest is being served.

In the narrative, further discussion outlines the protocols that ensure that Board Members operate free of conflict of interests. Standards indicate that there must be protocol that specifies roles, duties, and responsibilities of governance.

The information provided by the country explains that they do have standards that serve the public. Per the guidelines, NCFMEA may wish to discuss with the country about how the public interest is served.
 
Country Response
ACCM would propose that the highest standards are attained with acquiring an M.D. degree so therefore the public interest is served by having highly qualified professionals. The most important way of serving the public interest is to ensure that students who graduate are sufficiently well trained and motivated to become competent Physicians who are aware of their responsibilities to the public both as professionals and as private citizens. During their time on campus, St. Matthew's University students are encouraged to become involved in local Community Projects (for example: with Cayman Heart Foundation, whose office in based in the local hospital).
ACCM reviews SMU Annual Database (Exhibit 4 P.18-22, 31-32) each year and SMU Self-Study (Exhibit 15 P.27-31, P.53-55, 65-66, Sections III – V) every two years and writes up regular reports (Exhibit 7 P.8-9 & Exhibit 29 P.11-15, 21), including inspection site visit of campus, faculty including documentation.
 
Analyst Remarks to Response
Information in the narrative discusses how the public interest is served through having competent medical professionals and through the encouragement of local community involvement. Information is regularly reviewed during an annual review of database information, thru self-study evaluations, and via other pertinent information related to student performance. Documentation provided shows how SMU evaluates student performance in efforts to ensure the competencies of the students enrolled in its program.
 
Staff Conclusion: Comprehensive response provided
 
Mission and Objectives, Question 2
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2). With regard to the periodic re-evaluation and monitoring of medical schools, ACCM receives a formal updated database from the medical school in February each year (Exhibit 4). The school is required to answer a list of questions covering all major aspects of the governance of the school. This includes academic performance of students as well as information on Residency Match rates. The school also provides a list of Residency programmes into which graduates have been accepted.

ACCM defines its standards of educational quality as Elements (Exhibit 1). Element 1 establishes the requirements for institutional goals that include the educational mission, goals and objectives. ACCM requires the institution to publish and distribute its goals among its students, faculty and the public, generally through an institutional catalogue (Exhibit 23) or other publishing media. The agency requires the medical school to engage in a planning process that sets the direction for the institution and identifies measurable outcomes that identify accomplishment of the goals or areas in need of improvement. Among other things, minimum institutional goals require the offering of a degree programme that fulfills or exceeds the provisions summarized in the Elements of Accreditation (Exhibit 1: Element 1.1.4 p.2):
A graduate’s acquisition of a critical amount of knowledge and development of adequate skill to advance to and complete post-graduate training;
A graduate’s acquisition of the professional attributes expected by the academic community and physicians;
A graduates’ obtainment of licensure to provide quality health care, continuance of a life-long habit of learning as a way of keeping abreast of current medical advances; and
Assurance to students, parents, patients, postgraduate training directors, licensing authorities, government regulators and society that accredited programmes have met commonly accepted standards for quality education.

ACCM Protocol (Exhibit 2) (or procedures) requires on-site inspection teams to meet with the Chief Executive Officer of the medical school to review the institution’s educational goals for compliance and to summarize in a written report the educational goals of the medical school. The report comments on whether the institution has met its goals and these goals are familiar to faculty and students, and the extent to which the institution makes an effort to enhance its ability to reach its goals. Through testing, the agency requires the institution to ensure that students pass the USMLE step 1 examination before beginning the 3rd year clinical science coursework. In addition, the agency recommends that before graduation, students should also pass the USMLE Step 2 examination.

ACCM protocol specifically charges the on-site inspection team with determining if the education goals statement:
1. Is properly stated
2. Is publicized and distributed among its students, faculty and the public.
3. Seeks to sponsor a programme that fulfills or exceeds requirement to achieve accreditation.
4. Graduates only individuals who have acquired a critical amount of knowledge and skills to advance and complete postgraduate training.
5. Seeks to graduate only individuals who are able to secure licensure, provide quality patient care, and who have the capacity to keep medical knowledge current through self-learning and after completing the training.
 
Analyst Remarks to Narrative
In the country’s narrative, they indicate that ACCM has set standards for medical schools that comply with their Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012. Additionally, ACCM annually receives a formal updated self-profile database from each medical school they accredit. The combination of the standards in conjunction with the database provides the foundation for evaluating the effectiveness of the educational program at SMU.

Specifically, Standard 4.1.3 states “A curriculum committee of faculty members shall be responsible for developing and evaluating a curriculum that provides a general medical education so that its graduates are prepared to pursue further training at graduate level. The management of the curriculum shall involve the participation of the faculty and the administration in an integrated manner.”
 
Mission and Objectives, Question 3
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 (Exhibit 1) and ACCM Protocol for Accreditation 2012 (Exhibit 2, Section V & X). With regard to the periodic re-evaluation and monitoring of medical schools, ACCM receives a formal updated database from the medical school in February each year (Exhibit 4). The school is required to answer a list of questions covering all major aspects of the governance of the school. This includes academic performance of students as well as information on Residency Match rates. If these objectives are not met, there are certain criteria set down within the ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 to deal with this.
 
Analyst Remarks to Narrative
In the country’s narrative, they indicate that the medical school must follow the standards for medical schools that comply with the Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012. Additionally, the narrative cites the use of the annual database information from the school for evaluation of objectives of the medical school.

Specifically, Standard 1.1.1 states “The goals shall be formally adopted by the Board of Trustees of the institution and by the faculty (as a whole body or through its recognized representatives) and shall be re-evaluated annually.” While the school retains the control of the delivery of its teaching, learning objectives must be embedded into the curriculum.
 
Mission and Objectives, Question 4
 
Country Narrative
ACCM defines its standards of educational quality as Elements (Exhibit 1). Element 1 establishes the requirements for institutional goals that include the educational mission, goals and objectives. ACCM requires the institution to publish and distribute its goals among its students, faculty and the public, generally through an institutional catalogue or other publishing media. ACCM requires the medical school to engage in a planning process that sets the direction for the institution and identifies measurable outcomes that identify accomplishment of the goals or areas in need of improvement. Among other things, minimum institutional goals require the offering of a degree programme that fulfills or exceeds the provisions summarized in the Elements of Accreditation (Element 1.1.4 p.2):
A graduate’s acquisition of a critical amount of knowledge and development of adequate skill to advance to and complete post-graduate training;
A graduate’s acquisition of the professional attributes expected by the academic community and physicians;
A graduates’ obtainment of licensure to provide quality health care, continuance of a life-long habit of learning as a way of keeping abreast of current medical advances; and
Assurance to students, parents, patients, postgraduate training directors, licensing authorities, government regulators and society that accredited programmes have met commonly accepted standards for quality education.

ACCM protocol (or procedures) (Exhibit 2, Section V & X) requires ACCM on-site inspection teams to meet with the Chief Executive Officer of the medical school to review the institution’s educational goals for compliance and to summarize in a written report the educational goals of the medical school. The report comments on whether the institution has met its goals and these goals are familiar to faculty and students, and the extent to which the institution makes an effort to enhance its ability to reach its goals. Through testing, ACCM requires the institution to ensure that students pass the USMLE step 1 examination before beginning the 3rd year clinical science coursework. In addition, the agency recommends that before graduation, students should also pass the USMLE Step 2 examination.

The protocol specifically charges the on-site inspection team with determining if the education goals statement:
Is properly stated
Is publicized and distributed among its students, faculty and the public.
Seeks to sponsor a programme that fulfills or exceeds requirement to achieve accreditation.
Graduates only individuals who have acquired a critical amount of knowledge and skills to advance and complete postgraduate training.
Seeks to graduate only individuals who are able to secure licensure, provide quality patient care, and who have the capacity to keep medical knowledge current through self-learning and after completing the training.

Element 1 of ACCM Elements establishes ACCM’s requirements for the educational mission, goal and objectives of a medical school:
“The institution shall develop educational goals which define its mission. The goals shall be adopted by the Board of Trustees of the institution and shall be re-evaluated periodically to reflect external and demographic changes in its constituencies…As a minimum the institution goals shall include:
Sponsoring a Doctor of Medicine (M.D.) degree programme which fulfils or exceed the provisions summarized in the Elements of Accreditation
Its graduates have acquired a critical amount of knowledge and have developed adequate skill to advance to and complete post-graduate training.
Its graduates have acquired the professional attributes (knowledge, skills, attitudes and behaviour) expected by the academic community and society of a physician.
Its graduates be able to secure licensure, to provide quality health care and to continue a life-long habit of learning as a way to remain abreast of current medical advances,
To assure students, parents, patients, post-graduate training directors, licensing authorities, government regulators and society that accredited programmes have met commonly accepted standards for quality education.

ACCM Protocol requires the on-site inspection team to meet with the Chief Executive Officer of the medical school to review the educational goals of the institution for compliance with Element 1.
Specifically the team is charged with determining “if the educational goals statement:

Is properly stated

Is publicized and distributed among its student, faculty and the public.

Seeks to sponsor a programme that fulfils or exceeds requirements to achieve accreditation

Graduates only individuals who have acquired a critical amount of knowledge and skills to advance and complete postgraduate training

Seeks to graduate only individuals who are able to secure licensure, provide quality patient care, and who have the capacity to keep his medical knowledge current through self-learning and after he completes his training”

ACCM Protocol requires the ACCM team to summarize in its report the educational goals of the medical school, to comment on whether they are appropriate for the school, whether they have been achieved, whether the faculty and students are familiar with the goals and whether the college is contemplating any major effort to enhance its ability to reach its goals.

Due, inter alia, to the insistence of the ACCM the student is required to pass USMLE step 1 examination before s/he can continue to participate in the core subjects associated with 3rd year clinical science (Exhibit 4 p.p.8-11 ). ACCM recommends that USMLE Step 2 examination should be passed before the student is graduated.

With regard to the periodic re-evaluation and monitoring of medical schools, ACCM receives a formal updated database from the medical school in February each year (Exhibit 4). The school is required to answer a list of questions covering all major aspects of the governance of the school. This includes academic performance of students as well as information on Residency Match rates. The school also provides a list of Residency programmes into which graduates have been accepted. If these objectives are not met, there are certain criteria set down within the ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 to deal with this.
 
Analyst Remarks to Narrative
In the country's narrative, they indicate that the medical school must follow the educational program standards for medical schools that comply with the Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012.

Specifically, Standard 1.1.4 discusses outcome based metrics by ensuring that graduates are developing knowledge and skills to advance, that they develop professional attributes of the academic community/physicians, that they stay informed of current medical practices, and that they meet commonly accepted standards for quality education. Also, Standard 4.6.3 discusses objectives of the clerkship to have graduates develop the knowledge, skills, attitudes and behaviors that the profession and the public expect of the physician.

The ACCM on site inspection teams are required to review the institution's educational goals for compliance. The reports should include a review of the appropriateness of the educational goals of the medical school. The institution reviews whether they have been achieved, the faculty, student's familiarity with goals and the role the institution has in ensuring the goals are reached.

NCFMEA may wish to request documentation that shows how the on site inspection team review the institution's goals for compliance under this guideline.
 
Country Response
ACCM inspection team is provided with a copy of the curriculum before their visit to the campus. The curriculum is regularly reviewed and a comprehensive update was completed in 2013. While on campus, ACCM inspectors meet all heads of Department and review with them their familiarity with the curriculum, their teaching goals and methods.
All students have regular examinations to monitor progress. SMU has a greater than 85% success rate with USMLE Steps one and two, which suggests that the teaching is satisfactory and covers the curriculum required.
Students are interviewed and are given the opportunity to voice their opinions regarding the quality and comprehensiveness of teaching across every department.
ACCM reviews SMU Annual Database (Exhibit 4) each year and SMU Self-Study (Exhibit 15 Sections III & V P.56-58) every two years and writes up regular reports (Exhibit 7 P.3-9 & 29 P.8 & 22), including inspection site visit of campus, faculty including documentation.
 
Analyst Remarks to Response
Additional information provided in the narrative explains that the onsite inspection team receives curriculum information to review prior to the visit. Additionally, it is explained that the inspection team meets with department chairs to review the curriculum and with students to allow them to voice their opinions related to the teaching they receive.

Documentation of the onsite inspection teams report demonstrates that curriculum was reviewed in 2010-2011 for the appropriateness of the educational goals of the medical school. Further provided in the onsite inspection team report was that the team met with a group of students who were ‘happy with the teaching and facilities of the university.’ There have been no student complaints filed. The onsite inspection team report indicates that meetings were held with the new faculty and with the Department chairs, as specified in the narrative.

Also included in the narrative, is a statement that indicates that the curriculum was last updated in 2013. No documentation was supported for the 2013 curriculum review.

 
Staff Conclusion: Comprehensive response provided
 
Mission and Objectives, Question 5
 
Country Narrative
Students are required to undergo and pass USLME Step 1 & 2 and NBME Shelf Exams as well as undertaking clinical training (Exhibit 1: Element 5 & 11). The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and provide an education that adheres to LCME standards (Exhibit 1: Element 1 & 2).

Element 1 of ACCM Elements establishes the Commission’s requirements for the educational mission, goal and objectives of a medical school: “The institution shall develop educational goals which define its mission. The goals shall be adopted by the Board of Trustees of the institution and shall be re-evaluated periodically to reflect external and demographic changes in its constituencies… As a minimum the institution goals shall ensure graduates:
Sponsor a Doctor of Medicine (M.D.) degree programme which fulfils or exceed the provisions summarized in the Elements of Accreditation
have acquired a critical amount of knowledge and have developed adequate skill to advance to and complete post-graduate training.
have acquired the professional attributes (knowledge, skills, attitudes and behaviour) expected by the academic community and society of a physician.
be able to secure licensure, to provide quality health care and to continue a life-long habit of learning as a way to remain abreast of current medical advances,
assure students, parents, patients, post-graduate training directors, licensing authorities, government regulators and society that accredited programmes have met commonly accepted standards for quality education.

ACCM Protocol requires the on-site inspection team to meet with the Chief Executive Officer of the medical school to review the educational goals of the institution for compliance with Element 1. Specifically the team is charged with determining “if the educational goals statement:
Is properly stated
Is publicized and distributed among its student, faculty and the public.
Seeks to sponsor a programme that fulfils or exceeds requirements to achieve accreditation
Graduates only individuals who have acquired a critical amount of knowledge and skills to advance and complete postgraduate training
Seeks to graduate only individuals who are able to secure licensure, provide quality patient care, and who have the capacity to keep his medical knowledge current through self-learning and after he completes his training”
 
Analyst Remarks to Narrative
The learning outcomes based structure of the country's preparation of medical programs expressly requires medical programs to demonstrate that its graduates have the requisite knowledge and competencies expected of a medical school graduate. The students are required to take and pass the USMLE, the NBME Shelf examinations, and have completed clinical training.

These competencies are defined in the country's standards documents (the Elements of Accreditation 2014, ACCM Protocol for Accreditation 2012, and that adhere to LCME standards.) Additionally, the on site inspection team is expected to review these elements when conducting their review and determining institutional compliance. However, the country has not provided documentation that would evidence the on-site inspection teams review and assessment of USMLE and NBME pass rates to demonstrate ACCM’s application of its standards at the institution.

NCFMEA may wish to request documentation would evidence the review of USMLE and NBME pass rates at the institution to demonstrate ACCM’s application of its standards.
 
Country Response
ACCM reviews SMU Annual Database (Exhibit 4 P.18-22, 31-32) each year and SMU Self-Study (Exhibit 15 Sections III & V P.56-58) every two years and writes up regular reports (Exhibit 7 P.12-13 & 29 P.11-15, 21), including reviewing USLME/NBME pass rates.
If USMLE/NBME pass rates are below a certain standard, recommendations and compliance measures for improvements are made and checked on whether implemented within a reasonable timescale.
However, as these rates have been over 85% therefore ACCM standards have been adhered to.
 
Analyst Remarks to Response
Additional documentation has been provided that showcases how the onsite inspection team reviewed the pass rates related to USLME Step 1 and Step 2, being 85% and 86% respectively. It is noted that the NBME shelf exams are a requirement for Basic Science and Introduction to Clinical Medicine Courses.
 
Staff Conclusion: Comprehensive response provided
 
Governance, Question 1
 
Country Narrative
Yes, ACCM requires medical schools to be legally authorized or licensed to provide a programme of medical education.

The Educational Council granted approval for SMU to register to operate in the country pursuant to Section 32 of the Education Law (1999) (Exhibit 10). The University Charter, in a memorandum of understanding, required the school to receive the approval of the Ministry of Education to establish a medical school in the Cayman Islands in November 2000 (Exhibit 11). The Executive Council, includes government ministers, approved the application to offer a medical education programme at SMU on January 4, 2002. The Education Council approved the SMU registration and licensure application on April 4, 2002, that authorized the school to confer the degree of the doctor of medicine.

Element 2 (Exhibit 1) describes the organizational structure of the institution and requires it to have legal authorization and to be licensed by the appropriate governmental or regulatory authority, as government-supported or private independent entity, to offer degree programmes beyond the baccalaureate level in courses of instruction leading to the M.D. degree. An independent and voluntary Board of Trustees (BOT) is the highest authoritative body of the institution (Exhibit 22). Members of the BOT may include founders or the public who have an interest in the general welfare of the institution. The BOT members must be free of conflicting interests and cannot include any affiliate of the medical school who has a financial or business interest in the institution, e.g., an employee, consultant or family member/relative with connections to the school. The BOT governs the institution, in consultation with the chief academic officer, divisional heads, and representatives of the faculty. Its role, duties and responsibilities include establishing broad institutional policies; providing institutional direction; securing financial resources; selecting the chief executive officer (CEO), the chief academic officer (CAO) and their deputies and overseeing the management’s performance of its duties and responsibilities. The institutional policies define the oversight of management’s performance, e.g., the CEO reports to the BOT. However, the institution’s by-laws and regulations define the roles, duties and responsibilities of the administrative officers, academic officers, faculty, faculty government, students, faculty and procedures.

ACCM inspection team reviews whether BOT members are free of conflict and reports on the legal authority of the school to operate and offer degrees, and verifies whether the corporate organization meets the governance requirements. The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 and provide an education that adheres to LCME standards (Exhibit 1 & 2).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on faculty members such as CV’s and Meetings held in regard to administration of Medical Education programmes (Exhibit 4).
 
Analyst Remarks to Narrative
In the country’s narrative, they indicate that ACCM requires medical schools to be legally authorized to provide medical education. Included in the documentation was the approval for SMU by the Educational Council. In addition, the University Charter and MOU were established to receive the approval of the Ministry of Education to establish a medical school in the Cayman Islands.

Additionally, the country explains the role of the independent and voluntary Board of Trustees (BOT) as the highest authoritative body of the institution. The BOT has defined roles and responsibilities of its members and indicates that they must be free of conflicts of interests. ACCM inspection teams review the BOT as part of their review and ensure that they maintain compliance with the ACCM Protocols for Accreditation 2012 and LCME standards.
 
Governance, Question 2
 
Country Narrative
Yes, the administrators of medical schools are held accountable for the operation and success of the medical school and its programmes to an authority external and independent of the medical school which is ACCM. ACCM is an independent accrediting body recognised and authorised by both the medical school and the government of Cayman Islands (Exhibit 5). ACCM is responsible for ensuring that medical programmes comply with its standards and policies in the interest of both the medical school and the public (Exhibit 1 & 2).

ACCM Protocol (Exhibit 2) requires that the inspection team ensures that Board members are free of conflicting interests. The Protocol requires that the team reports whether the college is chartered, licensed and authorised to award the M.D. degree by the regulatory body that governs educational institutions in that jurisdiction. The college must annex all documents to demonstrate its authority to operate and to award the M.D. degree.

Again in Element 2 (i.e. Corporate Organization) ACCM’s requirements for governance are as follows:
“In consultation with the Chief Academic Officer, divisional heads and representatives of the faculty the board shall govern the institution by: Establishing broad institutional policies, Providing institutional direction, Securing financial resources, Selecting the Chief Executive Officer, the Chief Academic Officer and their deputies and Overseeing the management’s performance of its duties and responsibilities.

ACCM Protocol requires the inspection team to ensure that the medical school complies with the Elements. Element 2 requires that the institution’s by-laws and codes of regulation shall delineate the roles, duties and responsibilities of the key administrative and academic officers, the faculty committees as outlined in these documents. ACCM Protocol requires the team to report specifically on each of these areas of governance, in particular whether Board members serve without conflicts of interest with the medical school and are independent of the administration and whether the Board properly exercises its authority in overseeing the administration performance of its duties and responsibilities (Exhibit 22). The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 and provide an education that adheres to LCME standards.
 
Analyst Remarks to Narrative
As stated in the country's narrative (and per signed government agreement), the medical school is accountable to the external and independent body, ACCM. ACCM Protocol requires the inspection team to review the Elements of Accreditation 2014 for compliance and assurance that educational quality is not compromised.
 
Administrative Personnel and Authority, Question 1
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 and provide an education that adheres to LCME standards (Exhibit 1 & 2).

Element 3 (Exhibit 1) addresses institutional management and administration and requires an institution to “design an administrative structure so that each division is able to perform its unique responsibilities efficiently. The design and the size of the administration shall also be of sufficient magnitude for the size of the student body and the scope of the programme.” This element requires the college’s Board of Trustees to approve the appointment of the Chief Executive Officer (CEO), Chief Academic Officer (CAO), and faculty members and requires the CAO to carry out institutional policies and to implement the educational objectives of the institution. The principal administrative and academic heads of the medical school shall maintain open lines of communication with each other.

Element 3 also requires the CAO to hold an MD degree and, possess adequate qualifications and experience in medical education, research and patient care to lead and supervise the educational programme at the institution. To support the CAO, the institution must have a competent team of professional staff in the management of the educational programme. These members include individuals representing: Deans, Associate Deans and Assistant Deans; Professional staff and secretarial support; student admissions; faculty affairs; education financing, accounting, budgeting, and fundraising; clinical facilities; curriculum and academic affairs; student services and student affairs; postgraduate and continuing medical education; research; alumni affairs; library; student financial assistance; record keeping; and public safety. ACCM expects the institution to evaluate the effectiveness of the CAO and staff and the effectiveness and efficiency of the leadership of the medical school in the self-study.

Element 3 additionally addresses the institution’s responsibilities regarding the affiliated institutional locations. ACCM requires the institution to outline the authorities and responsibilities of the CAO and faculties of the allied health programmes and their affiliated hospitals from those of the medical school dean and faculty. To avoid overuse of the faculty resources that the institution shares among other allied health programmes, the institution shall give faculty members additional time for classroom preparation, student tutoring and committee work. The CAO ensures that those students at satellite health care facilities receive the same quality of education and the same standard of student evaluation as provided at the parent campus. To achieve this goal and to implement the academic policies of the institution, the dean shall appoint, at each satellite health care facility, an assistant dean (who reports directly to the dean), a department faculty (who reports to the respective divisional head), and administrative personnel (who reports directly to the supervisor at the parent campus).

ACCM ensures the administration is effective and appropriate by receiving a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on faculty members such as CV’s and Meetings held in regard to administration (Exhibit 4).

ACCM inspects the school and its facilities with an Interim Inspection every two years as well as providing a Report on the school which is sent to the School and the Cayman Islands government (Exhibit 7 & 9, 24 & 25). The protocol requires the on-site inspection team to meet with key members of the medical school’s administration, faculty and student affairs personnel to discuss curriculum, school policies and practices, and the provision of student services to ascertain the effectiveness of the school’s management of instructional resources and include the findings in a written report (Exhibit 2: Sections VII, VIII, IX).

The ACCM Report (Exhibit 7) ensures that the Chief Academic Officer of the medical school has sufficient access to resources and authority of the University President to effectively administer the medical educational programme. As far as the ACCM is aware, access to the resources and authority to effectively instruct students remains satisfactory.
 
Analyst Remarks to Narrative
The country's standards are outlined in the ACCM Elements of Accreditation 2014, ACCM Protocol for Accreditation 2012, and adhere to LCME standards. ACCM requires SMU to attest to the qualifications, adequacy, and competency of its staff to carry out the curriculum in terms of content, educational expertise, and organization. Specific standards exist in relation to size and design, qualifications and experience, resources, authority, and institution’s responsibilities regarding the affiliated institutional locations.
 
Administrative Personnel and Authority, Question 2
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1: Element 1, 3, 4 Section 4.1.2, 8, 9 & 11). Element 3 expects the Chief Academic Officer (CAO) of a medical school to hold an M.D. degree, possess adequate qualifications and experience in medical education, research and patient care to lead and to supervise the educational programme of the institution. The on-site inspection team interviews the CAO, and reviews the most recent performance review and reports on the CAO’s qualifications by commenting on how well that person has led the medical school and carried out the responsibilities of the position.

ACCM’s Protocol requires the on-site inspection team to report on the qualifications of the chief academic officer and the comment on how well that individual has led the college and carried out his/her responsibilities. It must also report on the most recent performance review of the chief academic officer (Exhibit 2: Sections VII, VIII, IX).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on faculty members such as CV’s and Meetings held in regard to administration of Medical Education programmes (Exhibit 4).
 
Analyst Remarks to Narrative
The country discusses in its narrative the responsibility of the Chief Academic Officer of the medical school. In addition to meeting ACCM’s qualifications and experience requirements, he/she is interviewed by the on site inspection team. The review of the team includes a performance review in conjunction with how he/she has carried out responsibilities for his/her position. However, no documentation was provided to evidence the on site inspection team’s review and evaluation of the Chief Academic Officer’s experience and qualifications.

NCFMEA may wish to request documentation demonstrating the review of the Chief Academic officers qualifications and experience.
 
Country Response
The Chief Academic Officer’s curriculum vitae is available (Exhibit 36 CV p.16).
The Chief Academic Officer regularly visits the campus and meets with senior staff to review progress. Dr. John Randall also regularly visits clinical sites and meets with senior clinical teachers and students including reviewing facilities and progress. Reports of these visits are available if required.
We have not been provided with any written progress reviews of the CAO’s performance. ACCM interviewed the Chief Academic Officer during a site visit and was satisfied with the progress made under his stewardship.
ACCM reviews SMU Annual Database (Exhibit 4) each year and SMU Self-Study (Exhibit 15 P.11-12) every two years and writes up regular reports (Exhibit 7 P.15-16 Recommendations & 29 P.16-18), including inspection site visit of campus, faculty including documentation which includes checking on any new Faculty members, their CV’s and interviewing them, with this same procedure being carried out when present CAO took up position.
 
Analyst Remarks to Response
The curriculum vitae for Chief Academic Officer, Dr. John Randall was provided. His CV demonstrates that he meets the standards identified in ACCM Elements of Accreditation 2014 for qualifications and experience. The narrative provided explains that Dr. Randall 'visits clinical sites and meets with senior clinical teachers and students. He reviews facilities and the faculty/student progress. The agency explained that those reports would be available upon request.

The onsite inspection team report indicates that they were able to meet with Dr. John Randall via teleconference to discuss information regarding clinical medicine rotations. At the time, Dr. John Randall was serving in the capacity of both Dean of Clinical Sciences and Chief Academic Officer (CAO). At a 2013 NCFMEA meeting, the issue of a single person in both roles was raised and the country indicated that they had hired another person to fill the Dean of Clinical Sciences position. Confirmation on the SMU website does indicate two separate individuals hold these roles.

No documentation was provided in the onsite inspection team report that the Chief Academic Officer was interviewed regarding his performance as outlined in the ACCM Elements of Accreditation 2014. However, the narrative indicates that this review of performance did occur.

NCFMEA may wish to request copies of the reports that showcase how the CAO reviews clinical sites. Additionally, they may wish to request background on the performance discussion with the CAO during the onsite inspection team visit. Noted is the significance related to confidentiality of personnel manners, however it may be helpful for the function of this performance review to be included in the onsite inspection team visit report, therefore documenting this occurrence as demonstrating compliance with the ACCM standards.
 
Staff Conclusion: Additional Information requested
 
Administrative Personnel and Authority, Question 3
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1: Element 2, 3, 8, 9 & 11), (Exhibit 2: Sections VII, VIII, IX). Element 3 additionally addresses the institution’s responsibilities regarding the affiliated institutional locations. ACCM requires the institution to outline the authorities and responsibilities of the CAO and faculties of the allied health programmes and their affiliated hospitals from those of the medical school dean and faculty. To avoid overuse of the faculty resources that the institution shares among other allied health programmes, the institution shall give faculty members additional time for classroom preparation, student tutoring and committee work. The CAO ensures that those students at satellite health care facilities receive the same quality of education and the same standard of student evaluation as provided at the parent campus. To achieve this goal and to implement the academic policies of the institution, the dean shall appoint, at each satellite health care facility, an assistant dean (who reports directly to the dean), a department faculty (who reports to the respective divisional head), and administrative personnel (who reports directly to the supervisor at the parent campus).

ACCM protocol requires the on-site inspection team to meet with key members of the medical school’s administration, faculty and student affairs personnel to discuss curriculum, school policies and practices, and the provision of student services to ascertain the effectiveness of the school’s management of instructional resources and include the findings in a written report (Exhibit: 7 & 9, 24 & 25).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on faculty members such as CV’s and Meetings held in regard to access and resources (Exhibit 4).
 
Analyst Remarks to Narrative
As stated in the country's narrative, ACCM outlines the difference in responsibilities for the CAO, contrasted with the medical school dean and faculty. For faculty, there is an allowance of additional time for classroom preparation, student tutoring, and committee work. Assurance of the quality of education across all locations (including satellites) occurs in part due to the assignment of an assistant dean, department of faculty and administrative personnel.

Accreditation Reports following site visits February 25-26, 2013, show review of faculty and instructional personnel data. In the 2013 special report of Cayman Islands to the NCFMEA, it was noted that the Chief Academic Officer also held the Position of Dean of Clinical Sciences. Since the visit, the two roles have been separated allowing the University as Dean of Clinical Sciences to perform independently the role of the Chief Academic Officer.
 
Chief Academic Official, Question 1
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1: Element 2, 3 Section 3.1.3, 4 Section 4.6 & 8), (Exhibit 2: Sections VII, VIII, IX).

Element 3 expects the Chief Academic Officer (CAO) of a medical school to hold an M.D. degree, possess adequate qualifications and experience in medical education, research and patient care to lead and to supervise the educational programme of the institution.

ACCM on-site inspection team interviews the CAO, and reviews the most recent performance review and reports on the CAO’s qualifications by commenting on how well that person has led the medical school and carried out the responsibilities of the position.

ACCM receives a formal updated database from the medical school in February each year (Exhibit 4). The school is required to answer a list of questions covering all major aspects of the governance of the school including information on faculty members and CV’s.
 
Analyst Remarks to Narrative
The country's Element 3 ensures the competency and qualifications of the staff and specifically in section 3.1.3, the Chief Academic Official. In addition to meeting experience qualifications, the country states in its narrative that the on site inspection team is required to interview the Chief Academic Official. The review evaluates how well the Chief Academic official has carried out the responsibilities of the position. However, no evidence of the on site inspection teams review was provided to demonstrate ACCM’s review and assessment of the Chief Academic officials performance and or qualifications.

NCFMEA may wish to request documentation demonstrating the review and assessment of the Chief Academic officials performance and qualifications.
 
Country Response
The Chief Academic Officer’s curriculum vitae is available (Exhibit 36 CV p.16).
The Chief Academic Officer regularly visits the campus and meets with senior staff to review progress. Dr. John Randall also regularly visits clinical sites and meets with senior clinical teachers and students including reviewing facilities and progress. Reports of these visits are available if required.
We have not been provided with any written progress reviews of the CAO’s performance.
ACCM interviewed the Chief Academic Officer during a site visit and was satisfied with the progress made under his stewardship.
ACCM reviews SMU Annual Database (Exhibit 4 P.18-22, 31-32) each year and SMU Self-Study (Exhibit 15 P. 11-12 & Sections III & V P.56-58) every two years and writes up regular reports (Exhibit 7 P.8 & 29 P.16-18), including inspection site visit of campus, faculty including documentation which includes checking on any new Faculty members, their CV’s and interviewing them, with this same procedure being carried out when present CAO took up position.
 
Analyst Remarks to Response
The curriculum vitae for Chief Academic Officer, Dr. John Randall was provided. His CV demonstrates that he meets the standards identified in ACCM Elements of Accreditation 2014 for qualifications and experience. The narrative provided explains that Dr. Randall 'visits clinical sites and meets with senior clinical teachers and students. He reviews facilities and the faculty/student progress. The agency explained that those reports would be available upon request.


The onsite inspection team report indicates that they were able to meet with Dr. John Randall via teleconference to discuss information regarding clinical medicine rotations. At the time, Dr. John Randall was serving in the capacity of both Dean of Clinical Sciences and Chief Academic Officer (CAO). At a 2013 NCFMEA meeting, the issue of a single person in both roles was raised and the country indicated that they had hired another person to fill the Dean of Clinical Sciences position. Confirmation on the SMU website does indicate two separate individuals hold these roles.

No documentation was provided in the onsite inspection team report that the Chief Academic Officer was interviewed regarding his performance as outlined in the ACCM Elements of Accreditation 2014. However, the narrative indicates that this review of performance did occur.

NCFMEA may wish to request copies of the reports that showcase how the CAO reviews clinical sites. Additionally, they may wish to request background on the performance discussion with the CAO during the onsite inspection team visit. Noted is the significance related to confidentiality of personnel manners, however it may be helpful for the function of this performance review to be included in the onsite inspection team visit report, therefore documenting this occurrence as demonstrating compliance with the ACCM standards.
 
Staff Conclusion: Additional Information requested
 
Chief Academic Official, Question 2
 
Country Narrative
The selection process for the chief academic official of the medical school is carried out by the Board of Trustees who identify a suitable candidate through a recruitment process which includes interviews and review of Curriculum Vitae's.

ACCM Element 8 also addresses faculty participation in the hiring, retention, promotion and disciplinary processes (Exhibit 1). The relevant section of this element states “[t]he recruitment and selection of the faculty as well as all other academic positions of the institution, shall be the result of the collective efforts of the chief academic officer, department heads, faculty representatives and administration.

ACCM Self-study (Exhibit 12) addresses personnel policies in which the institution assesses the appointment, renewal of appointment, promotion, tenure and dismissal of faculty. For example, a faculty search committee assists with recruitment and interviews top candidates along with student body representatives. The committee selects its preferences and submits its recommendations to the appropriate academic official, who forwards the names of the preferred choices to the CEO along with a request to offer the applicant an employment contract. A school may have its own protocol for hiring, but it must show how the faculty is involved in the process. To encourage retention among faculty, this element also requires the institution to provide a reasonable level of compensation to its faculty that includes health insurance, disability insurance, and a retirement pension programme.

Additionally, ACCM requires institutions to offer faculty academic freedom, a reasonable level of job security or equitable workloads in a faculty contract, a faculty tenure system or factors such as number of courses, types of courses, number of classroom contact hours, research time committee work, etc. Element 8 also addresses procedures an institution must have for the evaluation and promotion of faculty based on competency, performance, and discipline that involves faculty members in making these decisions.
 
Analyst Remarks to Narrative
The country states that the Board of Trustees is responsible for selecting the chief academic official of the medical school through recruitment, interviews, and CV reviews. ACCM ensures the competency and qualifications of such individual through various accreditation processes. For example, faculty, department heads, and other representatives/administration have input into the selection of suitable candidates.
 
Faculty
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1: Element 4, 6 & 8), (Exhibit 2: Sections VII, VIII, IX).

Element 6 addresses the participation of faculty on committees for the admission of new and transfer students. This element requires a Faculty Committee on admissions to define the size and characteristics of the student body after consultation with the institution’s administration. The Faculty Committee defines the admission requirements and makes final decisions of the students admitted to the educational programme. The faculty bases its decisions on admission for each semester on factors such as the available square footage per student, faculty-student ratios, etc. The committee’s decision shall not be affected by factors such as age, sex, race, religion, national origin, financial interest, inside influence, or outside pressure. The faculty admission committee process to evaluate and screen applicants includes personal interviews and the following considerations:
a) Grade point averages;
b) The type and degree of difficulty of courses the applicant enrolled in;
c) Scores on the medical school admission test;
d) Proficiency of the applicant’s writing skills;
e ) Proficiency of the applicant’s communication skills;
f) Personal hygiene and grooming standards of the applicant;
g) Evaluations from college pre-professional committees or undergraduate faculty members; and
h) Ability of the applicant to communicate effectively and to articulate his motivation, experience and other matters during a personal interview.

During the preparation of the self-study, ACCM expects the institution’s faculty committee to validate the selection criteria to determine whether the results of the admission process ensures that the class size is appropriate in terms of number and raises the standard for the quality of applicants admitted to the programme (Exhibit 12).

Element 8 also addresses faculty participation in the hiring, retention, promotion and disciplinary processes. The relevant section of this element states “[t]he recruitment and selection of the faculty as well as all other academic positions of the institution, shall be the result of the collective efforts of the chief academic officer, department heads, faculty representatives and administration. ACCM Self-study addresses personnel policies in which the institution assesses the appointment, renewal of appointment, promotion, tenure and dismissal of faculty (Exhibit 12). For example, a faculty search committee assists with recruitment and interviews top candidates along with student body representatives. The committee selects its preferences and submits its recommendations to the appropriate academic official, who forwards the names of the preferred choices to the CEO along with a request to offer the applicant an employment contract. A school may have its own protocol for hiring, but it must show how the faculty is involved in the process. To encourage retention among faculty, this element also requires the institution to provide a reasonable level of compensation to its faculty that includes health insurance, disability insurance, and a retirement pension programme.

Additionally, ACCM requires institutions to offer faculty academic freedom, a reasonable level of job security or equitable workloads in a faculty contract, a faculty tenure system or factors such as number of courses, types of courses, number of classroom contact hours, research time committee work, etc. Element 8 also addresses the procedures an institution must have for the evaluation and promotion of faculty based on competency, performance, and discipline that involves faculty members in making these decisions.

Element 4 addresses the role of the faculty involvement in all phases of the medical college’s curriculum, including the clinical education portion. A medical school must have a curriculum committee of faculty members who are responsible for developing and evaluating a curriculum that provides a general medical education so that its graduates are prepared to pursue further training at the graduate level. The goal of the curriculum committee is to design a programme that encourages students to acquire an understanding of basic scientific knowledge, a fundamental to medicine. The committee shall develop a programme that promotes problems solving skills, an understanding of the principles of basic and translational research as applied to medicine and access to service learning. In addition the curriculum must have an orderly sequence of courses.

In designing clinical clerkships, the faculty curriculum committee requires all clinical instruction to be carried out in both inpatient and outpatient settings. Regarding oversight of clinical students, the curriculum committee stipulates the types of patients or clinical conditions that the students must see and ensures that faculty oversees workups of patients by clinical students in wards and clinics. The oversight required by this element includes a) providing a structured environment for students to learn and work; b) providing an academic organization that is controlled by the medical college; c) ensuring that medical students are taught by faculty members of the college; d) defining clerkship objectives; and e) scheduling adequate time for students to study and faculty to monitor the students’ clinical experience, among other things. The supporting documentation shows that SMU has a basic sciences curriculum committee and a clinical sciences curriculum committee. Each committee has specific responsibilities regarding the medical education curriculum that include the analysis of the course content and evaluation methods and results, ensuring that any inconsistencies are resolved in a timely manner.

ACCM protocol requires the team to report whether there is a faculty body and describe the duties and composition of the executive committees of the faculty body. Regarding faculty committees, the team identifies the principal standing committees and comments of the college’s requirements for committee work by members of the college’s faculty.

ACCM receives a formal updated database from the medical school in February each year (Exhibit 4). The school is required to answer a list of questions covering all major aspects of the governance of the school including information relating to these aspects. ACCM considers these exhibits essential to an effective review and reporting process because they support and bolster the credibility of the inspection report.
 
Analyst Remarks to Narrative
The country states in its narrative that ACCM ensures medical faculty involvement in decision related to this guideline, by involving faculty on the committee that determines admission of new and transfer students. Inspection teams review admission processes as part of their regular review. They additionally discuss faculty roles in hiring, retention, promotion and disciplinary processes. Faculty serves on the curriculum committee that reviews and maintains standards for its academic coursework and the clinical education of its students. Elements of Accreditation and documentation of self-study included in the petition demonstrate the application of these functions. While it appears ACCM has accreditation standards to address this question, no documentation was provided to demonstrate ACCM’s review and assessment of whether the faculty is appropriately involved in decisions related to the areas identified in this guideline.

NCFMEA may wish to request documentation that demonstrate ACCM’s review and assessment of whether the faculty is appropriately involved in decisions related to the areas identified in this guideline.
 
Country Response
SMU has a wide range of Committees in which faculty members are involved.
Most of these Committees are chaired by the faculty members.
Principal Committees include research, curriculum, disciplinary, student promotion, student awards, student admissions, faculty Senate and faculty promotions.
Based on the establishment of these Committees, their Minutes and discussions on campus with faculty members they are heavily involved in decisions made within St. Matthew’s University.
ACCM reviews SMU Annual Database (Exhibit 4) each year and SMU Self-Study (Exhibit 15 P.3-9, 76-77) which includes information on faculty involvement and documentation of Minutes of Committees (Exhibit 30, 31 & 32) and writes up regular reports (Exhibit 7 P.7, 11-12 & 29 P.8, 12-13).
 
Analyst Remarks to Response
Per request, documentation has been provided that showcases faculty involvement in a myriad of activities and committees at SMU. Specifically, documentation that included faculty minutes from the research, curriculum, and medical information technology, disciplinary, student promotion, student awards, safety, student admissions, faculty senate, and faculty promotions committees was provided to the Department.

Review of this information showcases faculty involvement in admissions, and all phases of the curriculum as outlined in the guidelines. Documentation was submitted to support faculty promotion but did not document any actions of discipline of the faculty.

The NCFMEA may wish to request clarification regarding if faculty are involved in discipline of faculty and related documentation.
 
Staff Conclusion: Additional Information requested
 
Remote Sites, Question 1
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1: Element 4, 8, 11 &12), (Exhibit 2: Sections VII, VIII, IX). ACCM accreditation process of a medical school must be for the entire educational programme and not individual parts of the programme separated geographically from the main campus. No part of the preclinical educational programme (basic sciences portion of the programme) may be taken outside the comparable country in which the medical school is located.
 
Analyst Remarks to Narrative
In the country’s narrative, they state that no part of the preclinical program is taken outside of the Cayman Islands, and that the accreditation process for the medical school must be for the entire program and not separated geographically from the main campus.
 
Remote Sites, Question 2
 
Country Narrative
It is assumed that hospital teaching and training in the 3rd and 4th years is not the subject of this Section. Teaching of all of the basic science subjects and those allied to the introduction to clinical medicine occur at the main campus, in laboratories in the Cayman Islands and at clinical venues such as Doctor’s offices and the Cayman Hospital. In the local hospital, students participate in clinical care in the emergency room, wards and radiology suites. ACCM admits that students’ experiences at the preclinical venues vary. However, the important focus of the patient-physician relationship is emphasized and available to students prior the start of the 3rd and before taking the USMLE Step 1 examination.

ACCM protocol (Exhibit 2) requires the on-site inspection team to evaluate the consistency of the medical programme curriculum at off-site locations. The ACCM reviews the roles of the CEO, CAO, Dean of the basic sciences and Chair of the preclinical sciences in conjunction with interviews of the dean of clinical sciences to determine whether the school conducts consistent student evaluations at all sites. In the Annual Database, SMU reported that students receive the same learning resources in key areas of the core rotations, regardless of whether the patient experience is seasonal or varied with respect to diseases observed. By using specific indicators, the faculty committees responsible for educational planning and/or curriculum evaluation evaluate the data and report the findings concerning equipment, and nature of teaching in detail and make recommendations for change to the deans and administrators (Exhibit 4).

ACCM Protocol (Exhibit 2): The college possesses the necessary administrative, educational, fiscal and learning resources to fulfil its educational goals. The protocol requires the team to meet with the deputy academic officer for curriculum, the chair of the curriculum committee and selected course directors to discuss the management of the curriculum. The team discusses the management of the basic sciences courses “to ascertain whether the educational experiences are the same as the parent medical college”. It appears that ACCM accepts the different venues in the Grand Cayman that St. Matthew’s (SMU) uses to enhance the basic science instruction before students actually begin clinical clerkship in the third year of instruction. It is clear that the inspection team evaluates these venues during the on-site inspections and they do not lack consistency in the review of the medical school.

Students are required to participate and undergo clinical training at geographically separated locations, both in the US and UK with the medical school having a Hospital Site Affiliation Agreement with each hospital (Exhibit 16). The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1: Elements 3, 4, 8 & 11), (Exhibit 2: Sections VII, VIII, IX).

ACCM receives a formal updated database from the medical school in February each year (Exhibit 4). The school is required to answer a list of questions covering all major aspects of the governance of the school including information on clinical facilities (Exhibit 21). ACCM inspects clinical facilities every two years (Exhibit 18) as well as providing a Report on each site which is sent to the school (Exhibit 8). Each Report lists recommendations (if appropriate) which the School must carry out.

The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1: Element 1, 3, 4, 8 & 11), (Exhibit 2: Sections VII, VIII, IX).
 
Analyst Remarks to Narrative
The response provided by the country does not fully address this question. The country references ACCM's Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 as its standards for addressing this guideline. It is further stated that all preclinical coursework is completed in the Cayman Islands. The country provides detailed documentation of the process they use for completing inspections of hospitals and the related affiliation agreements. However, the country also states in its narrative that "the students' experiences at the preclinical venues vary."

The NCFMEA may wish to request additional information regarding the mechanism that the country has for ensuring consistency of student's knowledge and comparable evaluation across locations.
 
Country Response
St. Matthew’s University runs a comprehensive introduction to clinical medicine course. All students are taught in the laboratory to take a history, perform a clinical examination and certain procedures such as BP measurement. They are also instructed in resuscitation of Children and adults.
They spend sometime in the local Georgetown Hospital where they shadow clinicians. Because of the nature of clinical medicine it is not possible for all students to see the same patients, however they are all instructed in the same principles of good patient communication and care.
ACCM reviews SMU Annual Database (Exhibit 4) each year and SMU Self-Study (Exhibit 15 P.39-43, 52-53) which includes information provided by SMU on clinical venues (Exhibit 21) which is used to ensure consistency of student's knowledge and comparable evaluation across locations and writes up regular reports.
As previously stated, ACCM also inspects clinical sites including interviewing faculty, curriculum and students. Student’s experiences may vary due to each clinical site having and using different methods and ways of instruction. However, this is not to say that the student’s experience does not result in consistency and comparable evaluation across locations.
ACCM provides a Report on each site which is sent to the school (Exhibit 18). Each Report (Exhibit 33) lists recommendations (if appropriate) which the School must carry out to ensure the highest standards are met as well as written reports (Exhibit 7 P.10 & 29 P.10-11). If these are not implemented, the School has to consider no longer using the site and may have to seek another suitable site, which has happened in the past.
The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1: Element 1, 3, 4, 8 & 11), (Exhibit 2: Sections VII, VIII, IX).
 
Analyst Remarks to Response
The country has several standards that ensure that the educational experiences at remote sites are comparable to the main
campus and that students are evaluated in a comparable manner at all sites. The country requires consistency among
assessments, curriculum, and faculty. Medical programs must ensure that appropriate mechanisms are in place to ensure
consistency among student evaluations. The country has provided documentation relative to these standards.
 
Staff Conclusion: Comprehensive response provided
 
Program Length, Question 1
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation (Exhibit 1: Element 4 Section 4.1.1, 5, & 6). The length of the programme shall be no less than 130 weeks and offered over four academic years. Element 4 requires a medical education programme to consist of no less than 130 weeks offered over four academic years. However, at SMU the minimum number of weeks of instruction to obtain an M.D. degree is 147 weeks over four academic years.

To access compliance, the team reviews the following: The overall curricular objectives, Course objectives, Course content, Laboratory exercises, types of patients available for teaching purposes, the number of patients assigned to students to work up each week, Clinical skills students are required to master and Redundancy of curricular materials.

ACCM team reviews the integration of the basic science and clinical science courses, in addition to the multidisciplinary courses and senior elective courses offered by the programme during the freshmen, sophomore, junior and senior years. This includes reviewing the overall curricular objectives, course objectives, course content, laboratory exercise, types of patients available for teaching, the number of patients assigned to students to work up each week, clinical skills students are required to master, and redundancy of curricular materials. In addition, the team attends basic science course lectures and laboratory sessions during the on-site inspection.

ACCM receives a formal updated database from the medical school in February each year (Exhibit 4). The school is required to answer a list of questions covering all major aspects of the governance of the school including information on medical programmes.

The country is not a member of the EC.
 
Analyst Remarks to Narrative
In the country’s narrative, they indicate that they are not a member of the EC. At SMU, the minimum number of weeks of instruction to obtain an M.D. degree is 147 weeks over four academic years. The Elements of Accreditation 2014 outlined by ACCM require a minimum of 130 weeks over four academic years.
 
Curriculum, Question 1
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 (Exhibit 1: Element 4, 5, 8, 9 & 11).
Element 4 states that “the programme shall provide a general and broad learning in the principal medical disciplines”.

Element 4 requires the Curriculum to include both didactic and practical instruction in the biomedical sciences disciplines representing – anatomy, histology, physiology, biochemistry, medical ethics, neuroscience, biostatistics, microbiology, immunology, pathology, pharmacology, therapeutics, preventive medicine and basic and translational research. ACCM requires the medical school to describe the programme content in the basic sciences, including laboratory and other practical opportunities for direct application of scientific methods, observation and critical analysis.

Administration of SMU runs an Introduction to Clinical Medicine (ICM) Course (Pre-Clinical Sciences) with a Chairman of the Department, 5 full-time and 21 part-time staff. The majority of the latter are Cayman Islands Hospital Consultants.

ACCM’s Protocol requires the on-site inspection team to review overall curricular objectives, course content, laboratory exercise, the types and number of patients available for teaching purposes. The team is also required to observe lectures and labs in a variety of basic and clinical sciences. The on-site evaluation team’s report must address the content and structure of the curriculum in meeting the medical school’s educational goals. It must also report on the role of the curriculum committee in overseeing the curriculum.

ACCM protocol requires inspection team to evaluate compliance through meeting with department chairs and course directors and attending the basic science departments’ course lectures and laboratory sessions (Exhibit 2: Sections VII, VIII, IX).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on requirements for medical programmes (Exhibit 4).
 
Analyst Remarks to Narrative
In the country's narrative, ACCM specifies that the Elements of Accreditation 2014 require each medical school to ensure that the acquisition of knowledge and skills for basic medical training are adequate for student learning. Furthermore the on site inspection team is required to review for compliance of these standards. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4), inspections carried out and onsite reports (Exhibit 7 P.10-15 & 29 P.10-15) written up.
 
Analyst Remarks to Response
Additional information provided in the narrative explains that a review is conducted related to reviewing the institution for adherence to the fundamental principles of medicine.

Documentation of the onsite inspection teams report demonstrates that curriculum was reviewed and 'radically updated' in 2010-2011 for the appropriateness of the educational goals of the medical school. Specifically key elements included integration between courses and semesters, more emphasis on team based learning, expanded lab experiences, enhanced preclinical focus, and increased focus on molecular medicine.
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 2
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 (Exhibit 1: Element 4, 5, 8, 9 & 11).
Element 4 states that “the programme shall provide a general and broad learning in the principal medical disciplines”.

Element 4 requires the educational programme relating to the basic sciences to include both didactic and practical instruction in the biomedical sciences disciplines representing – anatomy, histology, physiology, biochemistry, medical ethics, neuroscience, biostatistics, microbiology, immunology, pathology, pharmacology, therapeutics, preventive medicine and basic and translational research. ACCM requires the medical school to describe the programme content in the basic sciences, including laboratory and other practical opportunities for direct application of scientific methods, observation and critical analysis.

Administration of SMU runs an Introduction to Clinical Medicine (ICM) Course (Pre-Clinical Sciences) with a Chairman of the Department, 5 full-time and 21 part-time staff. The majority of the latter are Cayman Islands Hospital Consultants.

St Matthew’s Institutional Self Study (Exhibit 15): The basic sciences curriculum committee (BSCC) oversees all courses taught at all sites in the basic science years. This committee analyses the course content, evaluation methods and the results of courses. SMU recognises the importance of identifying professional values for its students at the didactic and personal levels. Professionalism therefore serves as a tool used to identify behaviours deemed as important in individuals in their role as students, practitioners and members of health care teams. These personal values and principle are emphasised in pre-clinical courses including introduction to psychiatry and ethics.

ACCM’s Protocol requires the on-site inspection team to review overall curricular objectives, course content, laboratory exercise, the types and number of patients available for teaching purposes (Exhibit 2). The team is also required to observe lectures and labs in a variety of basic and clinical sciences. The on-site evaluation team’s report must address the content and structure of the curriculum in meeting the medical school’s educational goals. It must also report on the role of the curriculum committee in overseeing the curriculum.

ACCM protocol requires inspection team to evaluate compliance through meeting with department chairs and course directors and attending the basic science departments’ course lectures and laboratory sessions. The team shall discuss and report on the college’s integration of the basic science and clinical sciences courses. Students at medical school must complete laboratory work in the areas of Gross Anatomy; Microscopic Anatomy; Neuro-anatomy; and Microbiology (Exhibit 2: Sections VII, VIII, IX).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on requirements for medical programmes (Exhibit 4).
 
Analyst Remarks to Narrative
The country's narrative and Elements of Accreditation 2014 appear to document the requirements under this guideline. A self-study from SMU explains the role and rigor of the basic sciences curriculum committee to ensure proper standards related to the education. The on-site inspection team is required to evaluates all aspects of the educational curriculum, including lectures and labs. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
The onsite ACCM team inspected and visited all laboratories within SMU and met with the majority of instructors.
ACCM team witness a range of lectures and practical demonstrations such as Anatomy, Histology and History taking. ACCM were satisfied that the standards of teaching and facilities were of a high standard.
 
Analyst Remarks to Response
Additional information provided in the narrative explains a review is conducted related to reviewing the institution for adherence to the basic sciences component of a medical program.

The provided onsite inspection teams report demonstrates that curriculum was reviewed and 'radically updated' in 2010-2011 for the appropriateness of the educational goals of the medical school. Specifically stated the onsite inspection team reports that the review of the new basic science curriculum is thought to result in a more effective use of student's time.

Additionally, in the narrative, ACCM discusses the facilities as a compliment to the student learning in the basic science curriculum. Documentation provided in the onsite inspection team report indicates a review and adequacy determination of the labs that includes large lecture halls, small-group study space, and expanded clinical skills laboratories.
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 3
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 (Exhibit 1: Element 4, 5, 8, 9 & 11).

SMU has an active Research Committee. Students are assigned research projects during their first Trimester and are required to finish them at the end of their second Trimester. Students may opt for a topic of their own choosing if they wish. Some of the Science Courses such as Evidence-based medicine (EBM) and Bio-statistics have a research component and can assist students with their project. Projects are graded and awards are given for the best projects. Students are encouraged to present their projects as poster or oral presentations (Exhibit 4).

ACCM Element 4 requires the “curriculum committee of faculty members to develop and evaluate a curriculum that provides a general medical education to prepare student to pursue further training at the graduate level.” Faculty must regularly assess the students’ clinical skills, knowledge, and attitudes. An assessment also must include the students’ ability to interpret clinical data, laboratory data, radiographic data, to solve patient problems and to develop simple manage plans. To broaden the focus of “the clinical programmes, the school shall introduce principles in the practice of medicine in one field, [that] incorporates diagnostic and therapeutic techniques from other clinical areas, using an integrated and multidisciplinary approach” (Exhibit 1).

ACCM’s Protocol requires the on-site inspection team to review overall curricular objectives, course content, laboratory exercise, the types and number of patients available for teaching purposes (Exhibit 2). The team is also required to observe lectures and labs in a variety of basic and clinical sciences. The on-site evaluation team’s report must address the content and structure of the curriculum in meeting the medical school’s educational goals. It must also report on the role of the curriculum committee in overseeing the curriculum. ACCM protocol requires inspection team to evaluate compliance through meeting with department chairs and course directors and attending the basic science departments’ course lectures and laboratory sessions (Exhibit 2: Sections VII, VIII, IX).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on requirements for medical programmes (Exhibit 4).
 
Analyst Remarks to Narrative
Research and scholarly activity are embedded in the requirements for the medical degree in the Cayman Islands. In the country's narrative, they explain that students are assigned research projects during their first trimester and that there are additional opportunities for research in the science courses. Scholarly activity is infused in the curriculum and a consideration of the on-site inspection team. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM inspection team was provided with Minutes of the research committee during onsite inspection.
ACCM met with the Chairman of the research committee and were satisfied that students were able to do some limited research in the context of their busy study schedules. We also saw during our visit some poster presentations by students based on their research.
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4, 30 & 32 (Appendix 2 Committee Meeting Minutes 2013-2014), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
Additional information provided in the narrative explains that research is an important consideration. The narrative explains that during the onsite inspection team visit they met with Dr. B. Robson as the chair of the research committee. Documentation of the research committees meeting minutes was provided.

The provided onsite inspection teams report does demonstrate that research was reviewed by the team during their visit. Specifically, it indicates that there is a research lab which is available to students who are encouraged to be involved with research projects either independently or supported by faculty members. Also, it is encouraged of faculty and students to engage in research activity which furthers their knowledge of the process of science, improves the art of medicine, and increases their appreciation of the balance between research and the artful practice of medicine.
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 4
 
Country Narrative
ACCM Element 4: (Exhibit 1) requires each medical school to provides “oversight over the learning experience of clinical students”, which is defined in various aspects of the Elements, and requires the involvement of the college’s curriculum committee in ensuring that the faculty oversees instructional programmes for active learning and independent study to enable students develop the necessary skills for lifelong learning.

Starting with Semester 1, SMU introduces students to the concept of life-long, self –directed learning. Students are instructed in how to access additional support with study skills, goal setting and self assessment. The school provides students with an online platform that incorporates lecture notes and slides, provides email and other communication forums (Exhibit 15: p. 37).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on medical school’s programme (Exhibit 4).
 
Analyst Remarks to Narrative
The country discusses in its narrative the Elements of Accreditation 2014 that includes Element 4.1.7, which states: "There must be opportunity for active learning and independent study to foster the skills necessary for lifelong learning. The country establishes "lifelong learning" as one of its components of the curriculum. However, no documentation was provided to demonstrate how ACCM applies its lifelong learning standards at the institutions.

NCFMEA may wish to request documentation that demonstrates ACCM’s application of its lifelong learning standards under this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Self-Study (Exhibit 15 P.37-39), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
Additional information provided in the narrative explains that learning is an important consideration. Documentation of the onsite inspection teams report demonstrates that the team reviewed the curriculum for independent study. Specifically noted in the report is that there is “a research lab which is available to students who are encouraged to be involved with research projects either independently or supported by faculty members.”
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 5
 
Country Narrative
Element 4: (Exhibit 1) ACCM requires each medical school to provides “oversight over the learning experience of clinical students”, which is defined in various aspects of the Elements, and requires the involvement of the college’s curriculum committee in ensuring that the faculty oversees the workup of patients by students.

Oversight shall consist of: provision of a structured environment for students to work, an academic controlled organisation and supervision by faculty. There should be defined period of clerkship and adequacy of time for study. The faculty of the medical school should ensure practice opportunities (including practical procedures), monitoring of students clinical experience, fostering problem solving skills, observing student performance and offering timely remediation. The oversight of students includes attendance records and, most importantly, the encouragement required to ensure professional attitudes consistent with patient care.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on medical school’s programme (Exhibit 4).
 
Analyst Remarks to Narrative
In the country's narrative, they provided documentation of the SMU Core Subjects List. The basic sciences are reviewed as part of the on-site inspection team review. In addition to observation, the country sites in its narrative that the inspection team ensures compliance through meetings with course directors and department chairs. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
Students are taught to independently research the literature, study independently or with other groups of students.
 
Analyst Remarks to Response
While documentation provided indicates that service learning to the community is a factor in the admissions to the program, there is no indication of service learning of medical students during the program. The self-study provided by SMU, it also indicates the significance of service provided by faculty members both within the university and community. In an earlier narrative response to another guideline (mission and objectives, question 1), it was stated that “during their time on campus, St. Matthew's University students are encouraged to become involved in local Community Projects (for example: with Cayman Heart Foundation, whose office in based in the local hospital).”

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Staff Conclusion: Additional Information requested
 
Curriculum, Question 6
 
Country Narrative
The medical school is required to include the following subjects in the basic sciences (Exhibit 4: p.p.8-11) (Exhibit 27 p.p.1-3). ACCM’s Protocol requires the on-site inspection team to review overall curricular objectives, course content, laboratory exercise, the types and number of patients available for teaching purposes. The team is also required to observe lectures and labs in a variety of basic and clinical sciences. The on-site evaluation team’s report must address the content and structure of the curriculum in meeting the medical school’s educational goals. It must also report on the role of the curriculum committee in overseeing the curriculum.

ACCM protocol requires the inspection team to evaluate compliance through meeting with department chairs and course directors and attending the basic science departments’ course lectures and laboratory sessions. The team shall discuss and report on the college’s integration of the basic science and clinical sciences courses. Students at medical school must complete laboratory work in the areas of Gross Anatomy; Microscopic Anatomy; Neuro-anatomy; and Microbiology (Exhibit 2 Sections VII, VIII, IX).

SMU has an active Research Committee. Students are assigned research projects during their first Trimester and are required to finish them at the end of their second Trimester. Students may opt for a topic of their own choosing if they wish. Some of the Science Courses such as Evidence-based medicine (Capital EBM) and Bio-statistics have a research component and can assist students with their project. Projects are graded and awards are given for the best projects. Students are encouraged to present their projects as poster or oral presentations.

ACCM receives a formal updated database from the medical school in February each year.The school is required to answer a list of questions covering all major aspects of the governance of the school including information on subjects in the basic sciences (Exhibit 4).
 
Analyst Remarks to Narrative
In the country's narrative, they provided documentation of the SMU Core Subjects List. The basic sciences are reviewed as part of the on-site inspection team review. In addition to observation, the country sites in its narrative that the inspection team ensures compliance through meetings with course directors and department chairs. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
The onsite inspection teams report demonstrates that the basic science curriculum was reviewed in 2010-2011 for the appropriateness of the educational goals of the medical school. Further provided in the onsite inspection team report was discussion of a robust variety of courses offered at SMU. The self-study SMU provided discusses student involvement in research projects related to the basic sciences.
 
Staff Conclusion: Comprehensive response provided
 
Curriculum, Question 7
 
Country Narrative
ACCM’s Protocol (Exhibit 2) requires the on-site inspection team to review overall curricular objectives, course content and laboratory exercises. The team is also required to observe lectures and labs in a variety of basic and clinical sciences. The on-site evaluation team’s report must address the content and structure of the curriculum in meeting the medical school’s educational goals. It must also report on the role of the curriculum committee in overseeing the curriculum. The protocol requires the inspection team to evaluate compliance through meeting with department chairs and course directors and attending the basic science departments’ course lectures and laboratory sessions. The team shall discuss and report on the college’s integration of the basic science and clinical sciences courses. Students at medical school must complete laboratory work in the areas of Gross Anatomy; Microscopic Anatomy; Neuro-anatomy; and Microbiology

The laboratory portion of the basic sciences curriculum requirements are:

Anatomy: Dissected, plastinated, cadaveric specimens and plastic models are used to demonstrate topographical anatomy, along with radiological images. Ultrasound is used to demonstrate location and appearance of normal organs.

Histology: The students learn to use the microscope to identify various tissues. Virtual microscopy is also used to examine normal cells and tissues.

Neuroscience: Plastinated specimens and plastic models are used. MRI images are taught in the didactic sessions via slide projection.

Biochemistry: no laboratory classes.

Physiology: laboratory classes utilizing EKG, blood pressure measurement and physical exams for respiratory system and cardiovascular system.

Pharmacology: no laboratory classes.

Microbiology: Students learn how to plate out specimens and to perform Gram
and other stains.

Pathology: Gross specimens are taught in didactic sessions via slide projection. Microscopic structures of diseased tissues are taught via virtual microscopy.

Clinical Therapeutics: CT labs complement topics learned in ICM course by covering clinical and treatment scenarios.

Behavioural Science and Ethics: Laboratory exercises allow students to practice assessing and recommending treatments for patients with psychiatric disorders, including performing a mental status exam and writing a comprehensive psychiatric evaluation.

Clinical Skills Courses:

PD1: Communication Skills: Patient Centred History, Physician Centred History,

Techniques of Examination, Vital Signs, MSK History taking and physical examinations

PD2: Vital Signs, Neuro History-taking and physical examination.

PD3: History taking and physical of ENT, CVS, PVD, GIT, MGS, Breast, Pediatrics.

ICM: History taking and Physical of Respiratory system, CVS, GIT, Neuro, Nephrology and Urology, Rheumatology, Obstetrics and Gynecology and Pediatrics.

Protocol: The present information is based on ACCM site inspections (Exhibit 2: Sections VII, VIII, IX).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on the Curriculum (Exhibit 4 p.p.12-17).
 
Analyst Remarks to Narrative
In the country’s narrative, they provide outcomes that provide medical graduates with a variety of medical skills (e.g. taking blood pressure, capturing specimens, etc.) that are pertinent for wide exposure in the field. Additionally, they state that students gain from the laboratory experiences other skills that allow them to develop their communication abilities and review ethical clinical and treatment scenarios.
 
Clinical Experience, Question 1
 
Country Narrative
Response to 1st Question:
ACCM Element 4 requires the “curriculum committee of faculty members to develop and evaluate a curriculum that provides a general medical education to prepare student to pursue further training at the graduate level.” Faculty must regularly assess the students’ clinical skills, knowledge, and attitudes. An assessment also must include the students’ ability to interpret clinical data, laboratory data, radiographic data, to solve patient problems and to develop simple management plans. To broaden the focus of “the clinical programmes, the school shall introduce principles in the practice of medicine in one field, [that] incorporates diagnostic and therapeutic techniques from other clinical areas, using an integrated and multidisciplinary approach” (Exhibit 1: Element 4).

2nd part of 1st Question regarding subjects:
Element 4 requires a medical school to include the following clinical science subjects in its curriculum:
• Internal medicine (not less than 12 weeks)
• Surgery (not less than 12 weeks)
• Paediatrics (not less than 6 weeks)
• Obstetrics and gynaecology (not less than 6 weeks)
• Psychiatry (not less than 6 weeks)
• Family medicine (not less than 4 weeks), whether offered as a separate course or integrated into the five major clinical disciplines above
• Clinical electives (not less than 26 weeks)

Response to 2nd Question:
ACCM Element 4 requires the college to offer clinical programmes oriented towards primary care (Exhibit 1). The medical college must consistently and equally administer the programme under close faculty supervision of patient care in the hospital and ambulatory facilities at all affiliated hospitals. Clinical instruction must be carried out in both inpatient and outpatient settings. To ensure that students have acquired the core clinical skills specified in the school’s educational programme objectives, second semester students at the medical school are taught to perform the special skills necessary in focused ear/nose and throat, cardiovascular, respiratory, neurological, gastrointestinal, male and female genitourinary, musculoskeletal and endocrine examinations. The programme design must provide the student with daily patient census representing a broad range of commonly occurring diseases. Also, the school must provide oversight of the learning experience and stipulate the types of patients or clinical conditions that the student must have in accordance with the clerkship objectives.

In designing clinical clerkships, Element 4 encourages the programme to encourage students to master medical sciences, clinical skills, and to develop professional demeanour for graduate training. The programme design prepares students for careers as physicians devoted to the delivery of primary care and to continue a life-long habit of learning. To maintain patient trust and public confidence, this element requires the faculty to develop the appropriate professional attributes expected by the public and physicians and to teach students to uphold the highest standards of behaviour, conduct integrity and ethics. Oversight of students by the curriculum committee should stipulate the types of patients or clinical conditions that the students must see and ensure that its faculty oversees workups of patients by clinical students in the wards and clinics. Therefore, faculty members from the medical school who report to the chief of the department or the course director should staff each discipline. The facilities for clinical training should include accredited hospitals, of sufficient size, quality and accessibility to serve the needs of the institution to have a professionally managed and a well-stocked library and offer classroom facilities. Medical schools must maintain – in force at all times - an affiliation agreement with each health care facility where students are present. Every medical school should define and distribute to students and the supervising faculty members a list of learning objectives and types of patients or clinical condition that students must see during the clerkship (Exhibit 1).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on clinical experiences (Exhibit 4 p.p.14-17).

Answer to 3rd Question:
Element 4 (Exhibit 1) states that “in designing clinical clerkships, the curriculum committee shall require all clinical instruction be carried out in both inpatient and outpatient settings. There shall be adequate daily patient census representing a broad range of commonly occurring diseases available for students to study. Instruction shall be supervised by the faculty and shall be centred on patients and their illnesses”. All instruction shall offer adequate numbers of hours of 1) lectures, 2) conferences 3) faculty teaching rounds, 4) resident rounds each week. There should be 5) adequate number of new patients to work up each week, 6) adequate number of existing patients to follow each week and 7) adequate faculty review and critique of students workups and presentations of patients. Furthermore all clerkships shall maintain patient logs to monitor the number and variety of patient seen by the students”.

SMU provides clinical instructions covering all these aspects (Exhibit 27 p.p. 4-13).
 
Analyst Remarks to Narrative
The country states in its narrative that medical programs in the Cayman Islands all require clinical science subjects in the curriculum that range from 4-26 weeks on the following topics: internal medicine, surgery, pediatrics, obstetrics, psychiatry, family medicine, and other clinical electives.

The country has provided documentation of its Elements of Accreditation 2014 that outlines standards related to the student's clerkship experience. The clinical science core is taught in conjunction with the curriculum, students are exposed to a variety of medical aspects pertinent for the field. Documentation of these subjects is provided in the SMU core subject listing.
 
Clinical Experience, Question 2
 
Country Narrative
Element 4: (Exhibit 1) ACCM requires each medical school to provides “oversight over the learning experience of clinical students”, which is defined in various aspects of the Elements, and requires the involvement of the college’s curriculum committee in ensuring that the faculty oversees the workup of patients by students.

Oversight shall consist of: provision of a structured environment for students to work, an academic controlled organisation and supervision by faculty. There should be defined period of clerkship and adequacy of time for study. The faculty of the medical school should ensure practice opportunities (including practical procedures), monitoring of students clinical experience, fostering problem solving skills, observing student performance and offering timely remediation. The oversight of students includes attendance records and, most importantly, the encouragement required to ensure professional attitudes consistent with patient care.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on medical school’s programme (Exhibit 4).
 
Analyst Remarks to Narrative
In the country’s narrative, they state the significance of the clerkship experience and other practice scenarios in the classroom for assuring that the students have practiced the necessary needed skills. Also, included in their Elements of Accreditation 2014 is Element 1.1.4(c) that states institutional goals should include "graduates having acquired the professional attributes (knowledge, skills, attitudes and behaviors) expected by the academic community and society of a physician.” They require the institution to provide an annual database that measures data related to the medical school and is used for determining effectiveness of the program.
 
Clinical Experience, Question 3
 
Country Narrative
Answer to Question 1:
ACCM is concerned that the medical school and hospital “should give students opportunities to practice and develop clinical skills and concepts. The faculty must assign to each student 13-16 new patients to work up every week (i.e. such as taking patient histories, performing physical examinations, data collection and developing simple management plans)” (Exhibit 1: Element 4). The faculty should also require students to write orders to be promptly reviewed and corrected by faculty. In a country such as the UK, where laws prohibit medical students from writing orders, the college may fulfil this provisional by substituting, for example, patient logs.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on medical school’s programme (Exhibit 4 p.p. 12-17, 23-30).

Answer to Question 2:
ACCM Protocol requires ACCM inspection team to examine the medical school’s oversight of clinical students in different wards and clinics in different hospitals, determining whether the school provides a structured learning environment, whether the clinical departments are staffed by physicians who are faculty members of the medical school, whether the school defines and distributes to students and supervising faculty a list of learning objectives at the beginning of each clerkship, etc. (Exhibit 2: Sections VII, VIII, IX) . The team is also required to examine the number of new patients assigned to students each week and the methods used by the faculty to critique students’ performance in their clerkship. The ACCM team is required to review the specific clinical departments providing clerkships. This includes meeting with faculty and tours of facilities. In its report, the team must address all of these items (Exhibit 18). For example, it must describe the number of hours of clerkships as well as the percentage of time devoted to inpatient and outpatient learning, the methods and the frequency of student evaluation etc., the comparability of learning in the main campus with those in hospital surroundings. The faculty must monitor students in ward teaching rounds, case conferences mortality and morbidity conferences, medical rounds, lectures and small group teaching. The faculty must regularly assign and critique student case presentations. The must regularly review patient logs to ensure each student is exposed to a variety of patients and diseases. The faculty should insist on active student participation in the process of identifying patient illnesses and developing management plans. The faculty should also regularly critique student performance and offer systematic, targeted and timely feedback so that students can improve their skills day-by-day. All St. Matthew’s University courses in the 3rd (core) and 4th (elective) years are taught in hospitals in the US and UK. The ACCM apply the same criteria as mentioned above and elsewhere to standards. They also apply the same directives as those in the Affiliated Hospital Site Questionnaire (Exhibit 8).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on medical school’s programme (Exhibit 4 p.p. 12-17, 23-30) (Exhibit 21).
 
Analyst Remarks to Narrative
In the country's narrative, they state the onsite inspection team reviews both outpatient and inpatient learning. Additionally, the Elements of Accreditation 2014, Element 4.4 on Clinical Clerkships states, "In designing clinical clerkship, the curriculum committee shall require all clinical instruction be carried out in both inpatient and outpatient settings."

Additional information provided in the Curriculum section, cites the multidisciplinary subjects that are taught in throughout the curriculum. However, the included exhibit titled 'ACCM Inspection of Core Rotations at North Virginia Mental Health Institute' indicates that there are no outpatient services offered at this site. In another exhibit, Clinical Chief Site Visit Summary for St. Agnes Hospital it cites both outpatient and inpatient learning. There is no additional information that supports how a student at North Virginia Mental Health Institute is able to gain outpatient experience

More information is needed from the country to clarify the country's requirements under this section.
 
Country Response
North Virginia mental health institution does not presently have any outpatient clinics. However, some of the staff psychiatrists at this institution have outpatient clinics outside the institution. They are currently looking at this possibility with St. Matthew’s University, of allowing students to attend these clinics. Although there is no outpatient facility, the inpatient psychiatric facilities and teaching experience are exceptional.
ACCM inspects different hospital sites providing different core rotations and a number of reports are enclosed demonstrating outpatient experience (Exhibit 33).
 
Analyst Remarks to Response
Documentation provided in the narrative indicates that North Virginia Mental Health Institute (NVMHI) does not presently offer outpatient clinics. The narrative explained that some of the staff who work at NVMHI, are affiliated with settings that do have those services outside of this clinic, and that some discussion has occurred about affording this opportunity to students who complete their clerkship at NVMHI. Additional documentation showcases the review of outpatient services at another clerkship site, Whipps Cross University Hospital.

While it is noted in the narrative about the superior quality of NVMHI, it is contrary to what is stated in ACCM's standards for clerkship experience for its students. NCFMEA may wish to request follow up information on the status of the conversations with NVMHI and/or discuss other means of student exposure to outpatient services for students that complete their clerkship at NVMHI.
 
Staff Conclusion: Additional Information requested
 
Supporting Disciplines
 
Country Narrative
As part of the students training in Clinical Medicine during their introduction to Clinical Medicine Courses on campus and during their hospital rotations, they are expected to be instructed in diagnostic imaging, clinical pathology and other relevant diagnostic modalities.

ACCM Element 4 “A curriculum committee of faculty members shall be responsible for developing and evaluating a curriculum that provides a general medical education so that its students are prepared to pursue further training at graduate level (Exhibit 1). The fundamental scientific knowledge of medicine shall also include new discoveries, new technologies, new understanding of disease, new diagnostic techniques and new methods of treatment. In order to avoid curricular isolation and narrowness of focus, the clinical programmes shall introduce principles in the practice of medicine in one field, which incorporates diagnostic and therapeutic techniques from other clinical areas, in an integrated and multidisciplinary approach”. Students are commonly advised in their 4th year to take an elective in a subject they wish to know more about (Exhibit 12).

The college should provide a structured environment for students to learn and work. Each discipline should be staffed by faculty members from the medical school who report to the chief of department or the course director. Regarding the medical facilities for the clinical training of students, Element 4 requires medical schools to secure access to hospitals and to emphasise ambulatory facilities. These facilities shall recommend hospitals accredited by such bodies as the ACGME and the British NHS in all clinical disciplines where undergraduate medical education is offered. Element 4 further requires the institution’s affiliated clinical teaching to be “of sufficient size, quality and accessibility to serve the needs of the institution”, to have a professionally managed and well-stocked library and to offer classroom facilities. Medical schools are required to “maintain -in force at all times- an affiliation agreement with each health care facility where students are present”. The medical school should define and distribute to students and the supervising faculty members a list of learning objectives and types of patients or clinical conditions that must be seen upon commencement of each clerkship. Core Syllabi for each rotation are supplied to students and faculty.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including educational experience (Exhibit 4).
 
Analyst Remarks to Narrative
In the country’s narrative, they explain that students receive instruction in diagnostic imaging, clinical pathology and other relevant diagnostic modalities. The country has included the Elements of Accreditation 2014 which outlines standards for institutions to ensure that the disciplines support general medical practice. Additional documentation includes ACCM’s guide to the institutional self-study that include several questions that ask about ways in which the institution meets the requirements of this guideline.
 
Ethics, Question 1
 
Country Narrative
Answer to Question 1:
Element 4 requires the clinical curriculum to include topics of special concern to society and the practice of medicine that includes, among other things, medical ethics, death and dying, domestic violence, alcohol and substance abuse, obesity, child abuse, human sexuality, public health, cost management, mental health issues, health maintenance, and geriatrics (Exhibit 1). SMU teaches epidemiology as a basic science course, while medical ethics is taught in the hospital by a preceptor. The programme design prepares students for graduate training and for careers as physicians devoted to the delivery of primary care. Ethical issues are covered in all clinical modules where relevant.

Answer to Question 2:
The design of the programme shall encourage students to master medical sciences, clinical skills, and to develop a professional demeanour for graduate training. The design of the programme shall also prepare students for careers as physicians devoted to the delivery of primary care. This programme incorporates an understanding of medical ethics and human values.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including monitoring and evaluation (Exhibit 4).
 
Analyst Remarks to Narrative
As outlined in the country's narrative, requirements regarding medical ethics and human values are embedded throughout the country's framework, particularly in competencies of intelligence, integrity, personal and emotional characteristics.
 
Communication Skills, Question 1
 
Country Narrative
Answer to Question 1:
To ensure that students possess the intelligence, integrity, personal and emotional characteristics perceived as necessary to become effective physicians, ACCM Element 6 requires that medical schools admit only those new and transfer students with these attributes. The school’s admission committee must assess the proficiency of an applicant’s writing skills and verbal communication skills as part of the admissions process. ACCM Element 4 defines professional support and encouragement. Supervising faculty members are expected to act as mentors and regularly demonstrate to students the values, attitude, and conduct physicians must practice in order to develop trusting working relationship with patients. Therefore “faculty should regularly observe, critique, and promote and evaluate the development of appropriate professional attributes in clinical students.” (Exhibit 1, Element 4 & 6).

Answer to Question 2:
To evaluate student promotion, Element 5 requires the supervising faculty, by direct interaction, to evaluate the student’s professional demeanour, behaviour and working relationships with patients, family of patients, colleagues, and other health care professionals (Exhibit 1, Element 4, 5 & 6).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including monitoring and evaluation (Exhibit 4 p.p.18-22).
 
Analyst Remarks to Narrative
In the country's narrative, they stress the importance of ensuring that students are proficient in both written and oral communication. In addition, the communication skills students are evaluated throughout their tenure with the medical program, beginning with the admissions process. The Elements of Accreditation 2014, Element 4.1.8 states, "the curriculum shall promote the development of problem solving skills, communication skills, procedural competency an understanding of the principles of basic and translational research, and ethics as applied to medicine, and access to service learning opportunities." This is further articulated in Element 4.3.7 that states, "the clinical program will continue to develop the students' communication skills, including communications with patients and their families, colleagues and other health professionals."
 
Design, Implementation, and Evaluation, Question 1
 
Country Narrative
ACCM Element 4 requires the medical school to have a curriculum committee of faculty members who shall be responsible for developing and evaluating a curriculum that provides a general medical education to prepare its graduates to pursue further training and for careers as physicians devoted to the delivery of primary care (Exhibit 1). The system to evaluate the curriculum requires the curriculum committee to evaluate continuously curriculum weaknesses, goals, content, effectiveness, method of instruction and the degree to which the institutional achieves its goals. A school may measure the effectiveness of the curriculum by student attrition rate, student performance on standardized examinations, percentage of eligible graduates passing the USMLE and professional licensing examinations, percentages of graduates accepted into residency training programmes, follow up of graduates in employment and sampling the opinions of students and graduates. The curriculum committee of faculty may use these data sources to strengthen the curriculum. For example: Based on first time takers in 2013-2014 the pass rate on the USMLE Step 1 examination was 94% and for all takers the total pass rate for the same period was 95% percent (Exhibit 4 p.p.6-7).

SMU Annual Database Report 2013-2014 states “Students entering 5th semester are require to pass USMLE Step 1 prior to entering the clinical science semesters. The NBME subject shelf tests are now used in Basic Sciences, Introduction to Clinical Medicine (ICM) and all Clinical Sciences courses. SMU requires students to pass USLME Step 2 on completion of studies. First time Pass Rates of 92% in CK and 89% in CS from 1st July 2013 to 30th June 2014 were achieved by SMU students. SMU graduates from July 2013 through June 30 2014 had a 75 % residency placement in a large number of residency programmes. Residency Programmes where SMU residents have been accepted include Brown University, John Hopkins, Vanderbilt, McGill and others (Exhibit 15: p. 53-54 & Appendix 16) (Exhibit 4 p.p.18-32). ACCM Protocol requires inspection team to evaluate the effectiveness of the institution’s system of programme evaluation by appraising the programme outcomes and the mechanisms used to collect information and the extent to which the institution uses the information to improve the curriculum and instruction (Exhibit 2).
 
Analyst Remarks to Narrative
According to the Elements of Accreditation 2014, the institution is expected to have faculty committees in place, one of which conducts oversight and development of the curriculum. They require the institution to provide and review an annual database that measures data related to the medical school as it relates to assessing curriculum. However, no documentation was provided to demonstrate ACCM’s review and assessment of the curriculum committees review of curriculum at the institution.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the curriculum under this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4, 30, 31 & 32 Appendix 2 Committee Meeting Minutes 2013-2014) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
Additional information provided in the narrative explains that the onsite inspection team receives curriculum information to review prior to the visit. Additionally, it is explained that the inspection team meets with department chairs to review the curriculum and with students to allow them to voice their opinions related to the teaching they receive.

The onsite inspection teams report demonstrates that curriculum was reviewed in 2010-2011 for the appropriateness of the educational goals of the medical school. Further provided in the onsite inspection team report was that the team met with a group of students who were ‘happy with the teaching and facilities of the university.’ There have been no student complaints filed. The onsite inspection team report indicates that meetings were held with new faculty and with the Department chairs, as specified in the narrative.

Also included in the narrative, is a statement that indicates that the curriculum was last updated in 2013. No documentation was included for the 2013 curriculum review.
 
Staff Conclusion: Comprehensive response provided
 
Design, Implementation, and Evaluation, Question 2
 
Country Narrative
Answer to Question 1:
Yes. The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014, Element 4 & 8 (Exhibit 1) requiring schools to have its own system for evaluation which is covered in St. Matthew’s Institutional Self-Study Questionnaire (Exhibit 15).

ACCM Protocol requires the inspection team to review and report on the institutions system of programme evaluation (Exhibit 2 Section VII, VIII & IX). The team reports on the indicators utilized by the curriculum committee to appraise programme outcomes such as scores on exams including standardized and licensed exams, graduation rates, residency acceptance rates, the employment status of graduates, student and graduate surveys. The team reports on the mechanisms used by the institution to monitor the quality of instruction and the breadth and depth of course content, the mechanisms used to collect information, and to what extent the institution has used the information to appraise and improve curriculum courses and instruction (Exhibit 7 & 9, 24 & 25).

Answer to Question 2:
No, ACCM does not mandate the evaluation of the curriculum all medical schools to be provided by some centralized authority or body as it carries out its own evaluation.
 
Analyst Remarks to Narrative
The requirements for medical school curricula are delineated in the Elements of Accreditation 2014. The on site inspection teams review the school for compliance with the standards as outlined. In the country’s narrative, they indicate that ACCM does not have a mandate for the evaluation of the curriculum by a centralized authority.
 
Design, Implementation, and Evaluation, Question 3
 
Country Narrative
Answer to Question 1:
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 (Exhibit 1: Element 4 & 8). Element 4 requires the medical school to have a curriculum committee of faculty members who shall be responsible for developing and evaluating a curriculum that provides a general medical education to prepare its graduates to pursue further training and for careers as physicians devoted to the delivery of primary care (Exhibit 1). The system to evaluate the curriculum requires the curriculum committee to evaluate continuously curriculum weaknesses, goals, content, effectiveness, method of instruction and the degree to which the institutional achieves its goals. A school may measure the effectiveness of the curriculum by student attrition rate, student performance on standardized examinations, percentages of graduates accepted into residency training programmes, percentage of eligible graduates passing the USMLE and professional licensing examinations follow ups of graduates in employment and sampling the opinions of students and graduates. The curriculum committee of faculty may use these data sources to strengthen the curriculum. For example: Based on first time takers in 2013-2014 the pass rate on the USMLE Step 1 examination was 94% and for all takers the total pass rate for the same period was 95% percent (Exhibit 4 p.p.6-7).

Annual Database Report 2013-2014 states “Students entering 5th semester are require to pass USMLE Step 1 prior to entering the clinical science semesters. The NBME subject shelf tests are now used in Basic Sciences, Introduction to Clinical Medicine (ICM) and all Clinical Sciences courses. SMU requires students to pass USLME Step 2 in order to graduate. Pass Rates of 92% in CK and 89% in CS from 1st July 2013 to 30th June 2014 were obtained by first time takers at SMU. SMU from July 2013 through June 30 2014 had a 75 % residency placement of those who applied to the National Residency Matching Program (NRMP) (Exhibit 4 p.p.20, 31-32). 26 students chose alternate career paths, such as administration or doctoral programmes.

ACCM Protocol requires inspection team to evaluate the effectiveness of the institution’s system of programme evaluation by appraising the programme outcomes and the mechanisms used to collect information and to the extent that the institution uses the information to improve the curriculum and instruction (Exhibit 2 Section VII, VIII & IX).

Answer to Question 2:
ACCM Protocol requires the inspection team to review and report on the institutions system of programme evaluation (Exhibit 2 Section VII, VIII & IX). The team reports on the indicators utilized by the curriculum committee to appraise programme outcomes such as scores on exams including standardized and licensed exams, graduation rates, residency acceptance rates, the employment status of graduates, student and graduate surveys. The teams report on the mechanisms used by the institution to monitor the quality of instruction and the breadth and depth of course content, the mechanisms used to collect information, and to what extent the institution has used the information to appraise and improve curriculum courses and instruction.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including programme effectiveness (Exhibit 4). By comparing these annual databases and other reports (Exhibit 7 & 9, 24 & 25), ACCM can continually assess data to ensure programme effectiveness and continuous improvement.
 
Analyst Remarks to Narrative
As stated in the country's narrative, the Elements of Accreditation 2014 set the standards for determining appropriateness of identified targets. ACCM requires each institution to provide and review an annual database that measures data related to the medical school. In the narrative, they specifically mention the following measures: student attrition rate, student performance on standardized examinations, percentages of graduates accepted into residency training programs, percentage of eligible graduates passing the USMLE, and professional licensing examinations follow ups of graduates in employment and sampling the opinions of students and graduates.

The Protocol for the Accreditation of Colleges of Medicine 2012, states that "the inspection team also is responsible for generating a written inspection report that identifies strengths, weaknesses of the medical college, and recommendations for improvement." It was also explained, that ACCM reviews the information collected in the annual database to determine if additional sources of improvements can be made. However, no documentation (such as the on site teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrate ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
As stated in the country's narrative, the Elements of Accreditation 2014 set the standards for determining appropriateness of identified targets. ACCM requires each institution to provide and review an annual database that measures data related to the medical school. In the narrative, they specifically mention the following measures: student attrition rate, student performance on standardized examinations, percentages of graduates accepted into residency training programs, percentage of eligible graduates passing the USMLE, and professional licensing examinations follow ups of graduates in employment and sampling the opinions of students and graduates.

The Protocol for the Accreditation of Colleges of Medicine 2012, states that "the inspection team also is responsible for generating a written inspection report that identifies strengths, weaknesses of the medical college, and recommendations for improvement." It was also explained, that ACCM reviews the information collected in the annual database to determine if additional sources of improvements can be made. However, no documentation (such as the on site teams report) was provided to demonstrate ACCM's review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrate ACCM's review and assessment of the institutions relative to this guideline.
 
Staff Conclusion: Comprehensive response provided
 
Admissions, Recruiting, and Publications, Question 1
 
Country Narrative
Answer to Question 1:
ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including MCAT results (Exhibit 4 p.4-5). The total mean MCAT scores for all students admitted in 2014 was 20. We do not have routinely available the number of times that each student has taken MCAT.

Answer to Question 2:
ACCM Element 6 (Exhibit 1) requires that students must have taken a medical school admission test such as MCAT as part of medical schools admission practices to ensure they have the competency to become effective physicians.
 
Analyst Remarks to Narrative
As stated in the country's narrative, ACCM requires each institution to provide and review an annual database that measures data related to the medical school that includes a mean MCAT score. They indicate that they do not collect the number of times that a student has taken the MCAT. Additionally explained, the country indicates that taking a test such as the MCAT is a consideration for admissions.

NCFMEA may wish to request that ACCM consider collecting data on the number of times that the student has taken the MCAT.
 
Country Response
The school collects an MCAT transcript from prospective students which include information on all takes of the MCAT for that student. The transcript and its information is part of the consideration of a student in the admissions process. The school’s database only records a single MCAT score for applicants. The MCAT transcript, however, becomes part of each student’s permanent application file.
ACCM intends to request this data on the number of times that the student has taken the MCAT in the future as part of the Annual Database information that is reviewed each year.
 
Analyst Remarks to Response
The narrative describes that MCAT transcripts are collected from all prospective students that includes the number of attempts to take the MCAT. The current annual database collected from the institution only includes a single score on MCAT. It is indicated that this will be added to the annual database request for the future.

NCFMEA may wish to follow up to determine if this information is included in the future as part of the Annual Database information that is reviewed each year.
 
Staff Conclusion: Additional Information requested
 
Admissions, Recruiting, and Publications, Question 2
 
Country Narrative
Answer to Question 1:
ACCM has established requirements for medical school student admissions in Element 6 (Exhibit 1) and it states the following:
At a minimum, admitted students shall possess three years of undergraduate education, including the completion of one year each of biology (with lab), physics (with), English, and two years of chemistry (with lab). Students may concentrate their undergraduate studies in any field of interest. However, a baccalaureate degree is preferred.
Individuals shall:
Be in good physical and mental health.
Possess:
A record of academic excellence,
A good personal character,
Standards of behaviour and conduct that will reflect favourably on themselves and on the medical profession,
Personal integrity,
Appropriate motivation and the sincere desire to serve their fellow man.

In addition, ACCM Element 6 suggests that the admissions committee develop a process to evaluate and screen applicants for the attributes and characteristics cited above in an orderly process that is applied uniformly. ACCM encourages the admissions committee to conduct personal interviews in which screening of applicants includes, among other things, the following:
Grade point averages
The type and degree of difficulty of courses taken
Scores on the medical school admission test
Proficiency of the applicant’s writing skills
Proficiency of the applicant’s communication skills
Evaluations from college pre-professional committees or undergraduate faculty members

Regarding readmission, Element 6 requires the institution to define its policy regarding students who were suspended or dismissed for academic and non-academic reasons. ACCM requires the institution’s policy and criteria for readmission to meet or exceed its admissions standards on aptitude, health, character, and motivation. Also, ACCM requires medical school to define its policy on acceptance of transfer credits and not permit a transfer to occur beyond the sophomore year.

During the on-site inspection, ACCM protocol requires the team to report on the school’s admission policies, student selection requirements, the structure and role of the admission committee in the admission process, the demographics of the freshman class over a three-year period, implementation of the school’s readmission policies and policies on the admission of transfer students (Exhibit 2: Section VII, VIII, IX). ACCM also monitors the application pools, GPA and MCAT categories of present and projected students lists provided by the institution in the Annual Database Report (Exhibit 4: p.p. 3-5).

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including admission requirements (Exhibit 4).

Answer to Question 2:
These are national admission standards as ACCM is the accrediting body for the Cayman government. ACCM ensures compliance by ensuring that standards of operation meet those required by the Elements of Accreditation of ACCM (Exhibit 1) which meet with LCME Guidelines as in the Caribbean medical schools currently under accreditation by ACCM, the student body is predominantly North American. The Liaison Committee on Medical Education (LCME) is the recognised accreditation authority for the accreditation of medical education programmes leading to the degree of M.D. in the United States and Canada. ACCM's standards and processes are therefore aligned with the Guidelines of the LCME. The medical schools have been accredited, subject to their continuing compliance with the ACCM required standards. All are subject to regular interim site inspections of the basic medical science campus as well as inspection of all affiliated clinical training sites.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including admission requirements (Exhibit 4).
 
Analyst Remarks to Narrative
As stated in the country's narrative, the Elements of Accreditation 2014, specifically Element 6, outlines the specific standards that institutions must have for selection and admission of new and transfer students for medical school in the Cayman Islands. ACCM, by agreement with the Cayman Islands Government, serves as the accrediting body for medical schools in the Cayman Islands. In turn, they set the national standards for admissions in the country. The narrative indicates that standards for Cayman Islands are aligned with the Guidelines of the LCME.
 
Admissions, Recruiting, and Publications, Question 3
 
Country Narrative
ACCM Elements requires that Individuals shall: Be in good physical and mental health. Possess: A record of academic excellence, A good personal character, Standards of behaviour and conduct that will reflect favourably on themselves and on the medical profession, Personal integrity, Appropriate motivation and the sincere desire to serve their fellow man (Exhibit 1).

In addition, ACCM Element 6 suggests that the admission committee develop a process to evaluate and screen applicants for the attributes and characteristics cited above in an orderly process that is applied uniformly. ACCM encourages the admissions committee to conduct personal interviews in which the screenings applicants includes, among other things, the following:
Grade point averages
The type and degree of difficulty of courses taken
Scores on the medical school admission test
Proficiency of the applicant’s writing skills
Proficiency of the applicant’s communication skills
Evaluations from college pre-professional committees or undergraduate faculty members

Regarding readmission, Element 6 requires the institution to define its policy regarding students who were suspended or dismissed for academic and non-academic reasons. ACCM requires the institution’s policy and criteria for readmission to meet or exceed its admissions standards on aptitude, health, character, and motivation. Also, ACCM requires medical schools to define its policy on acceptance of transfer credits and not permit a transfer to occur beyond the sophomore year.

During the on-site inspection, ACCM protocol requires the team to report on the school’s admission policies, student selection requirements, the structure and role of the admission committee in the admission process, the demographics of the freshman class over a three-year period, implementation of the school’s readmission policies and policies on the admission of transfer students (Exhibit 2: Section VII, VIII, IX). ACCM also monitors the application pools, GPA and MCAT categories of present and projected students lists provided by the institution in the Annual Database Report.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including admission requirements (Exhibit 4).
 
Analyst Remarks to Narrative
As previously stated, the Elements of Accreditation 2014 (specifically Element 6), outlines the specific standards that institutions must have for selection and admission of new and transfer students for medical school in the Cayman Islands. Specifically, Element 6.1.2 states, “upon consultation with the administration, a faculty committee on admissions shall define the size and characteristics of the student body.”
 
Admissions, Recruiting, and Publications, Question 4
 
Country Narrative
ACCM Elements of Accreditation have established the requirements for medical school student admissions in Element 6 (Exhibit1). ACCM Protocol (Exhibit 2: Section VII, VIII, IX) requires the on-site inspection team to meet with key admissions official to review the admissions requirements and processes, to examine the school’s policies with respect to transfer and visiting students and to determine whether the school’s processes and policies are followed in actuality.

ACCM team must report its findings with respect to each of these, verify the enrolment data provide by the institution and report whether an applicant pool of academically qualified students is available to fill the freshman class. More recently the Annual Database Reports of St Matthew’s provide ACCM with information regarding Application Pools, GPA and MCAT categories, present and projected lists of students (Exhibit 4: p.p.3, 6-7).

ACCM Element 6 (Exhibit 1) also requires the institution to publish its admissions policy in its academic catalogue. However, there is no reference in ACCM Elements to other requirements for school publications and advertising.

On the other hand, the ACCM Institutional Self Study (Exhibit 12 & 15) describes in some detail the process of recruitment and selection of medical students encompassing the full range of recruiting and marketing services. The size of the applications pool and the anticipated number of matriculation students are always measured against available resources of faculty, classroom and laboratory space and library/study facilities. Responsibility for the selection of student numbers resides with the Admissions Committee.

ACCM Element 12, Section 12.4 regarding Admissions also covers requirements regarding applicant pool size and entering class.
 
Analyst Remarks to Narrative
According to country's narrative, the Elements of Accreditation 2014 outline standards for determining appropriateness of size and qualifications of the entering class Specifically in Element 6.6 on student body size it states, “there is no minimum size requirement to be eligible for accreditation. However, there shall be sufficient enrolment to promote a collegial atmosphere of learning.” Several factors are considered including resources (including items but not limited to such as: library, faculty offices, faculty, patient facilities, and financial resources) available for this selection.
 
Admissions, Recruiting, and Publications, Question 5
 
Country Narrative
ACCM Element 6 (Exhibit 1) also requires the institution to publish its admissions policy in its academic catalogue (Exhibit 23). SMU publishes an official catalogue which provides comprehensive information regarding SMU. This includes its Mission Statement, Admission criteria, Course information, Tuition Fees and information about financial assistance. All documentation is in English. There is also a website (link: https://www.stmatthews.edu/) which provides further information and contact details. SMU also publishes the Student Handbook which provides detailed information regarding all aspects of the student’s University Medical School Course and facilities (Exhibit 17). It includes performance standards and expectations, methods of evaluation performance, guidelines regarding students Code of behaviour and professionalism and information regarding disciplinary procedures in the event of misconduct , including academic dishonesty.
 
Analyst Remarks to Narrative
A catalog for SMU documented a description of the school, admissions criteria, and the requirements for the award of the M.D. The catalog clearly addresses that courses will be taught in English. The catalog includes annual costs for attendance, including tuition, fees, and required health insurance. The SMU catalog publicizes its standards for student conduct and procedures for disciplinary action and information regarding student performance.
 
Admissions, Recruiting, and Publications, Question 6
 
Country Narrative
Answer to Question 1:
ACCM Element 5 (Exhibit 1) addresses a student’s access to review the accuracy of his or her records in the context of the standards of due process as it applies to rules regarding methods of student evaluation, grading, standards of achievement for promotion, standards of achievement for honour roll, process and criteria for student dismissals, process for appeals, the right to challenge adverse decision and to be represented by counsel. Otherwise, with the exception of the faculty and the administration, student records shall be kept confidential by the school. During an on-site inspection, the ACCM team reports on the institution’s process and criteria for student dismissal and student discipline (Exhibit 7 & 9, 24 & 25). The team determines whether the institution gives students prompt notification and the underlying reasons for the action. Regarding student appeals, the team assesses whether the institution gave the student the right to review the accuracy of their records and an opportunity for a hearing. ACCM has criteria in Elements of Accreditation for a student to access to his or her records to determine their accuracy.

Answer to Question 2:
ACCM Element 5, Section 5.2 addresses this. The records must be confidential and available only to faculty and administration with a need to know, unless released by the student or as otherwise governed by laws concerning confidentiality. Applicable law must govern the confidentiality of student records.
 
Analyst Remarks to Narrative
The country has a data protection act that ensures privacy, but also allows access to student records via the standards outlined in the Elements of Accreditation 2014.
 
Student Achievement, Question 1
 
Country Narrative
In Element 5 (Exhibit 1), ACCM requires institutions to have a student promotion and evaluation committee comprised of faculty members. Its purpose is to establish several methods for assessing the level of student knowledge and skills as compared to performance levels of students at other institutions. ACCM expects the school to have methods to distinguish the different degrees of student performance among the enrolled students. Each school must develop methods to assess performance in the areas of subject matter, course objectives, and the programme of studies. Additionally, ACCM expects each academic department or division of the institution to enforce its standards without regard to where the institution offers the courses, e.g. at the main campus or a satellite facility.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including evaluation of student achievement (Exhibit 4 p.p.18-22, 31-35).
 
Analyst Remarks to Narrative
The Elements of Accreditation 2014, Element 5.1.1 establishes a student and promotion evaluation committee that is comprised of faculty members. They cite "The committee establishes methods for assessing the level of student knowledge and skills as compared to performance levels of students at other institutions." Additionally, 5.1.2 states "the student promotion and evaluation committee shall define and recommend to the chief academic officer the degree of academic proficiency a student must attain before s/he is promoted to the next academic level and ultimately to graduation."
 
Student Achievement, Question 2
 
Country Narrative
Answer to Question 1:
Yes, national requirements regarding evaluation of medical schools, and has been for some time, is based on the United States Medical Licensing Examination (USMLE) Step 1 and 2. As has already been pointed out students entering fifth semester are required to pass USMLE Step 1 prior to entering the clinical science semesters.

In Element 5 (Exhibit 1), ACCM requires institutions to have a student promotion and evaluation committee comprised of faculty members. Its purpose is to establish several methods for assessing the level of student knowledge and skills as compared to performance levels of students at other institutions. ACCM expects the school to have methods to distinguish the different degrees of student performance among the enrolled students. Each school must develop methods to assess performance in the areas of subject matter, course objectives, and the programme of studies. Additionally, ACCM expects each academic department or division of the institution to enforce its standards without regard to where the institution offers the courses, e.g. at the main campus or a satellite facility.

Course directors are required to administer periodic and interim examinations to evaluate the degree of mastery of course material and the degree of problem solving skill attained. A student’s faculty advisor is responsible for “helping his student advisee to maintain satisfactory academic progress, to guide the student in determining a career path, and to direct the student to an appropriate postgraduate position for further training.

ACCM’s Protocol requires the on-site inspection team to meet with the Chair of the Student Promotion and Evaluation Committee and to review the methods which the medical school uses to evaluate students, including interim student evaluation and progress reports as well as the requirements for promotion, graduation and academic disciplinary action (Exhibit 2: Sections VII, VIII & IX).The team must report on, among other things, whether college policies concerning student promotion and evaluation are published, the methods of student evaluation employed by the medical school, whether the grading system has been applied uniformly, and the average score and passing percentage on standardized examinations, and the general view of students concerning the effectiveness of the methods used by the school in evaluating and promoting students.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including student achievement (Exhibit 4 p.p. 18-32, 31-35)).

Answer to Question 2:
In Element 5 (Exhibit 1), ACCM requires the medical school must have a Student Promotion and Evaluation Committee (SPEC) that defines, publishes and enforces its rules throughout the institution (Exhibit 1). The SPEC must include methods of student evaluation, a grading system, standards of achievement for promotion, standards of achievement for honour roll, processes and criteria for student dismissals, process for appeals, the right the challenge adverse decision and to be represented by legal counsel. In addition to the traditional test taking methods of student evaluation, the faculty must evaluate student performance based on observation of a student’s performance, proficiency and mastery of the fundamental clinical principles, clinical skills and problem solving abilities in each clinical area. Therefore, the criteria in this Element allow the medical school to establish its own methods of evaluating student achievement.

To determine if the requirements are adequate, ACCM inspection team meets with the Chairperson of the SPEC and reviews the methods the medical school uses to evaluate student performance in the basic science and clinical science courses (Exhibit 2: Section VII, VIII, IX). The team reviews interim student evaluations and progress reports with student feedback to ensure that faculty identifies weak students early enough to begin counselling and tutoring if required. The team reviews the school’s requirements for student promotion, graduation, and academic disciplinary actions and the minutes of the SPEC for evidence that student evaluation and promotion policies are developed and implemented. In addition the team reviews the college’s efforts in: Counselling students with regard to making satisfactory academic progress, selecting elective courses, guiding students in determining career paths and directing student to appropriate postgraduate positions.

The team report includes whether the college requires the publication of student promotion and evaluation policies, the methods of student evaluation, the uniform application of the grading system, the average score and passing percentage on standardized examinations, and the general view of students concerning the effectiveness of the methods used by the school in evaluating and promoting students.

ACCM receives a formal updated database from the medical school in February each year as well as an Institutional Self-Study every two years. The school is required to answer a list of questions covering all major aspects of the governance of the school including student achievement (Exhibit 4 & 15).
 
Analyst Remarks to Narrative
In the country's narrative, they discuss the significance of student achievement being related to preparing students for passing the USMLE exam. Students are required to pass this test before they can begin the clinical science semesters. In the Elements of Accreditation 2014, standards for student achievement are reviewed during the on-site inspection visit. The team meets with the Chair of the Student Promotion and Evaluation Committee (SPEC) to assess compliance under its student achievement standards. However, no documentation (such as the on site teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline that shows how the on site inspection team review the institution's goals for compliance under this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4, 30, 31 & 32) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
Additional documentation has been provided that showcases how the onsite inspection team reviewed the pass rates related to USLME Step 1 and Step 2, being 85% and 86% respectively. It is noted that the NBME shelf exams are a requirement for Basic Science and Introduction to Clinical Medicine Courses. Minutes from the student promotion committee were provided as documentation. They indicate an evaluation of student of academic progress and include notification to those that will be dismissed or placed on warning.
 
Staff Conclusion: Comprehensive response provided
 
Student Achievement, Question 3
 
Country Narrative
In Element 5 (Exhibit 1), ACCM requires the medical school must have a Student Promotion and Evaluation Committee (SPEC) that defines, publishes and enforces its rules throughout the institution (Exhibit 1). The SPEC must include methods of student evaluation, a grading system, standards of achievement for promotion, standards of achievement for honour roll, processes and criteria for student dismissals, process for appeals, the right the challenge adverse decision and to be represented by legal counsel. In addition to the traditional test taking methods of student evaluation, the faculty must evaluate student performance based on observation of a student’s performance, proficiency and mastery of the fundamental clinical principles, clinical skills and problem solving abilities in each clinical area. Therefore, the criteria in this Element allow the medical school to establish its own methods of evaluating student achievement.

To determine if the requirements are adequate, ACCM inspection team meets with the Chairperson of the SPEC and reviews the methods the medical school uses to evaluate student performance in the basic science and clinical science courses (Exhibit 2: Section VII, VIII, IX). The team reviews interim student evaluations and progress reports with student feedback to ensure that faculty identifies weak students early enough to begin counselling and tutoring if required. The team reviews the school’s requirements for student promotion, graduation, and academic disciplinary actions and the minutes of the SPEC for evidence that student evaluation and promotion policies are developed and implemented. In addition the team reviews the college’s efforts in: Counselling students with regard to making satisfactory academic progress, selecting elective courses, guiding students in determining career paths and directing student to appropriate postgraduate positions.

The team report includes whether the college requires the publication of student promotion and evaluation policies, the methods of student evaluation, the uniform application of the grading system, the average score and passing percentage on standardized examinations, and the general view of students concerning the effectiveness of the methods used by the school in evaluating and promoting students.

ACCM receives a formal updated database from the medical school in February each year as well as an Institutional Self-Study every two years. The school is required to answer a list of questions covering all major aspects of the governance of the school including student achievement (Exhibit 4 &15).
 
Analyst Remarks to Narrative
The ACCM has requirements embedded throughout their standards for continual assessment of student performance throughout the medical school program. The on site inspection team is required to meet with the Chair of the Student Promotion and Evaluation Committee (SPEC) to assess compliance under its student achievement standards. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4, 30, 31 & 32 Appendix 2 Committee Meeting Minutes 2013-2014) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
Additional documentation has been provided that showcases how the onsite inspection team reviewed the pass rates related to USLME Step 1 and Step 2, being 85% and 86% respectively. It is noted that the NBME shelf exams are a requirement for Basic Science and Introduction to Clinical Medicine Courses. Minutes from the student promotion committee were provided as documentation. They indicate an evaluation of student of academic progress and include references that notification will be given to those that will be dismissed or placed on warning.
 
Staff Conclusion: Comprehensive response provided
 
Student Achievement, Question 4
 
Country Narrative
Evaluation of St. Matthew’s University School of Medicine is, and has been for some time, based on the United States Medical Licensing Examination (USMLE) Step 1 and 2.

Yes. The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2). With regard to the periodic re-evaluation and monitoring of medical schools, ACCM receives a formal updated database from the medical school in February each year (Exhibit 4 p.p.31-32). The school is required to answer a list of questions covering all major aspects of the governance of the school. This includes academic performance of students as well as information on Residency Match rates (Exhibit 15 p.p.53-55 & Appendix 16). The school also provides a list of Residency programmes into which graduates have been accepted.

ACCM defines its standards of educational quality as Elements (Exhibit 1: Element 4, 6, 8, 11, 12 & 14). Element 1 establishes the requirements for institutional goals that include the educational mission, goals and objectives. ACCM requires the institution to publish and distribute its goals among its students, faculty and the public, generally through an institutional catalogue or other publishing media. ACCM requires the medical school to engage in a planning process that sets the direction for the institution and identifies measurable outcomes that identify accomplishment of the goals or areas in need of improvement. Element 14 requires medical schools to make every reasonable effort to collect data on postgraduate progression of their graduates.

ACCM Protocol requires the inspection team to review and report on the institutions system of programme evaluation (Exhibit 2 Section VII, VIII & IX). The team reports on the indicators utilized by the curriculum committee to appraise programme outcomes such as scores on exams including standardized and licensed exams, graduation rates, residency acceptance rates, the employment status of graduates, student and graduate surveys. The team reports on the mechanisms used by the institution to monitor the quality of instruction and the breadth and depth of course content, the mechanisms used to collect information, and to what extent the institution has used the information to appraise and improve curriculum courses and instruction.

ACCM protocol (Exhibit 2) (or procedures) requires on-site inspection teams to meet with the Chief Executive Officer of the medical school to review the institution’s educational goals for compliance and to summarize in a written report the educational goals of the medical school. The report comments on whether the institution has met its goals and these goals are familiar to faculty and students, and the extent to which the institution makes an effort to enhance its ability to reach its goals. Through testing, ACCM requires the institution to ensure that students pass the USMLE step 1 examination before beginning the 3rd year clinical science coursework. In addition, ACCM recommends that before graduation, students should also pass the USMLE Step 2 examination and the medical school requires this.

The medical schools have been accredited, subject to their continuing compliance with the ACCM required standards. All are subject to regular interim site inspections of the basic medical science campus as well as inspection of all affiliated clinical training sites (Exhibit 2: Section VII, VIII, IX). ACCM also monitors the application pools, GPA and MCAT categories of present and projected students lists provided by the institution in the Annual Database Report.

Regarding non-compliance of ACCM Elements relating to accreditation, ACCM Protocols must be adhered to and have protocols in place to deal with this (Exhibit 2: Section V, X, XI, XII)
 
Analyst Remarks to Narrative
As stated in the country's narrative, the ACCM has based their accreditation of SMU student evaluation on the USMLE. Standards for educational quality are included in the ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012. The on-site inspection team is required to review the following data: exams including standardized and licensed exams, graduation rates, residency acceptance rates, the employment status of graduates, student and graduate surveys. Medical schools in the country must maintain compliance with these standards in order to maintain accreditation. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up. SMU also has a Guide to Residency which is given to each student (Exhibit 34).
 
Analyst Remarks to Response
Additional documentation has been provided that showcases how the onsite inspection team reviewed the pass rates related to USLME Step 1 and Step 2, being 85% and 86% respectively. It is noted that the NBME exams are a requirement for Basic Science and Introduction to Clinical Medicine Courses.
 
Staff Conclusion: Comprehensive response provided
 
Student Achievement, Question 5
 
Country Narrative
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2). With regard to the periodic re-evaluation and monitoring of medical schools, ACCM receives a formal updated database from the medical school in February each year (Exhibit 4). The school is required to answer a list of questions covering all major aspects of the governance of the school.

St. Matthew’s University actively collects and utilizes information from students as part of its ongoing assessment of the program. The primary sources of this information are course evaluations and clinical rotation evaluations. Additionally, the school conducts a survey each semester of all clinical students and a pre-graduation survey of all prospective graduates (Exhibit 4 p.p. 18-22).

During the Basic Science portion of the programme, students complete and online (anonymous) evaluation of each course they take. Students are required to complete an evaluation for every course they take. Two areas are covered in student evaluations: 1) assessing course content to determine whether students believe that the course content is consistent with the syllabus objectives; and 2) assessing the effectiveness of the faculty in delivering the course material. The aim of the evaluation is to establish whether the curriculum assists students to achieve the skills, knowledge and attitudes that are required for their chosen profession. The Basic Science course evaluations are utilized in conjunction with student performance in both the assessment of courses as a whole, and the assessment of individual faculty members.

Similar to the evaluations of Basic Science courses (and faculty), students are required to complete a survey at the completion of each clinical rotation. The results of these surveys are aggregated, and are utilized in the assessment of individual clinical rotations and sites. The results of the student evaluations, along with student performance data are reviewed by the clinical department, including the Clinical Department Chairs, and shared with the clinical sites.

In addition to the end of rotation surveys, clinical students also complete a survey at the end of each semester. This survey focuses on their overall satisfaction with clinical medicine, including soliciting feedback on all SMU clinical staff.

All clinical students are surveyed at the end of each clinical rotation. These surveys are similar in content and goals to those used in basic sciences. Clinical students are also surveyed at the end of each semester. Rather than focusing on the specifics of any rotation (since this is handled with the rotation survey), this survey focuses on their overall satisfaction with clinical medicine, including soliciting feedback on all SMU clinical staff. Additionally, through SMUCourses, clinical students also have the opportunity to comment throughout their rotations on any concerns they may have.
 
Analyst Remarks to Narrative
The country ensures that students are actively involved in the program's internal quality assurance program through course evaluations, clinical evaluations, and end of semester surveys. They have provided documentation of an example of the course evaluation in the SMU Self-study document.
 
Student Services, Question 1
 
Country Narrative
ACCM Element 10 (Exhibit 1) addresses student services and includes counselling and guidance; student health; and student financial aid and budgeting. A faculty advisor shall be assigned to each student for academic and personal counselling which will include course selection, student conduct rules, postgraduate training, licensure, procedures for student appeals and filing grievances. The school will provide students with access to confidential psychological counselling on the campus. All new students will receive orientation to become familiar with institutional services and student regulations.

Element 10 also requires the medical school to provide basic medical services to students and their families. The medical school must publicize the availability of health insurance and long-term disability coverage. This element requires the institution to ensure students are vaccinated against communicable diseases prior to matriculation. Also as part of its educational and prevention programme, students shall receive instruction in the treatment and prevention of other infections and environmental diseases. The medical school shall grant medical leave to the student when deemed appropriate.

In addition, Element 10 requires the institution’s financial aid office to counsel and provide students with a detailed summary of the estimated costs of tuition, books, supplies, and personal living expenses to complete the entire medical programme of study. The institution counsels students on the amount and availability of financial aid. At the end of the students’ programme the institution shall counsel students on their student loan debt load, their responsibility for repayment, and the average monthly payments. ACCM expects the institution to comply with all government regulations regarding the administration and management of student aid programmes.

Students shall also have access to confidential psychological counselling on campus. Personal counselling and mental health services are available through the Dean of Student Affairs (Psychologist) or by referral to a local psychiatrist. SMU has a written policy available for students impaired by drugs or alcohol. It offers a suicide prevention and awareness program for medical students (Exhibit 4 p.p.33-34) (Exhibit 15).

ACCM inspection team reports whether the college provides student counselling in the following areas: Rules governing student conduct, confidential psychological counselling and the level of student satisfaction with the school’s counselling and guidance programme. On site, the team also reports on the following concerns regarding student health: the availability and cost of health insurance, disability coverage for student and their families, whether the college has policies for disease prevention, vaccination against communicable disease, and other environmental perils and the level of student satisfaction with the school’s counselling and guidance programme.

Regarding student financial aid and budgeting, the team reports on the following:
whether the college counsels and provides students with detailed costs for tuition, books, supplies, and personal living expenses for the entire programme
the availability of student financial aid
the extent to which the cost of education and the current level of financial aid adversely impacts the ability of the college to recruit and enroll students
the counselling of students on the average indebtedness, responsibilities for repayment and average monthly payments.
the college’s student loan default rates and its programme concerning default prevention on Title IV student loans
student satisfaction concerning the financial counselling offered by the college.

ACCM Protocol directs site teams to report on whether the college provides student counselling, including confidential psychology counselling. The team also reports on the availability and cost of health and disability insurance to students and their families. Finally, the team must report on the level of student satisfaction with the health and counselling services (Exhibit 2: Section VII, VIII, IX).
 
Analyst Remarks to Narrative
The country's narrative and Elements for Accreditation 2014 (specifically Element 10) discusses standards for institutions that involve providing counseling and guidance, student health resources, financial and budgeting support, and confidential psychological counseling. Each student is provided a faculty advisor who assists the student with academic and professional advice related to their medical careers.
 
Student Services, Question 2
 
Country Narrative
Answer to Question 1:
ACCM Element 5 (Exhibit 1) addresses a student’s access to review the accuracy of his or her records in the context of the standards of due process as it applies to rules regarding methods of student evaluation, grading, standards of achievement for promotion, standards of achievement for honour roll, process and criteria for student dismissals, process for appeals, the right to challenge adverse decision and to be represented by counsel. Otherwise, with the exception of the faculty and the administration, student records shall be kept confidential by the school.

During an on-siteACCM inspection, the team reports on the institution’s process and criteria for student dismissal and student discipline (Exhibit 7 & 9, 23 & 24). The team determines whether the institution gives students prompt notification and the underlying reasons for the action. Regarding student appeals, the team assesses whether the institution gave the student the right to review the accuracy of their records and an opportunity for a hearing. ACCM has criteria in the elements of accreditation for a student to access to his or her records to determine their accuracy.

Answer to Question 2:
ACCM Element 5 (Exhibit 1: Section 5.2) addresses this. The records must be confidential and available only to faculty and administration with a need to know, unless released by the student or as otherwise governed by laws concerning confidentiality. Applicable law must govern the confidentiality of student records.
 
Analyst Remarks to Narrative
ACCM has standards in the Elements of Accreditation 2014 publication to address this guideline which require the protection of student records. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
In the self-study provided by SMU, they explained that their graduates would need access to their permanent records. They apply Family Educational Rights and Privacy Act (“FERPA”) rules in determining whether or not to grant access to the student records.

While it is explained in the narrative that ACCM has criteria in the elements of accreditation for a student to access to his or her records to determine their accuracy and that the onsite inspection team reviews information during their visit, no evidence of this practice was included in the report. NCFMEA may wish to request clarification on how this information is reviewed during their onsite inspection team visit.
 
Staff Conclusion: Additional Information requested
 
Student Complaints, Question 1
 
Country Narrative
ACCM has three elements for medical schools to address student complaints (Exhibit 1). In Element 5, a section developed regarding student promotion and evaluation, the ACCM requires the Student Promotion and Evaluation Committee (SPEC) to enforce related rules that “shall consist of methods of student evaluation, grading system, standards of achievement for promotion, standards of achievement for honour roll, process and criteria for student dismissals, process for appeals, the right to challenge adverse decisions and to be represented by legal counsel. These rules also offer to the student the right to due process regarding notification, evidentiary presentation, and the right to review the accuracy of the records and to prepare a response to defence.

ACCM Protocol for the site team under Element 5 requires the team to report on the institution’s process and criteria for student dismissal and student discipline. During the review, the team will assess whether student receive prompt notification and the underlying reasons for the action taken by the school. The team will also report on the institution’s process for students to appeal an adverse decision.

Element 6 addresses student dismissals and requires the medical school’s SPEC to develop policies and procedures for dismissal of students who fail to meet the academic and behavioural standards. Each institution must publish the standards and make them available to every student. Additionally, the school’s dismissal procedures must include provisions for due process and appeal. ACCM protocol for the inspection team is not required to include a report on this section because it is duplicative of Element 4 regarding student promotion and evaluation.

Element 13 covers complaints to the medical school and complaints about the medical school. The element includes ensuring information and contact details about ACCM are included in SMU student handbook (Exhibit 17) including a link to ACCM’s website (Exhibit 3) which is how students are made aware of complaints procedures. The medical school is required to maintain a complaints log detailing complaints submitted, process and actions taken to resolve them.
Each of these elements and the accompanying protocol for the inspection teams only deals with student disciplinary or appeal actions, and not with the process an institution must have for handling student complaints related to the elements (accreditation standards). However, the Protocol addresses how the ACCM will investigate complaints the Commission receives (Exhibit 2: Section VII, VIII, IX). In addition to maintaining records of all complaints received, it will only review complaints that deal with a college’s failure to comply with the Elements of Accreditation (Exhibit 2: Section XIII). If the ACCM reviews the complaint and finds it credible and supported by sufficient evidence, the ACCM will forward a copy of the complaint to the college. If the college refutes the complaint, the ACCM will dismiss the complaint and notify the complainant at the conclusion of the inquiry. If the college fails to refute the complaint, the ACCM will open an inquiry that will focus only on the complaint. The ACCM will not review nor interfere in routine business decisions or operations of the college that includes, among other things, business decisions or operations of the college such as student and faculty dismissals. The ACCM will notify all complainants of this policy.

The SMU Student Handbook adopted procedures for handling complaints about program quality that ACCM established since September 2004 (Exhibit 17). The procedures require ACCM to only investigate complaints that, if substantiated, may constitute non-compliance with accreditation standards. It will not intervene on any complaint regarding admission, appointment, promotion or dismissal of faculty or students. However, the ACCM will include in its review of the college whether the college has in place appropriate procedures for handling such internal matters. The procedures outline the requirements that the complainant must meet to substantiate the complaint and the authorization to release information, the timelines for the school’s response, and the timelines for rendering a decision. If an ad hoc subcommittee of the ACCM makes an on-site visit it reports to the ACCM at its next regularly scheduled meeting and the ACCM will render its decision within 30 days of its meeting to the complainant.

ACCM has clearly outlined the policies and procedures that ensure due process to students with grievances as well as the procedures to ensure that student complaints regarding the elements of accreditation are timely resolved.

ACCM received one complaint from a student that was investigated and resolved in relation to computer/software malfunction during NBME Shelf Exams. SMU purchased additional new laptops to ensure students are not affected by unintended logouts during exams.
 
Analyst Remarks to Narrative
The country stipulates standards for student complaints in its Elements of Accreditation 2014. Institutions must have written policies for student grievances.
 
Student Complaints, Question 2
 
Country Narrative
Answer to 1st Question:
ACCM has three Elements for medical schools to address student complaints (Exhibit 1). In Element 5, a section developed regarding student promotion and evaluation, the ACCM requires the Student Promotion and Evaluation Committee (SPEC) to enforce related rules that “shall consist of methods of student evaluation, grading system, standards of achievement for promotion, standards of achievement for honour roll, process and criteria for student dismissals, process for appeals, the right to challenge adverse decisions and to be represented by legal counsel. These rules also offer to the student the right to due process regarding notification, evidentiary presentation, and the right to review the accuracy of the records and to prepare a response to defence.

ACCM Protocol for the site team under Element 5 requires the team to report on the institution’s process and criteria for student dismissal and student discipline. During the review, the team will assess whether student receive prompt notification and the underlying reasons for the action taken by the school. The team will also report on the institution’s process for students to appeal an adverse decision.

ACCM Element 6 addresses student dismissals and requires the medical school’s SPEC to develop policies and procedures for dismissal of students who fail to meet the academic and behavioural standards. The school must publish the standards and make them available to every student. Additionally, the school’s dismissal procedures must include provisions for due process and appeal. The protocol for the inspection team is not required to include a report on this section because it is duplicative of Element 4 regarding student promotion and evaluation.

Answer to 2nd part of Question 1:
Yes, students are made aware of this as ACCM Element 13 covers complaints to the medical school and complaints about the medical school. The Element includes ensuring information and contact details about ACCM are included in SMU student handbook (Exhibit 17) including a link to ACCM’s website (Exhibit 3) which is how students are made aware of complaints procedures. The medical school is required to maintain a complaints log detailing complaints submitted, process and actions taken to resolve them.

Each of these elements and the accompanying protocol for the inspection teams only deals with student disciplinary or appeal actions, and not with the process an institution must have for handling student complaints related to the elements (accreditation standards). However, the Protocol addresses how the ACCM will investigate complaints the Commission receives (Exhibit 2: Section VII, VIII, IX). In addition to maintaining records of all complaints received, it will only review complaints that deal with a college’s failure to comply with the Elements of Accreditation (Exhibit 2: Section XIII). If the ACCM reviews the complaint and finds it credible and supported by sufficient evidence, the ACCM will forward a copy of the complaint to the college. If the college refutes the complaint, the ACCM will dismiss the complaint and notify the complainant at the conclusion of the inquiry. If the college fails to refute the complaint, the ACCM will open an inquiry that will focus only on the complaint. The ACCM will not review nor interfere in routine business decisions or operations of the college that includes, among other things, business decisions or operations of the college such as student and faculty dismissals. The ACCM will notify all complainants of this policy.

The SMU Student Handbook adopted procedures for handling complaints about program quality that ACCM established since September 2004 (Exhibit 17). The procedures require ACCM to only investigate complaints that, if substantiated, may constitute non-compliance with accreditation standards. It will not intervene on any complaint regarding admission, appointment, promotion or dismissal of faculty or students. However, the ACCM will include in its review of the college whether the college has in place appropriate procedures for handling such internal matters. The procedures outline the requirements that the complainant must meet to substantiate the complaint and the authorization to release information, the timelines for the school’s response, and the timelines for rendering a decision. If an ad hoc subcommittee of the ACCM makes an on-site visit it reports to the ACCM at its next regularly scheduled meeting and the ACCM will render its decision within 30 days of its meeting to the complainant.

ACCM has clearly outlined the policies and procedures that ensure due process to students with grievances as well as the procedures to ensure that student complaints regarding the elements of accreditation are timely resolved.

Answer to Question 2:
ACCM received one complaint from a student that was investigated and resolved in relation to computer/software malfunction during NBME Shelf Exams. SMU purchased additional new laptops to ensure students are not affected by unintended logouts during exams.
 
Analyst Remarks to Narrative
The Elements of Accreditation 2014 has standards for developing effective complaint policies and it appears that ACCM receives complaints from students. The narrative has noted the receipt of a complaint regarding the technology during the NBME shelf exams and that this issue has been resolved through the purchase of new technology. The country has provided the location of its website where it publishes the complaint policy and contact for who to notify regarding complaints.
 
Finances, Question 1
 
Country Narrative
Response to Question 1:
ACCM Element 7 requires the institution to possess sufficient financial resources to carry out its mission for the size of its student body, possess adequate reserve of funds and seek alternative sources of income derived from such sources as endowment, annual giving to avoid taxing the schools resources (Exhibit 1). Although the application narrative states that the Commission requires that the institution debt not exceed 50 percent of the total assess, Element 7 specifically states “to ensure stability, the institutional debt shall not exceed more than 15% of its total assets.” Element 7 designates the institution’s Chief Financial Officer to oversee the institution’s financial resources, assist in preparing and controlling the budget, and supervise the accounting and reporting system and collect, manage, and disburse funds.

ACCM protocol ensures that the onsite inspection team reviews the minutes of the institution’s board of governors for evidence that it governs the college by securing financial resources, among other things (Exhibit 2: Section VII, VIII, IX). The inspection team assesses whether the income, such as endowment, annual giving, clinical services, government funds, grants, tuition and other sources sustained the expenses during the past three years, the changes in the income levels for the same period, and if deterioration exists, the institution’s plan to restore the college to a stable financial condition without adversely affecting educational quality. The team also reviews the roles of the department heads and faculty representatives in developing the institutional budget including whether their roles are advisory or participatory in final budget decisions. ACCM will also review the fiscal strength of a medical school when there is a substantive change, such as a change of ownership. ACCM will use the information obtained from an inspection team to determine whether the new owner can ensure that the medical school will continue to comply with the Elements of Accreditation.


Answer to Question 2:
ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including finances and independently audited accounts (Exhibit 19).


Answer to Question 3:
ACCM has the authority together, with an agreement with the government of Cayman Islands, and responsibility for evaluating the size and scope of medical education in different types of medical schools, private or for-profit. ACCM reports to the Cayman Islands government. The medical schools have been accredited, subject to their continuing compliance with the required standards which are set down in the ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2). In particular Element 1, 3, 4, 6, 11 and 12 address this. As there is only one medical school within the jurisdiction of the Government of the Cayman Islands, ACCM is the accrediting body for the medical school. The school is subject to regular interim site inspections of the basic medical science campus as well as inspection of all affiliated clinical training sites. ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on educational programmes (Exhibit 4).
 
Analyst Remarks to Narrative
The country has provided a documentation of an independent audit conducted by BEDARD, KUROWICKI & CO., CPA'S, PC CERTIFIED PUBLIC ACCOUNTANTS to review their financial stability. The Elements of Accreditation 2014 include standard elements for ensuring that financial capacity is appropriate to the size of the institution. The on site inspection team is required to review the minutes of the institution's board of governors who coordinate with department chairs and other faculty in regards to the financial capacity of the institution. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM auditors review the medical school’s finances annually and report to ACCM which are discussed at ACCM AGM annually (Exhibit 37).
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4, 30, 31 & 32 Appendix 2 Committee Meeting Minutes 2013-2014) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
Included in the country's narrative was information indicating that onsite inspection team reviews financial information. Element 7 listed in Exhibit 29 includes information that shows this information was presented and reviewed. There is no indication on the outcome of this review.

Minutes of a Friday May 23rd, 2014 meeting show that ACCM reviewed audited financial information and indicated that 'all accounts look healthy.'
 
Staff Conclusion: Comprehensive response provided
 
Facilities, Question 1
 
Country Narrative
ACCM’s Element 11 (Exhibit 1) addresses the college’s facilities and equipment as follows: “The institution shall own buildings, equipment and a campus of sufficient size, quality and design to fulfil its goals. University owned facilities shall include auditoriums, classrooms, student laboratories, a library, faculty offices, administrative offices, admission office, office for student services, research laboratories, sufficient animal care facilities, student dormitory facilities, dining facilities, student activities facilities, and recreational facilities.”

With respect to hospital and ambulatory facilities, Element 11 (Exhibit 1: Section 11.2) states: The institution shall offer a broad range of clinical services . . .[t]o ensure that students fulfil the educational requirements of the curriculum, the … clinical sciences program shall be placed under the direct control and supervision of the medical school dean, department chairs, and the faculty... In fulfilling its mission, the institution’s affiliated clinical teaching facilities shall also be of sufficient size, quality and accessibility to serve the needs of the institution. .. The medical school shall maintain, in force at all times, an affiliation agreement with each health care facility where students are present. The agreement shall be in writing and shall outline the roles and responsibilities of both parties in the education process. ..Such agreement shall include educational objectives, faculty responsibilities, evaluation procedures, classrooms, library resources, student study areas and quiet sleeping quarters for students scheduled to take calls.

ACCM Protocol requires ACCM on-site inspection team to inspect facilities and equipment for compliance with Element 11 including auditoriums, classrooms, student laboratories and lounges, faculty offices, administrative facilities, research laboratories and libraries (Exhibit 1 & 2). The protocol requires the on-site inspection team to report on the faculty in the basic and clinical sciences with respect to professional growth, continuing medical education, faculty collaboration, faculty research activities, professional security and academic freedom, workload, etc. The team is also required to ascertain the faculty views of the curriculum and the student body, faculty familiarity with the educational goals of the college, and faculty knowledge of student performance and the success of the medical school's graduates in post-graduate training and professional practice.

The team report should address whether the size, quality and design of the general facilities are sufficient for the size of the faculty and student body, the level of research activities and the nature of the curriculum. For each hospital and ambulatory facility, the team should report on the quality of the facility and whether affiliation agreements exist for each one.

The team is required to report whether the size of the faculty is adequate and proportional to match (a) the size of the student body, (b) the scope of patient care, and (3) the level of research activities. In addition, for each department, the team should report faculty size; the amount of space allocated to the department; the total budget and amount of contributions from other sources, e.g., parent university, research grants, clinical services and government; the percentage of time faculty devotes to teaching, research, patient care, and faculty committee work; and any major strengths or weaknesses in the department. Finally, the team is to report on a number of other faculty issues, such as workload, professional growth, policies for selection and promotion, etc.

ACCM Element 12 (Exhibit 1) and ACCM Protocol (Exhibit 2: Section XIII) also addresses this by requiring the school to report any substantive changes whether in regard to campus extensions, curriculum, resources or admissions.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on educational programmes (Exhibit 4 & 15).
 
Analyst Remarks to Narrative
The Elements of Accreditation (specifically Element 11), stipulates that facilities must be sufficient for realization of the curriculum, which includes those resources necessary for fulfillment of goals related to the medical school. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
Documentation of the onsite inspection teams report does demonstrate that facilities and equipment were reviewed during the visit. It was noted that significant improvements have been made over the last six years. This documentation provides evidence that the team reviewed facilities and equipment were reviewed for size, quality, and design of the general facilities to be sufficient for that of the institution.
 
Staff Conclusion: Comprehensive response provided
 
Facilities, Question 2
 
Country Narrative
Answer to Question 1:
ACCM’s Element 11 (Exhibit 1) addresses the college’s facilities and equipment as follows: “The institution shall own buildings, equipment and a campus of sufficient size, quality and design to fulfil its goals. University owned facilities shall include auditoriums, classrooms, student laboratories, a library, faculty offices, administrative offices, admission office, office for student services, research laboratories, sufficient animal care facilities, student dormitory facilities, dining facilities, student activities facilities, and recreational facilities.”

ACCM Protocol requires ACCM on-site inspection team to inspect facilities and equipment for compliance with Element 11 including auditoriums, classrooms, student laboratories and lounges, faculty offices, administrative facilities, research laboratories and libraries to ensure that medical school facilities include offices for faculty, administrators, and support staff; laboratories and other space appropriate for the conduct of 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 space for student study and space; and equipment for library and information access (Exhibit 1 & 2).

ACCM protocol requires the on-site inspection team to report on the faculty in the basic and clinical sciences with respect to professional growth, continuing medical education, faculty collaboration, faculty research activities, professional security and academic freedom, workload, etc. The team is also required to ascertain the faculty views of the curriculum and the student body, faculty familiarity with the educational goals of the college, and faculty knowledge of student performance and the success of the medical school's graduates in post-graduate training and professional practice.

The team report should address whether the size, quality and design of the general facilities are sufficient for the size of the faculty and student body, the level of research activities and the nature of the curriculum.

The team is required to report whether the size of the faculty is adequate and proportional to match (a) the size of the student body, (b) the scope of patient care, and (3) the level of research activities. In addition, for each department, the team should report faculty size; the amount of space allocated to the department; the total budget and amount of contributions from other sources, e.g., parent university, research grants, clinical services and government; the percentage of time faculty devotes to teaching, research, patient care, and faculty committee work; and any major strengths or weaknesses in the department. Finally, the team is to report on a number of other faculty issues, such as workload, professional growth, policies for selection and promotion, etc.

ACCM Element 12 (Exhibit 1) and ACCM Protocol (Exhibit 2: Section XIII) also addresses this by requiring the school to report any substantive changes whether in regard to campus extensions, curriculum, resources or admissions.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information on educational programmes (Exhibit 4 & 15).

Answer to Question 2:
The SMU medical school curriculum includes a course in Principles of Research and Evidence Based Medicine, with Biostatistics and Epidemiology. Students learn the nature of medical research and current developments in best practice and decision making. They learn to use to analyse and use correctly scientific literature and clinical knowledge and to understand Physician’s responsibility to remain up to date and to use information correctly (Exhibit 15: Appendix 1 p.p. 8-9). All students are assigned a research project during their first semester which they are expected to complete by the end of the second trimester.

The medical school does not use facilities for animal research.
 
Analyst Remarks to Narrative
As previously stated, the country's Elements of Accreditation (specifically Element 11), stipulates that facilities must be sufficient for realization of the curriculum, which includes those resources necessary for fulfillment of goals related to the medical school. The on-site inspection team is expected to review and report whether they believe that the facilities are adequate. However, no documentation (such as the on site inspection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
The onsite inspection teams report does demonstrate that facilities and equipment were reviewed during the visit. It was noted that significant improvements have been made over the last six years. This documentation provides evidence that the team reviewed facilities and equipment were reviewed for size, quality, and design of the general facilities to be sufficient for that of the institution. Specifically noted in the team review was a review of a large lecture theatre, technology in those rooms, and small group student study spaces. The team report also indicated that a research lab is available for student who wish to be involved in research projects and that student recreation facilities have improved.
 
Staff Conclusion: Comprehensive response provided
 
Faculty, Question 1
 
Country Narrative
Answer to Question 1 & 2:
The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 and provide an education that adheres to LCME standards (Exhibit 1 & 2).

Element 3 (Exhibit 1) addresses institutional management and administration and requires an institution to “design an administrative structure so that each division is able to perform its unique responsibilities efficiently. The design and the size of the administration shall also be of sufficient magnitude for the size of the student body and the scope of the programme.” This Element requires the college’s Board of Trustees to approve the appointment of the Chief Executive Officer (CEO), Chief Academic Officer (CAO), and faculty members and requires the CAO to carry out institutional policies and to implement the educational objectives of the institution. The principal administrative and academic heads of the medical school shall maintain open lines of communication with each other.
Element 3 also requires the CAO to hold an MD degree and, possess adequate qualifications and experience in medical education, research and patient care to lead and supervise the educational programme at the institution. To support the CAO, the institution must have a competent team of professional staff in the management of the educational programme. These members include individuals representing: Deans, Associate Deans and Assistant Deans; Professional staff and secretarial support; student admissions; faculty affairs; education financing, accounting, budgeting, and fundraising; clinical facilities; curriculum and academic affairs; student services and student affairs; postgraduate and continuing medical education; research; alumni affairs; library; student financial assistance; record keeping; and public safety. ACCM expects the institution to evaluate the effectiveness of CAO and staff including effectiveness and efficiency of the leadership of the medical school in the self-study.
Element 3 additionally addresses the institution’s responsibilities regarding the affiliated institutional locations. ACCM requires the institution to outline the authorities and responsibilities of the CAO and faculties of the allied health programmes and their affiliated hospitals from those of the medical school dean and faculty. To avoid overuse of the faculty resources that the institution shares among other allied health programmes, the institution shall give faculty members additional time for classroom preparation, student tutoring and committee work. The CAO ensures that those students at satellite health care facilities receive the same quality of education and the same standard of student evaluation as provided at the parent campus. To achieve this goal and to implement the academic policies of the institution, the dean shall appoint, at each satellite health care facility, an assistant dean (who reports directly to the dean), a department faculty (who reports to the respective divisional head), and administrative personnel (who reports directly to the supervisor at the parent campus).
ACCM ensures the administration is effective and appropriate by receiving a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects including information on faculty members such as CV’s and Meetings held in regard to administration (Exhibit 4).
ACCM inspects the school and its facilities with an Interim Inspection every two years as well as providing a Report on the school which is sent to the School and the Cayman Islands government (Exhibit 7 & 9, 24 & 25). ACCM protocol requires the on-site inspection team to meet with key members of the medical school’s administration, faculty and student affairs personnel to discuss curriculum, school policies and practices, and the provision of student services to ascertain the effectiveness of the school’s management of instructional resources and include the findings in a written report (Exhibit 2: Sections VII, VIII, IX)
The ACCM Report (Exhibit 7) suggests the Chief Academic Officer of the medical school should have sufficient access to resources and authority of the University President to effectively administer the medical educational programme. As far as ACCM is aware, access to the resources and authority to effectively instruct students remains satisfactory.
ACCM’s Element 11 (Exhibit 1) addresses the college’s facilities and equipment as follows: “The institution shall own buildings, equipment and a campus of sufficient size, quality and design to fulfil its goals. University owned facilities shall include auditoriums, classrooms, student laboratories, a library, faculty offices, administrative offices, admission office, office for student services, research laboratories, sufficient animal care facilities, student dormitory facilities, dining facilities, student activities facilities, and recreational facilities.”
ACCM Protocol requires ACCM on-site inspection team to inspect facilities and equipment for compliance with Element 11 including auditoriums, classrooms, student laboratories and lounges, faculty offices, administrative facilities, research laboratories and libraries to ensure that medical school facilities include offices for faculty, administrators, and support staff; laboratories and other space appropriate for the conduct of 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 space for student study and space; and equipment for library and information access (Exhibit 1 & 2).
ACCM protocol requires ACCM on-site inspection team to report on the faculty in the basic and clinical sciences with respect to professional growth, continuing medical education, faculty collaboration, faculty research activities, professional security and academic freedom, workload, etc. The team is also required to ascertain the faculty views of the curriculum and the student body, faculty familiarity with the educational goals of the college, and faculty knowledge of student performance and the success of the medical school's graduates in post-graduate training and professional practice.
The team report should address whether the size, quality and design of the general facilities are sufficient for the size of the faculty and student body, the level of research activities and the nature of the curriculum.
The team is required to report whether the size of the faculty is adequate and proportional to match (a) the size of the student body, (b) the scope of patient care, and (3) the level of research activities. In addition, for each department, the team should report faculty size; the amount of space allocated to the department; the total budget and amount of contributions from other sources, e.g., parent university, research grants, clinical services and government; the percentage of time faculty devotes to teaching, research, patient care, and faculty committee work; and any major strengths or weaknesses in the department. Finally, the team is to report on a number of other faculty issues, such as workload, professional growth, policies for selection and promotion, etc.

Answer to Question 3: In next Section due to lack of space here
 
Analyst Remarks to Narrative
The Elements of Accreditation 2014 includes standards for determining if the faculty is "sufficient magnitude for the size of the student body and the scope of the program." Additional elements include standards of qualifications that assist in determining appropriateness and qualifications for leadership at an institution. As stated in the narrative, faculty members that are shared between a parent location and a remote site are given additional time for classroom preparation, student tutoring, and committee work. Duties of leadership officials include providing assurance that students at remote locations are treated equally as those at the parent campus.

The on-site inspection team is expected to review and report if the faculties are adequate and qualified for the positions they hold, as well as providing a review of the facilities and equipment. However, no documentation (such as the on site inpsection teams report) was provided to demonstrate ACCM’s review and assessment of the institutions relative to this guideline.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
The provided onsite inspection teams report does demonstrate that faculty was reviewed during the visit. It was noted that 21 full time basic science faculty are employed and that this number has remained stable over time. There has been a decrease in the number of students and in turn an increase to the faculty to student ratio.

Additionally, it was noted that the onsite inspection team reviewed the clinical part time faculty members as well. It was noted that that there are a total of 262 trainers at the various clinical sites. The Dean of Clinical Sciences regularly reviews the appointment, job description, and performance of all staff members. The clinical sites are inspected by the ACCM commissioners on a regular basis.
 
Staff Conclusion: Comprehensive response provided
 
Faculty, Question 2
 
Country Narrative
There is only one medical school in the jurisdiction of the Cayman Islands Government, St Matthew’s University School of Medicine. As the majority of its professional staff, both medical and lay, come from outside the country the questions asked are not strictly appropriate. Taking basic and clinical sciences into consideration, the faculty to student ratio is approximately 1: 4. The qualifications in general are satisfactory. The conflict of interest is minimal in Basic Science and in full-time ICM Departments. A medical school such as St. Matthew’s has no alternative but to send its students to hospitals in different parts of the US and UK. In some cases, a conflict will exist between personal and professional interests. It continues to surprise the ACCM teams, however, how often hospital faculty are governed by teaching and training professionalism.

Answer to Question 2 from last Section as there was not enough space provided:
What are your country's requirements regarding the relationship between the instructional staff at remote sites and clinical locations and the medical school? For example, do you require that clinical-site instructors or supervising teachers are members of the medical school faculty?

The only remote sites are the clinical sites where students do their clinical training. These are based mainly in North America and a few are based in Great Britain.

ACCM Elements (Exhibit 1: Elements 3, 4, 8, & 11) recommends that all clinical sites have ACGME-residency training programmes (USA) or be recognised by the general medical council (GMC) for postgraduate training. The medical school is required to provide oversight over the learning experience of clinical students. There must be an academic organisation in each clinical site that is directly controlled by the medical school. It must encompass all major clinical departments and their subdivisions where the students receive their clinical education. Each clinical department must be staffed by physicians who are faculty members of the medical school and who report to the chief of the department or the course director.

Supervision of the medical students must be carried directly by physicians who are faculty members of the medical college. There must be faculty members in each core discipline where clerkships are taught. These faculty members should be physically present and available and in house and are specifically hired, paid and regularly evaluated for teaching, patient care and clinical research. The clinical staff may be experienced attending physicians or resident physicians under the supervision of attending physicians. However, all attending physicians must hold medical school appointments. The faculty must expose students to a broad range of learning experiences. They must require and monitor student attendance at ward teaching rounds, case conferences, mortality and morbidity meetings, grand rounds, lectures and evening on-call. The faculty must regularly assign and critique student case presentations. They must regularly review logs of cases seen by students and students’ disease entities/ procedures/skills checklist to ensure that each student has appropriate exposure to clinical material.

The faculty must regularly assess and provide a written evaluation of the student’s clinical skills, knowledge and attitudes on each rotation. Faculty should also regularly critique student performance and offer systematic targeted and timely feedback so that students can continually improve their skills. The faculty should evaluate each student by oral and written examinations, students’ case reports and narrative evaluation based on direct observation of the student. Students’ evaluations must be regular and provide feedback to student.

Student attendance policy must be in place. The faculty must provide professional and emotional support to students. The supervising Faculty should have a mentoring role and demonstrate to students the values; attitude and conduct physicians must practice in order to develop trusting relationships with patients. All formal faculty evaluations of students shall be sent to the medical school and will form part of the student record. (Exhibit 1: Element 4 p.p. 6-10).
 
Analyst Remarks to Narrative
It is stated in the country's narrative, that in the Cayman Islands there is only one medical school, SMU and that faculty conflict of interest is minimal. The Elements of Accreditation 2014 state in Element 8.2.1, that “The institution shall have policies that deal with circumstances in which the private interests of faculty or staff may be in conflict with their official responsibilities." However, no documentation was provided that shows the ACCM process for reviewing when the conflict of interest policy at the institution.

NCFMEA may wish to request documentation demonstrating ACCM’s review and assessment of the institutions relative to this guideline.
 
Country Response
ACCM does review and assess the institution relative to conflict of interest policy at the institution by reviewing the SMU Annual Database (Exhibit 4) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
As stated, there are guidelines and policies set in place within ACCM Elements of Accreditation to deal with situations should they arise.
 
Analyst Remarks to Response
Documentation provided in the self-study of SMU indicates all faculty members are full time residents of Grand Cayman during the academic year and are by contract not permitted to engage in other forms of employment without the expressed written consent of the Chancellor. Element 8.2.1 of the Elements of Accreditation 2014 indicates that 'the institution shall have policies that deal with circumstances in which the private interests of faculty or staff may be in conflict with their official responsibilities.'

While the note is included about no outside employment of the faculty in the self-study, no additional documentation provided shows if or how these policies were reviewed by the onsite inspection team or through other appropriate means. NCFMEA may wish to request documentation that shows how the conflict of interest policy was reviewed per standards outlined by ACCM.
 
Staff Conclusion: Additional Information requested
 
Library
 
Country Narrative
Yes. ACCM Element 9 (Exhibit 1) establishes library requirements and states:"To achieve the educational goals of its students and faculty, the institution shall maintain a library with adequate physical facilities of sufficient size and design, adequate collection, up-to-date equipment for using non-print materials, and a competent professional staff to manage the library and to assist its users."

In addition to the above, Element 9 specifies “the requirements for the library staff, library resources, inter-library relationships, and hospital libraries. . . . The library shall develop priorities for the selection of medical books, medical journals, and other non-print materials. These priorities shall include other learning materials such as the most advanced computer hardware, self-tutorial instructional software audio-visual materials, slides, and models to augment the traditional classroom and laboratory experience.”

Hospital libraries where students and faculty are engaged in education shall possess an adequate number and variety of books and periodicals to support a clinical education program. The holdings shall include standard reference materials and textbooks. A professional librarian shall staff the hospital library. The hospital library should offer adequate study areas. ACCM protocol (Exhibit 2) requires the on-site inspection team to meet with the chief librarian and to review and report whether the libraries have the adequate number and variety of books and periodicals including Wi-Fi and internet access to online medical information to support a clinical education program (Exhibit 18).

St. Matthew’s University School of Medicine is the largest medical library in Cayman Islands and lay down national standards.
 
Analyst Remarks to Narrative
ACCM has accreditation standards to address this guideline which require institutions to have sufficient resources and space. The standards also require that students and faculty have access to library services and that the library be managed by a well-trained administrative staff. It is noted that St. Matthew's University School of Medicine is the largest medical library in Cayman Islands.
 
Clinical Teaching Facilities, Question 1
 
Country Narrative
Answer to Question 1:
Yes, there are affiliation agreements between medical schools and clinical teaching sites (Exhibit 16). Teaching agreements are required between medical schools and clinical teaching sites, usually hospitals. They are, of course, approved by the institutions themselves and then assessed by ACCM (Exhibit 8). The teaching agreement between St. Matthew’s University School of Medicine and the Medical Service of the Cayman Islands Government is dealt with by the principals themselves.

Answer to Question 2:
For each hospital and ambulatory facility used by the college for clinical teaching purposes, Element 11 (Exhibit 1) requires the college’s affiliation with these facilities to be written and contain provisions outlining the roles and responsibilities of the hospital and college in the education process in these affiliated agreements. The agreements must contain provisions that include: Educational objectives, Faculty and department chief appointments and responsibilities, Evaluation procedures and Classrooms, library, student study areas, and sleeping rooms for students scheduled to take calls.

ACCM protocol (Exhibit 2: Section VII & VIII) requires the inspection team to evaluate the teaching hospitals, and report on their major clinical departments, ambulatory facilities, and hospital libraries and to discuss with hospital executives the role and responsibilities of the hospital and college and the relationship with the college (Exhibit 8 & 13). The sample agreement contains provisions consistent with the requirements of Element 11 (Exhibit 16). ACCM conducts an on-site review of previously reviewed and approved hospitals or clinical teaching sites at least once during the accreditation cycle. If the ACCM receives information that the college has affiliated with a new teaching site, an Accreditor will visit the new site within 12 months of the placement of students.

ACCM is responsible for ensuring the quality of the clinical teaching sites. At each Hospital or clinical teaching site that has been reviewed previously and approved by an Accreditor whose standards are comparable, an ACCM Accreditor conducts an on-site review at least once during the accredited period (Exhibit 18). At new sites the ACCM Accreditor conducts on-site review within 12 months of the placement of students. Also, at sites that have never been visited by an Accreditor, ACCM must conduct an on-site review within 12 months of the accreditation review of the school which includes ACCM visiting team of two Accreditors on these occasions.

Answer to Question 3:
Yes, ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information and changes regarding clinical sites (Exhibit 4 p.p. 23-30) (Exhibit 21).
 
Analyst Remarks to Narrative
ACCM is responsible for ensuring the quality of the clinical teaching sites. The teaching agreement is self managed between SMU and the Medical Service of the Cayman Islands Government. The institution initiates an agreement between the medical school and a clinical teaching site and is assessed by ACCM.

The Elements of Accreditation 2014, specifically Element 11.2.7, outlines standards for affiliation agreements of the clinical facilities. It states: “such agreement shall include educational objectives, faculty responsibilities, evaluation procedures and student access to appropriate hospital resources and facilities.”

The on site inspection team guidelines set expectations for evaluations of the teaching hospitals. Documentation provided of an ACCM inspection visit showcased that a review of the departments, the facilities (library included), and the relationship of the hospital to the college was conducted.
 
Part 3: Accreditation/Approval Processes and Procedures
Onsite Review, Question 1
 
Country Narrative
Site Visit: ACCM accreditation/approval process includes a thorough comprehensive on-site review of the school to include all of the training sites (if any), during which sufficient information is collected to determine if the school is in fact operating in compliance with ACCM accreditation and approval standards (Exhibit 1 & 2). This review includes, among other things, an analysis of the admission process, the curriculum, the qualifications of the faculty, the achievement of students and graduates, the facilities available to medical students (including the training facilities), and the academic support resources available to students. The accreditation/approval process must include an on-site review of all core clinical clerkship sites.
(a) At sites that have never been visited by an Accreditor (whose standards have been determined to be comparable), the Accreditor must conduct an on-site review within 12 months of the accreditation review of the school.
(b) At sites that have been reviewed previously and approved by an Accreditor whose standards are comparable, the Accreditor must conduct an on-site review at least once during the accredited period.
(c) At new sites (sites opened during the accredited period and that have never been visited previously), the Accreditor must conduct an on-site review within 12 months of the placement of students at those sites.

After a school has had its application for admission to provisional accreditation status reviewed by ACCM and finds that the college has met the eligibility criteria, ACCM will make a site visit to the school to evaluate whether it demonstrates a readiness and ability to comply with Elements of accreditation (Exhibit 1). After site visit and an on-site inspection report, ACCM decides to either grant or deny provisional accreditation. ACCM Protocol (Exhibit 2: Section VII & VIII) addresses the comprehensive on-site inspection conducted by ACCM. After ACCM directs a fully developed unaccredited medical college to begin the self-study, the college completes a profile, a self-study report (Exhibit 12), and submits a request for a comprehensive on-site inspection.

ACCM conducts a comprehensive on-site inspection of a medical college over four and a half days. If ACCM conducts an inspection of a satellite health care facility, it occurs over a two and half days. ACCM conducts on-site inspections in a predetermined and structured format as a blueprint for conducting the inspection and insuring that different teams evaluate different colleges in a uniform and consistent manner. The format includes the team meeting with the chief executive officer and the chief academic officer of the medical school to discuss the school’s organizational structure, mission and goals, and management. The team must also meet with the deputy academic officer for curriculum, the chair of the curriculum committee and selected course director to discuss the management of the curriculum, including the basic science and clinical science courses, multidisciplinary courses, and senior elective courses. It must interview several key administrators and educational personnel to assess the admission process, student promotion and evaluation regarding the methods for measuring student performance, graduation, counselling, academic disciplinary actions, academic progress, career choices, selection of post-graduate training, personal finances, student health, preventing transmission of infectious diseases, and career guidance. Those interviewed by the team include admissions officer and chair of the admissions committees concerning the school’s admission requirements and processes; the finance officer, selected department chairpersons and the faculty representatives, the chair person of the curriculum committee, selected course directors, chief librarian student services personnel, and students to ascertain the medical school’s compliance with each of the accreditation elements.

ACCM Protocol (Exhibit 2: Section VII & VII) for the accreditation of medical colleges specifies the daily format for conducting the on-site inspection, including the subjects for each group or individuals interviewed.The inspection team meets with chief academic officers and faculty representatives from other health care programs – which share a common faculty with the medical college - to assess the adequacy of the teaching staff and to determine whether faculty resources are utilized properly. The inspection team shall also meet with members of the administrative team, deputy course directors, and teaching staff at satellite health care facilities. In addition, it shall meet with the curriculum committee that supervises and monitors the curriculum and student educational experience to determine if consistency exists at all locations. The inspection team shall also meet with the student promotion and evaluation committee that supervises and monitors standards of student evaluation for consistency as well. Note: If an accrediting body is accrediting multiple schools that use a common core clinical clerkship site, where that site has a single coordinator responsible for the educational experience of students from the multiple schools, and where the accrediting body, whenever it visits that site, interviews students from all schools, then that site does not need to be visited more than once during the accredited period. Following visit, a report is drawn up including recommendations and sent to medical school and government (Exhibit 7 & 9, 24 & 25).

From accredited schools, ACCM receives a formal updated database from the medical school in February each year including an Institutional Self-Study (Exhibit 4 & 15). The school is required to answer a list of questions covering all major aspects of the governance of the school.

ACCM protocol (Exhibit 2: Section VII & VIII) requires the inspection team to evaluate the teaching hospitals, and report on their major clinical departments, ambulatory facilities, and hospital libraries and to discuss with hospital executives the role and responsibilities of the hospital and college and the relationship with the college. The sample agreements contain provisions consistent with the requirements of Element 11 (Exhibit 16). ACCM conducts an on-site review of previously reviewed and approved hospitals or clinical teaching sites at least once during the accreditation cycle. If the ACCM receives information that the college has affiliated with a new teaching site, an Accreditor will visit the new site within 12 months after the placement of students.
ACCM is responsible for ensuring the quality of the clinical teaching sites. At each Hospital or clinical teaching site that has been reviewed previously and approved by an Accreditor whose standards are comparable, an ACCM Accreditor conducts an on-site review at least once during the accredited period (Exhibit 18). At new sites, ACCM Accreditor conducts on-site review within 12 months of the placement of students. Also, at sites that have never been visited by an Accreditor, ACCM must conduct an on-site review within 12 months of the accreditation review of the school which includes ACCM visiting team of two Accreditors on these occasions.
 
Analyst Remarks to Narrative
The country has provided its accreditation protocol which outlines standards and procedures for reviewing a medical school and conducting an on site review as part of the accreditation process. They have additionally provided documentation of the affiliation agreement and sample site visit hospital inspection.

While some of the information mentioned in the guideline was reviewed, it is unclear to the reviewer about how the other items listed in this guideline are reviewed by the on site inspection team. (For example, an analysis of the admission process, the curriculum, and the qualifications of the faculty.)

NCFMEA may wish to request documentation demonstrating the on site inspection teams assessment of the admission process, the curriculum, and the qualifications of the faculty.


 
Country Response
ACCM does review and assess the institution relative to inspection of site, faculty and facilities by reviewing the SMU Annual Database (Exhibit 4) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up demonstrate this.
 
Analyst Remarks to Response
Additional information provided in the narrative explains that a review is conducted relative to adherence to the fundamental principles of medicine.

Documentation of the onsite inspection teams report demonstrates that curriculum was reviewed and 'radically updated' in 2010-2011 for the appropriateness of the educational goals of the medical school. Specifically key elements included integration between courses and semesters; more emphasis on team based learning, expanded lab experiences, enhanced preclinical focus, and increased focus on molecular medicine. Documentation provided in the onsite inspection team report indicates a review and adequacy determination of the labs that includes large lecture halls, small-group study space, and expanded clinical skills laboratories.

Minutes of various committees that faculty are involved with were submitted as evidence. Included in these minutes were analyses of the admission process, faculty, and student promotion.
 
Staff Conclusion: Comprehensive response provided
 
Onsite Review, Question 2
 
Country Narrative
Answer to Question 1:
Yes, onsite reviews encompass core clinical clerkship sites affiliated with medical school with teaching agreements are required between medical schools and clinical teaching sites, usually hospitals (Exhibit 16). They are, of course, approved by the institutions themselves and then assessed by ACCM (Exhibit 8). The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2). For each hospital and ambulatory facility used by the college for clinical teaching purposes, Element 11 (Exhibit 1) requires the college’s affiliation with these facilities to be written and contain provisions outlining the roles and responsibilities of the hospital and college in the education process in articulation agreements. The agreements must contain provisions that include: Educational objectives, Faculty and department chief appointments and responsibilities, Evaluation procedures and Classrooms, library, student study areas, and sleeping rooms for students scheduled to take calls.

ACCM protocol (Exhibit 2: Section VII & VIII) requires the inspection team to evaluate the teaching hospitals, and report on their major clinical departments, ambulatory facilities, and hospital libraries and to discuss with hospital executives the role and responsibilities of the hospital and college and the relationship with the college. The sample agreements contain provisions consistent with the requirements of Element 11 (Exhibit 16). ACCM conducts an on-site review of previously reviewed and approved hospitals or clinical teaching sites at least once during the accreditation cycle. If the ACCM receives information that the college has affiliated with a new teaching site, an Accreditor will visit the new site within 12 months after the placement of students.

ACCM is responsible for ensuring the quality of the clinical teaching sites. At each Hospital or clinical teaching site that has been reviewed previously and approved by an Accreditor whose standards are comparable, an ACCM Accreditor conducts an on-site review at least once during the accredited period (Exhibit 13 & 18). At new sites the ACCM Accreditor conducts on-site review within 12 months of the placement of students. Also, at sites that have never been visited by an Accreditor, ACCM must conduct an on-site review within 12 months of the accreditation review of the school which includes ACCM visiting team of two Accreditors on these occasions.

ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school including information and changes regarding clinical sites (Exhibit 4 & 15).

Answer to Question 2:
ACCM is responsible for ensuring the quality of the clinical teaching sites. At each Hospital or clinical teaching site that has been reviewed previously and approved by an Accreditor whose standards are comparable, an ACCM Accreditor conducts an on-site review at least once during the accredited period (Exhibit 13 & 18). At new sites the ACCM Accreditor conducts on-site review within 12 months of the placement of students. Also, at sites that have never been visited by an Accreditor, ACCM must conduct an on-site review within 12 months of the accreditation review of the school which includes ACCM visiting team of two Accreditors on these occasions.

ACCM protocol (Exhibit 2: Section VII & VIII) requires the inspection team to evaluate the teaching hospitals, and report on their major clinical departments, ambulatory facilities, and hospital libraries and to discuss with hospital executives the role and responsibilities of the hospital and college and the relationship with the college. The sample agreements contain provisions consistent with the requirements of Element 11 (Exhibit 16). ACCM conducts an on-site review of previously reviewed and approved hospitals or clinical teaching sites at least once during the accreditation cycle. If the ACCM receives information that the college has affiliated with a new teaching site, an Accreditor will visit the new site within 12 months after the placement of students.

ACCM receives a formal updated database from the medical school in February each year including an Institutional Self-Study. The school is required to answer a list of questions covering all major aspects of the governance of the school including information and changes regarding clinical sites (Exhibit 4 & 15).
 
Analyst Remarks to Narrative
The country states in its narrative In the country's narrative, they state that ACCM conducts a comprehensive review of core clerkship sites. The standards for these sites are included in the Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012. The institutions ability to comply with these standards is evaluated by the on site inspection team. An example team report was included as documentation of this process. Ultimately, it is stated that ACCM is responsible for ensuring the quality of the clinical teaching sites.
 
Onsite Review, Question 3
 
Country Narrative
Site Visit: ACCM accreditation/approval process includes a thorough comprehensive on-site review of the school to include all of the training sites (if any), during which sufficient information is collected to determine if the school is in fact operating in compliance with ACCM accreditation and approval standards (Exhibit 1 & 2). This review includes, among other things, an analysis of the admission process, the curriculum, the qualifications of the faculty, the achievement of students and graduates, the facilities available to medical students (including the training facilities), and the academic support resources available to students.
The accreditation/approval process must include an on-site review of all core clinical clerkship sites.
(a) At sites that have never been visited by an Accreditor (whose standards have been determined to be comparable), the Accreditor must conduct an on-site review within 12 months of the accreditation review of the school.
(b) At sites that have been reviewed previously and approved by an Accreditor whose standards are comparable, the Accreditor must conduct an on-site review at least once during the accredited period.
(c) At new sites (sites opened during the accredited period and that have never been visited previously), the Accreditor must conduct an on-site review within 12 months of the placement of students at those sites.
After a school has had it application for admission to provisional accreditation status reviewed by the ACCM, and the ACCM finds the college has met the eligibility criteria, the ACCM will make a site visit to the school to evaluate whether the college demonstrates a readiness and ability to comply with Elements of accreditation (Exhibit 1). After the site visit and an on-site inspection report, the ACCM decides to either grant or deny provisional accreditation. ACCM Protocol (Exhibit 2: Section VII & VIII) addresses the comprehensive on-site inspection conducted by the ACCM.
After ACCM directs a fully developed unaccredited medical college to begin the self-study, the college completes a profile, a self-study report (Exhibit 12), and submits a request for a comprehensive on-site inspection. For accredited schools, ACCM receives a formal updated database from the medical school in February each year. The school is required to answer a list of questions covering all major aspects of the governance of the school (Exhibit 4 & 15).

ACCM conducts a comprehensive on-site inspection of a medical college over four and a half days. If ACCM conducts an inspection of a satellite health care facility, it occurs over a two and half days. The ACCM conducts on-site inspections in a predetermined and structured format as a blueprint for conducting the inspection and insuring that different teams evaluate different colleges in a uniform and consistent manner. The format includes the team meeting with the chief executive officer and the chief academic officer of the medical school to discuss the school’s organizational structure, mission and goals, and management. The team must also meet with the deputy academic officer for curriculum, the chair of the curriculum committee and selected course director to discuss the management of the curriculum, including the basic science and clinical science courses, multidisciplinary courses, and senior elective courses. It must interview several key administrators and educational personnel to assess the admission process, student promotion and evaluation regarding the methods for measuring student performance, graduation, counselling, academic disciplinary actions, academic progress, career choices, selection of post-graduate training, personal finances, student health, preventing transmission of infectious diseases, and career guidance. Those interviewed by the team include admissions officer and chair of the admissions committees concerning the school’s admission requirements and processes; the final officer, selected department chairpersons and the faculty representatives, the chair person of the curriculum committee, selected course directors, chief librarian student’s services personnel, and students to ascertain the medical school’s compliance with each of the accreditation elements. ACCM Protocol (Exhibit 2: Section VII & VII) for the accreditation of medical colleges specifies the daily format for conducting the on-site inspection, including the subjects for each group or individuals interviewed.
The inspection team meets with chief academic officers and faculty representatives from other health care programs – which share a common faculty with the medical college - to assess the adequacy of the teaching staff and to determine whether faculty resources are utilized properly. The inspection team shall also meet with members of the administrative team, deputy course directors, and teaching staff at satellite health care facilities. In addition, it shall meet with the curriculum committee that supervises and monitors the curriculum and student educational experience to determine if consistency exists at all locations. The inspection team shall also meet with the student promotion and evaluation committee that supervises and monitors standards of student evaluation for consistency as well. Note: If an accrediting body is accrediting multiple schools that use a common core clinical clerkship site, where that site has a single coordinator responsible for the educational experience of students from the multiple schools, and where the accrediting body, whenever it visits that site, interviews students from all schools, then that site does not need to be visited more than once during the accredited period. Following visit, a report is drawn up including recommendations and sent to medical school and government (Exhibit 7 & 9, 24 & 25).

ACCM protocol (Exhibit 2: Section VII & VIII) requires the inspection team to evaluate the teaching hospitals, and report on their major clinical departments, ambulatory facilities, and hospital libraries and to discuss with hospital executives the role and responsibilities of the hospital and college and the relationship with the college(Exhibit 8 & 13). The sample agreement contains provisions consistent with the requirements of Element 11 (Exhibit 16). ACCM conducts an on-site review of previously reviewed and approved hospitals or clinical teaching sites at least once during the accreditation cycle. If the ACCM receives information that the college has affiliated with a new teaching site, an Accreditor will visit the new site within 12 months after the placement of students.
ACCM is responsible for ensuring the quality of the clinical teaching sites. At each Hospital or clinical teaching site that has been reviewed previously and approved by an Accreditor whose standards are comparability, an ACCM Accreditor conducts an on-site review at least once during the accredited period (Exhibit 18). At new sites the ACCM Accreditor conducts on-site review within 12 months of the placement of students. Also, at sites that have never been visited by an Accreditor, ACCM must conduct an on-site review within 12 months of the accreditation review of the school which includes ACCM visiting team of two Accreditors on these occasions.
 
Analyst Remarks to Narrative
The country cites ACCM’s standards that includes an accreditation/approval process which requires an on site evaluation of all clinical clerkship sites. This includes those that have never been visited, those previously reviewed, and at all new sites within the appropriate timeframes. The country has provided sample documentation that showcases the review process.
 
Onsite Review, Question 4
 
Country Narrative
Educational programmes are offered by the medical school and there are affiliation agreements between medical schools and clinical teaching sites (Exhibit 16). Teaching agreements are required between medical schools and clinical teaching sites, usually hospitals. They are, of course, approved by the institutions themselves and then assessed by ACCM (Exhibit 8). The teaching agreement between St. Matthew’s University School of Medicine and the Medical Service of the Cayman Islands Government is dealt with by the principals themselves. The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2).

For each hospital and ambulatory facility used by the college for clinical teaching purposes, Element 11 (Exhibit 1) requires the college’s affiliation with these facilities to be written and contain provisions outlining the roles and responsibilities of the hospital and college in the education process in articulation agreements. The agreements must contain provisions that include: Educational objectives, Faculty and department chief appointments and responsibilities, Evaluation procedures and Classrooms, library, student study areas, and sleeping rooms for students scheduled to take calls.

ACCM protocol (Exhibit 2: Section VII & VIII) requires the inspection team to evaluate the teaching hospitals, and report on their major clinical departments, ambulatory facilities, and hospital libraries and to discuss with hospital executives the role and responsibilities of the hospital and college and the relationship with the college. The sample agreements contain provisions consistent with the requirements of Element 11. ACCM conducts an on-site review of previously reviewed and approved hospitals or clinical teaching sites at least once during the accreditation cycle (Exhibit 13 & 18). If the ACCM receives information that the college has affiliated with a new teaching site, an Accreditor will visit the new site within 12 months after the placement of students.
 
Analyst Remarks to Narrative
The country states that the institutions in conjunction with the clinical clerkships site initiate formal affiliation agreements. ACCM assesses the agreements for compliance with the standards outlined in the ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012. The country has provided sample documentation that showcases an affiliation agreement.
 
Onsite Review, Question 5
 
Country Narrative
Educational programmes are offered by the medical school and there are affiliation agreements between medical schools and clinical teaching sites (Exhibit 16). Teaching agreements are required between medical schools and clinical teaching sites, usually hospitals. They are, of course, approved by the institutions themselves and then assessed by ACCM (Exhibit 8). The teaching agreement between St. Matthew’s University School of Medicine and the Medical Service of the Cayman Islands Government is dealt with by the principals themselves. The medical school must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1 & 2).

For each hospital and ambulatory facility used by the college for clinical teaching purposes, Element 11 (Exhibit 1) requires the college’s affiliation with these facilities to be written and contain provisions outlining the roles and responsibilities of the hospital and college in the education process in articulation agreements. The agreements must contain provisions that include: Educational objectives, Faculty and department chief appointments and responsibilities, Evaluation procedures and Classrooms, library, student study areas, and sleeping rooms for students scheduled to take calls.

ACCM protocol (Exhibit 2: Section VII & VIII) requires the inspection team to evaluate the teaching hospitals, and report on their major clinical departments, ambulatory facilities, and hospital libraries and to discuss with hospital executives the role and responsibilities of the hospital and college and the relationship with the college. The sample agreement contains provisions consistent with the requirements of Element 11 (Exhibit 16). ACCM conducts an on-site review of previously reviewed and approved hospitals or clinical teaching sites at least once during the accreditation cycle (Exhibit 13). If the ACCM receives information that the college has affiliated with a new teaching site, an Accreditor will visit the new site within 12 months after the placement of students.

Site Visit: ACCM accreditation/approval process includes a thorough comprehensive on-site review of the school to include all of the training sites (if any), during which sufficient information is collected to determine if the school is in fact operating in compliance with ACCM accreditation and approval standards (Exhibit 1 & 2). This review includes, among other things, an analysis of the admission process, the curriculum, the qualifications of the faculty, the achievement of students and graduates, the facilities available to medical students (including the training facilities), and the academic support resources available to students.

The accreditation/approval process must include an on-site review of all core clinical clerkship sites.
(a) At sites that have never been visited by an Accreditor (whose standards have been determined to be comparable), the Accreditor must conduct an on-site review within 12 months of the accreditation review of the school.
(b) At sites that have been reviewed previously and approved by an Accreditor whose standards are comparable, the Accreditor must conduct an on-site review at least once during the accredited period.
(c) At new sites (sites opened during the accredited period and that have never been visited previously), the Accreditor must conduct an on-site review within 12 months of the placement of students at those sites.

ACCM is an accrediting body which accredits multiple schools that use a common core clinical clerkship site, where that site has a single coordinator responsible for the educational experience of students from the multiple schools, and where the accrediting body, whenever it visits that site, interviews students from all schools, then that site does not need to be visited more than once during the accredited period.

ACCM is responsible for ensuring the quality of the clinical teaching sites. At each Hospital or clinical teaching site that has been reviewed previously and approved by an Accreditor whose standards are comparable, an ACCM Accreditor conducts an on-site review at least once during the accredited period (Exhibit 13 & 18). At new sites the ACCM Accreditor conducts on-site review within 12 months of the placement of students. Also, at sites that have never been visited by an Accreditor, ACCM must conduct an on-site review within 12 months of the accreditation review of the school which includes ACCM visiting team of two Accreditors on these occasions.

The ratio of the Commissioners to accredited medical schools is 3 to 1. The experience and qualifications of the Commissioners/on-site evaluators are specified the Protocol. They “represent individuals who possess the academic qualifications and the experience necessary to effectively evaluate medical colleges for accreditation”.

Additionally, representation, qualifications and experience of Commissioners include:

(1) An earned M.D. from a medical school.

(2) Completion of postgraduate training.

(3) Specialty certification from a recognised medical society.

(4) Experience as a chief medical officer of a medical college.

(5) Nine members have experience as a chief or senior faculty of a clinical department at a medical college and are/were also concerned with patient care.

(6) Two members have experience as a chief or senior faculty in a basic science department at a medical college (with M.D.). Many have experience in mainly clinical but also in basic science departments.

(7) Experience as a medical administrator at a postgraduate teaching hospital.

(8) Experience in undergraduate and postgraduate education, teaching, research.

(9) Experience in the medical school evaluation process.

(10) One is an obligatory lay-member.

ACCM receives a formal updated database from the medical school in February each year as well as an Institutional Self-Study (Exhibit 15). The school is required to answer a list of questions covering all major aspects of the governance of the school including information and changes regarding clinical sites (Exhibit 4 p.p. 23-30) (Exhibit 21).
 
Analyst Remarks to Narrative
As previously stated, the institutions in conjunction with the clinical clerkships site initiate formal affiliation agreements. ACCM assesses the agreements for compliance with the standards outlined in the ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012. The institutions ability to comply with these standards is evaluated by the on-site inspection team. An example team report was included as documentation of this process. Ultimately, it is stated that ACCM is responsible for ensuring the quality of the clinical teaching sites.

The country states that ACCM is an accrediting body which accredits multiple schools that use a common core clinical clerkship site, where that site has a single coordinator responsible for the educational experience of students from the multiple schools, and where the accrediting body, whenever it visits that site, interviews students from all schools. As per the guidelines, that site does not need to be visited more than once during the accredited period.
 
Qualifications of Evaluators, Decision-makers, Policy-makers
 
Country Narrative
All of the ACCM inspection team members are themselves Commissioners of ACCM who are qualified by training and experience as medical educators to make policy and accreditation decisions and must comply with ACCM Protocol (Exhibit 2 p.p.5-10). In addition, each on-site inspection team consists of three Commission members.

Members (Commissioners) serve ACCM without compensation. They represent individuals who possess the academic qualifications and experience necessary to effectively evaluate medical colleges for accreditation.

ACCM Protocol defines the experience and qualifications of the Commissioners/on-site evaluators to include:
An earned M.D. from a medical college.
Completion of postgraduate training.
Specialty certification from a recognized medical society.
Experience as a chief academic officer of a medical college.
Experience as a chief or senior faculty of a basic science department.
Experience as an administrator at a postgraduate teaching hospital.
Experience in undergraduate and graduate medical education, teaching, research and patient care.
Experience in the medical school evaluation process.
Commissioners representing the public

ACCM adjusts the size of its membership in proportion to the number of medical schools it accredits, with a ratio of Commissioners to accredited medical schools set at 3 to 1. The protocol for accreditation also described the specific qualifications and duties of the members who serve on inspections teams at the medical colleges.

Training is on-going through Commissioners being involved in and having access to written and electronic materials relating to ACCM, having a set number of duties and gaining experience including reviewing Annual Databases, writing reports, processing Applications from medical schools seeking accreditation, scheduling and carrying out onsite inspections of medical schools and clinical sites (Exhibit 2 p.p.5-10).
 
Analyst Remarks to Narrative
ACCM has provided the information regarding their standards for commissioner's which demonstrates the Commission's qualifications as decision makers and policy makers. The ACCM commissioners are composed of a membership that is proportional to the number of medical schools it accredits. It includes academics, practitioners, and public members. The narrative indicates that training is conducted, but no documentation of the training was provided.

It is stated that training is conducted for individuals involved in the accreditation processes. NCFMEA may wish to request documentation of this training.
 
Country Response
As stated, training is on-going through Commissioners being involved in and having access to written and electronic materials relating to ACCM, having a set number of duties and gaining experience including reviewing Annual Databases, writing reports, processing Applications from medical schools seeking accreditation, scheduling and carrying out onsite inspections of medical schools and clinical sites.
Therefore, there is no actual specific documentation apart from ACCM providing each Commissioner with the ACCM Handbook (Exhibit 35), including ACCM Protocol and Elements and any other relevant information on file that is required.
Training has taken place in the past when new members are accepted and join ACCM to become Convenors with the last training session being held in 2012 (Exhibit 39).
As all positions on the ACCM Board are presently filled and no new members have joined, therefore no training sessions have taken place since that date.
 
Analyst Remarks to Response
Additional information provided in the narrative explains that training is on-going so that Commissioners are able to successfully complete their duties. In addition, the country has provided documentation of new member training that occurred in 2012. It is stated that no new members have joined since that time.
 
Staff Conclusion: Comprehensive response provided
 
Re-evaluation and Monitoring, Question 1
 
Country Narrative
ACCM accreditation period is six years and the college must undergo a comprehensive re-evaluation for each accreditation period. Member institutions accredited by the ACCM must meet ACCM Elements (or standards) and Protocol of accreditation for colleges of medicine (Exhibit 1 & 2). ACCM grants accreditation after a team of Commissioners conduct a thorough on-site inspection of the institution. The on-site inspection includes a review of the parent campus, all satellite health care facilities and sites where the college maintains an educational presence.

Since each accredited institution must maintain continued compliance with the elements of accreditation, ACCM requires an accredited college to submit an annual database report. The information reported by the college in the annual database report includes the following:
• Institutional Information
• Admissions
• Enrollment
• Faculty
• Curriculum
• Evaluation
• USMLE
• NBME
• Hospitals
• Graduation and Residency
• General Information
• Administration

ACCM reviews the medical college’s report (Exhibit 4) and supporting documentation (Exhibit 15) to determine whether the college remains in compliance with the elements. If the annual report and/or supporting documentation indicated that a college has fallen out of compliance with ACCM Elements, ACCM will begin a programme review at the college to determine whether it is necessary to change the school’s accreditation status. At the midpoint of the accreditation period, ACCM will also conduct an on-site inspection at the college (Exhibit 7 & 9, 24 & 25).

Other post accreditation oversight rendered by ACCM includes substantive changes or adverse actions taken by another accrediting agency or regulatory body. Whenever a college undergoes a change in ownership or governance, the college is required to complete relevant portions of the Profile pertaining to the change. ACCM will schedule an on-site inspection of the college within six months from the receipt of the notification letter from the college. In addition, if the college wants to establish a new branch campus, the ACCM requires the college to complete the applicable portions of the profile and to include with the letter projections concerning the branch’s revenue and expenses. From the date of receipt of the college’s notification letter, ACCM will conduct an on-site inspection within six months.

Annual Surveillance of Accreditation Programme:
ACCM requires all colleges accredited by ACCM to maintain continued compliance with ACCM Elements and Protocol. The principle compliance tool utilized by ACCM to monitor compliance is a document entitled the Annual Database Report. Each year, ACCM forwards an Annual Survey/Database Report to the colleges for completion. If the annual survey indicates a school has fallen out of compliance, the Commission will “open a program review on the college to determine whether to change its accreditation status”.

Change of Ownership: dealt with by ACCM Element 12 (Exhibit 1) and ACCM Protocol Section XIII (Exhibit 2)

Investigation of Complaints to the Commission: dealt with by ACCM Element 13 (Exhibit 1) and ACCM Protocol Section V - XVI (Exhibit 2), ACCM Website (Exhibit 3) and through the SMU Student Handbook (Exhibit 17).

ACCM Procedures for handling Complaints about Programme Quality: ACCM Protocol Section XVI – Appendix A (Exhibit 2 p.54)

Investigation of Complaints to ACCM (ACCM Section XIII): ACCM will review only complaints that deal with a college’s failure to comply with ACCM Elements of Accreditation. If the complaint is credible….then ACCM will forward a copy….to the college. If the college fails to refute the charges, ACCM will open an inquiry and will notify the complainant of its findings at the conclusion of the inquiry.

It is assumed but not actually documented in the Protocol (but stated in ACCM Procedures for handling Complaints about Programme Quality, 2004) that the college would have also to be contacted regarding the inquiry. The degree of seriousness of the complaint and the reply of the college would obviously affect the inquiry. Were the position to be of a serious nature the inquiry committee would not shrink from advising ACCM of the need for the college to be called into question.

ACCM has written procedures to investigate complaints it receives involving a college’s failure to comply with the elements of accreditation. After reviewing the complaint to determine its credibility, ACCM will forward a credible complaint to the college for a response. If ACCM does not find the complaint credible or the college refutes the complaint, ACCM will dismiss the complaint and notify the complainant of its decision. Although ACCM annually publishes a list of colleges it accredits and a list of colleges seeking accreditation, ACCM has not received any significant complaints during the past year.
 
Analyst Remarks to Narrative
The country's reaccreditation interval is a maximum of six years.
 
Re-evaluation and Monitoring, Question 2
 
Country Narrative
Answer to Question 1:
The medical school must adhere to the standards set down by ACCM by complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 (Exhibit 1: Element 13) (Exhibit 2: Sections VII, VIII, IX).

Since each accredited institution must maintain continued compliance with the elements of accreditation, ACCM requires an accredited college to submit an annual compliance survey or annual database report. The information reported by the college in the annual database report includes the following:
• Institutional Information
• Admissions
• Enrollment
• Faculty
• Curriculum
• Evaluation
• USMLE
• NBME
• Hospitals
• Graduation and Residency
• General Information
• Administration

ACCM reviews the medical college’s report (Exhibit 4) and supporting documentation (Exhibit 15) to determine whether the college remains in compliance with the elements. If the annual report and/or supporting documentation indicated that a college has fallen out of compliance with ACCM Elements, ACCM will begin a programme review at the college to determine whether it is necessary to change the school’s accreditation status. At the midpoint of the accreditation period, ACCM will also conduct an on-site inspection at the college (Exhibit 7 & 9, 24 & 25).

Investigation of Complaints to the Commission: dealt with by ACCM Element 13 (Exhibit 1) and ACCM Protocol Section V - XVI (Exhibit 2) and through the SMU Student Handbook (Exhibit 17).

ACCM Procedures for handling Complaints about Programme Quality: ACCM Protocol Section XVI – Appendix A (Exhibit 2 p.54).

Investigation of Complaints to ACCM (Exhibit 2: Section XIII): ACCM will review only complaints that deal with a college’s failure to comply with ACCM Elements of Accreditation. If the complaint is credible….then ACCM will forward a copy….to the college. If the college fails to refute the charges, ACCM will open an inquiry and will notify the complainant of its findings at the conclusion of the inquiry.

It is assumed but not actually documented in ACCM Protocol (but stated in ACCM Procedures for handling Complaints about Program Quality, 2004) that the college would have also to be contacted regarding the inquiry. The degree of seriousness of the complaint and the reply of the college would obviously affect the inquiry. Were the position to be of a serious nature the inquiry committee would not shrink from advising ACCM of the need for the college to be called into question.

ACCM has written procedures to investigate complaints it receives involving a college’s failure to comply with the elements of accreditation. After reviewing the complaint to determine its credibility, ACCM will forward a credible complaint to the college for a response. If ACCM does not find the complaint credible or the college refutes the complaint, ACCM will dismiss the complaint and notify the complainant of its decision. Although ACCM annually publishes a list of colleges it accredits and a list of colleges seeking accreditation, the ACCM has not received any significant complaints during the past year.

Answer to Question 2:
The accrediting body can only investigate Student complaints which relate to non compliance with ACCM Elements (Exhibit 1) and will only consider complaints that have not been resolved satisfactorily at the institutional level.

ACCM Element 13 requires the medical school to provide information to students about the mechanism for submitting complaints to SMU on their website and in the SMU student handbook (Exhibit 17). The medical school is expected to keep a log of complaints received and ACCM keeps a log of complaints made to it, together with action and time taken to process any such complaints.

If the number of complaints which upon investigation appear appropriate exceeds more than a small number (e.g. 4) per year, an additional meeting with the chief academic officer and senior staff will be arranged with a view to demanding that corrective action be taken at a management level and the Board of Trustees is informed.

The SMU medical school maintains a log of student’s complaints and has a protocol for dealing with these internally within a specific time frame. ACCM investigates complaints that, if substantiated, may constitute non-compliance with ACCM Elements. Details are published in the SMU Student Handbook (Exhibit 17) and in the Elements (Exhibit 1: p.p. 22-23).

Complaints are infrequent. An increase in the number of serious complaints would require ACCM reconsider the medical school’s accreditation status and may prompt additional visits to the campus and /or clinical sites.
 
Analyst Remarks to Narrative
The country has provided its process for reviewing student complaints which are also outlined on the ACCM website. On an annual basis, ACCM requires an institution to submit an annual database report that encompasses information related to their compliance with the standards set in the Elements of Accreditation 2014.
 
Substantive Change
 
Country Narrative
ACCM reviews the medical college’s report and supporting documentation to determine whether the college remains in compliance with ACCM Elements (Exhibit 1: Element 12) and Protocol (Exhibit 2: Section XIII).

If the annual report indicates that a college has fallen out of compliance with ACCM Elements, ACCM will begin a programme review at the college to determine whether it is necessary to change the school’s accreditation status. At the midpoint of the accreditation period, ACCM will also conduct an on-site inspection at the college.

Other post accreditation oversight rendered by ACCM includes substantive changes or adverse actions taken by another accrediting agency or regulatory body. Whenever a college undergoes a change in ownership or governance, the college is required to complete relevant portions of the Profile pertaining to the change. ACCM will schedule an on-site inspection of the college within six months from the receipt of the notification letter from the college. In addition, if the college wants to establish a new branch campus, ACCM requires the college to complete the applicable portions of the profile and to include with the letter projections concerning the branch’s revenue and expenses. From the date of receipt of the college’s notification letter, ACCM will conduct an on-site inspection within six months.

ACCM protocol requires a college undergoing a change in governance or establishing a branch campus to complete applicable portions of the profile. For these changes, ACCM will schedule an on-site inspection within six months after it receives a notification letter from the college. With respect to establishing a branch campus, the college must also complete the applicable portions of the profile that includes the revenue and expenses for the branch. ACCM will also determine whether to continue, change or add conditions to the terms of the college’s accreditation. In addition, ACCM will schedule an on-site inspection of the branch within six months from receipt of the notification letter from the college.

For each substantive change, the ACCM inspection team will prepare an inspection report on whether the new owner or governors can ensure that the college or whether the branch campus will continue to comply with the elements of accreditation. ACCM will decide whether to continue, change or add conditions to the terms of the college’s accreditation based on the findings in the inspection report.
 
Analyst Remarks to Narrative
According to the narrative, ACCM requires universities to report substantive changes related to the following: campus extensions, curriculum changes, resource changes, and changes in admission numbers. Element 12 of the Elements of Accreditation 2014 documents the specifics for notification.

In the country's narrative, they state that the on site inspection team is required to review substantive changes and will make necessary adjustments to accreditation status if necessary.

NCFMEA may wish to request documentation that shows how the on site inspection team review the institution's goals for compliance under this guideline.
 
Country Response
ACCM does review and assess the institution relative to this guideline by reviewing the SMU Annual Database (Exhibit 4) and SMU Self-Study (Exhibit 15), inspections carried out and onsite reports (Exhibit 7 & 29) written up.
 
Analyst Remarks to Response
Additional information provided in the narrative explains that a review is conducted related to substantive change. The provided onsite inspection teams report demonstrates that substantive change was reviewed during the visit. Specifically stated the onsite inspection team reports that a review of the new basic science curriculum, the basic science campus, and the total medical facility has occurred
 
Staff Conclusion: Comprehensive response provided
 
Conflicts of Interest, Inconsistent Application of Standards, Question 1
 
Country Narrative
Answer to Question 1:
To ensure that bias or conflict of interest by those involved in the accreditation evaluation and decision-making processes do not exist, the ACCM Protocol (Exhibit 1: p.p. 5 -10) addresses the independence of the Commissioners involved in these processes as follows: “To maintain independence of the Commission and to avoid conflicts of interest, new Commissioners shall not be selected or elected by individuals and organizations such as:
1. An officer of the accredited college or the college itself.
2. An officer of a college seeking accreditation of the college itself.
3. An officer of a related professional association or the association itself.”
The same individuals listed above do not participate in the development of review of the Commission budget.

Additionally, ACCM policy states an individual may be disqualified from serving on the Commission or inspection team if any of the following conditions exist:
1. Is employed by the medical college seeking accreditation. Employed means as a full-time faculty member, administrator or consultant.
2. Was employed by another institution that has a substantial contractual business relationship with the medical college seeking accreditation.
3. Was employed by another institution that has the same ownership or governance as the medical college seeking accreditation.
4. Was enrolled at the medical school seeking accreditation, meaning as a full-time student or resident.
5. Was connected to the chief academic officer seeking accreditation. This means as colleagues employed by the same organization and who carried on regular professional interaction at their previous places of employment. This provision excludes situations in which there were no professional contacts, in spite of common institutional affiliations.
6. Was employed at a medical college that maintained a substantive working relationship with the medical college seeking accreditation.
7. Has a prejudicial view towards the college seeking accreditation.
8. Is related to an employee of the college by blood or marriage.

Finally, the ACCM inspection team reviews the college’s bylaws and codes of regulation for evidence that the duties and responsibilities of the principals in the college are free of conflicting interests with the college. These policies contain an extensive list of exclusions that prevents a Commissioner from participating on an inspection team or making an accreditation decision that challenges the objectivity of the accreditation process.

Answer to Question 2:
To ensure that ACCM Elements(Exhibit 1) of accreditation are applied consistently, the Commissioners themselves conduct every aspect of the accrediting operations, e.g. on-site inspections, policy-making and decision-making. To control against the inconsistent application of the standards, the Commission conducts the inspection in a predetermined and structured format that serves a blueprint for conducting the inspection and ensuring that different teams evaluate different colleges with equal uniformity and consistency.
 
Analyst Remarks to Narrative
As stated in the narrative, the country requires commissioners to maintain 'independence' of a conflict of interest by ensuring that they do not meet conflict criteria outlined in the ACCM Protocol for Accreditation 2012. It is additionally stated that the Commissioners are the ones who do the on-site inspection visit as well as the making the decisions. However this practice is somewhat uncommon among accrediting organizations.

NCFMEA may wish to additional information explaining how conflicts of interest are prevented (during the accreditation approval process) since commissions conduct site visits and also make the accreditation decision.
 
Country Response
ACCM Commissioners have no relationship with the medical school other than to act as inspectors and Accreditors.
There is no incentive or personal motivation for conflict possible.
Each Commissioner signs a Conflict of Interest Form on becoming a Director of ACCM (Exhibit 38).
Should the NCFMEA wish for additional information, please let ACCM know what is required and also ACCM would be happy to explain at NCFMEA presentation how conflicts of interest are prevented (during the accreditation approval process) if requested.
 
Analyst Remarks to Response
Additional information provided in the narrative explains that no additional benefit is gained (of the individual) by having a commissioner act as an accreditor or inspector. Documentation provided shows a blank Conflict of Interest Form.

NCFMEA may wish to request the signed copies of the Conflict of Interest forms by all ACCM Commissioners and/or any additional information related to this topic.
 
Staff Conclusion: Additional Information requested
 
Conflicts of Interest, Inconsistent Application of Standards, Question 2
 
Country Narrative
All medical schools must adhere to the standards set down by ACCM by fully complying with ACCM Elements of Accreditation 2014 and ACCM Protocol for Accreditation 2012 and provide an education that adheres to LCME standards (Exhibit 1 & 2).

One of ACCM’s controls against the inconsistent application of standards is the utilization of the Commissioners themselves to conduct every aspect of its accrediting operations, from on-site inspection to policy-making and decision-making by following and being fully compliant with ACCM’s Protocol (Exhibit 2).

It is ACCM’s policy that the inspection teams that conduct the on-site reviews of medical schools are composed of the Commissioners themselves. The policy states further that, in general, each team is composed of at least three Commissioners.

As another control against the inconsistent application of standards, ACCM requires the on-site inspection to be conducted in a predetermined and structured format. According to ACCM, “this format will serve as a blueprint for….ensuring that different teams evaluate different colleges with equal uniformity and consistency”.
 
Analyst Remarks to Narrative
ACCM’s Protocol for Accreditation 2012 publication has standards and procedures regarding consistent reviews. However, as noted previously, commissioners are the ones who do the on site inspection visit as well as the making the decisions. This practice is somewhat uncommon among accrediting organizations.

NCFMEA may wish to additional information explaining how conflicts of interest are prevented (during the accreditation approval process) since commissions conduct site visits and also make the accreditation decision.
 
Country Response
ACCM Commissioners act as a team (3 for a full review, 2 for an interim review).
ACCM Commissioners follow specific guidelines and all are present for the whole period of the visit.
There is no incentive or personal motivation for conflict possible.
Each Commissioner signs a Conflict of Interest Form on becoming a Director of ACCM (Exhibit 38).
Should the NCFMEA wish for additional information, please let ACCM know what is required and also ACCM would be happy to explain at NCFMEA presentation how conflicts of interest are prevented (during the accreditation approval process) if requested.
 
Analyst Remarks to Response

Additional information provided in the narrative explains that no additional benefit is gained (of the individual) by having a commissioner act as an accreditor or inspector. Documentation provided shows a blank Conflict of Interest Form.

NCFMEA may wish to request the signed copies of the Conflict of Interest forms for ACCM Commissioners and/or any additional information related to this question.
 
Staff Conclusion: Additional Information requested
 
Accrediting/Approval Decisions, Question 1
 
Country Narrative
ACCM has incorporated ACCM accreditation Elements (standards) and Protocol (Exhibit 1 & 2) in all of the steps involving the evaluation and decision-making process of colleges of medicine for the countries it represents.

ACCM requires the colleges to provide specific information that is keyed into the accreditation Elements in the annual survey/data reports. The Annual Database (Exhibit 4) and the Institutional Self-Study (Exhibit 12) requires colleges to provide extensive and specific information based on the Elements. ACCM receives an annual database from the school with information on the previous year’s outcome data and financial reports (Exhibit 4). In addition, ACCM requires a comprehensive self-study document (Exhibit 15) to be completed by the medical school every 5-6 years.

Following acceptance as suitable for accreditation, the medical school is visited every two years for review and a complete re-evaluation for re-accreditation occurs every 6 years (Exhibit 7 & 9, 24 & 25). Clinical sites are evaluated regularly based on reports from students and visited at least once during the 6 year accreditation period.

The structured on-site inspection is based on ACCM Elements and uses predetermined questions found in ACCM Protocol to ensure that the on-site review is consistent at every college reviewed by the ACCM (Exhibit 7 & 9, 24 & 25).

The decisions made by ACCM consider outcomes based on the performance of students on licensure examinations, residency acceptance, and graduate employment. For example, all students who enter the fifth semester of study must pass the USMLE Step 1, before entering the clinical science semesters. First time takers during 2013-2014 had 94% pass rate of the USMLE Step 1 (Exhibit 15 p.20). SMU Annual Database Report 2013-2014 reveals the importance of the insistence of the ACCM on the necessity of St Matthew’s to pass Step 1 prior to entering clinical science semesters and the improvement in the standard of reporting the employment status of graduates. The latter will continue to be a priority and lead to improvements in the relevant section of the questionnaire.

ACCM collects data on the pass rates for the Step 2CK (92%) and Step2CS (89%) examination and graduates who obtained residencies (Exhibit 15 p.21). Despite the emphasis on participation by graduates in various post graduate activities such as residencies and employment, ACCM may need to describe how it uses the outcome information in deciding whether the grant the school accreditation status. The ACCM has not established any student performance benchmarks, but collects the information from the schools annually to determine whether the school has made improvements.
 
Analyst Remarks to Narrative
ACCM has clearly and comprehensively written standards and procedures outlined in the Elements of Accreditation 2014 that ensures decisions are based on compliance with those standards. The annual database report which reflects the institution's review of current status and offers suggestions for improvement has been provided.
 
Accrediting/Approval Decisions, Question 2
 
Country Narrative
ACCM requires the colleges to provide specific information that is keyed into the accreditation Elements in the annual survey/data reports. The Annual Database (Exhibit 4) and the Institutional Self-Study (Exhibit 12) requires colleges to provide extensive and specific information based on the Elements.

The structured on-site inspection is based on ACCM Elements (Exhibit 1) and uses predetermined questions found in ACCM Protocol (Exhibit 2) to ensure that the on-site review is consistent at every college reviewed by the ACCM (Exhibit 7 & 9, 24 & 25).

The decisions made by ACCM consider outcomes based on the performance of students on licensure examinations, residency acceptance, and graduate employment. For example, all students who enter the fifth semester of study must pass the USMLE Step 1, before entering the clinical science semesters. First time takers during 2013-2014 had 94% pass rate of the USMLE Step 1 (Exhibit 15 p.20). SMU Annual Database Report 2013-2014 reveals the importance of the insistence of the ACCM on the necessity of St Matthew’s to pass Step 1 prior to entering clinical science semesters and the improvement in the standard of reporting the employment status of graduates. The latter will continue to be a priority and lead to improvements in the relevant section of the questionnaire.

There is clear evidence that student are achieving institutional objectives. SMU students are passing standardised exams imposed by external regulatory and licensing bodies, primarily the United States medical licensing examination (USMLE) series. They are matching to quality residency programs and gaining licensure following residency completion. Throughout this process their judgement and ability to practice confidently is assessed using recognised external method, providing objectivity and allowing SMU graduates to be compared directly with students from US and Canadian-based medical schools (Exhibit 12: p.p. 53-54 & Appendix 16) current and former clinical student representatives are engaged in an ongoing dialogue about the effectiveness and approach to clinical sciences, rotation and licensure issues.

Online surveys provide current clinical students with an opportunity to anonymously evaluate the staff and clinical practices each semester. The results are shared with the entire clinical team Chancellor and are used when the Curriculum which is a living document is continually evaluated for effectiveness in achieving the overall goal of the institution.

Graduates are not obliged to provide feedback regarding career progression. However, ACCM Institutional Self-Study encourages that such feedback be actively sought to enable the evaluation of the medical school programme (Exhibit 12).
 
Analyst Remarks to Narrative
The ACCM has provided a summary of how it evaluates performance for making accreditation decisions. Central to this decision are the database reports provided by each institution on an annual basis. Additionally, the country states in its narrative that it considers: outcomes based on the performance of students on licensure examinations, residency acceptance, and graduate employment.
 
Accrediting/Approval Decisions, Question 3
 
Country Narrative
ACCM collects data on the pass rates for the Step 2CK (92%) and Step2CS (89%) examination and graduates who obtained residencies (Exhibit 15 p.21). Despite the emphasis on participation by graduates in various post graduate activities such as residencies and employment, ACCM may need to describe how it uses the outcome information in deciding whether to grant the school accreditation status. The ACCM has not established any student performance benchmarks, but collects the information from the schools annually to determine whether the school has made improvements.

Cayman Islands graduates are not required to provide feedback. However, SMU continues to have ongoing dialogue with graduates in an effort to achieve more comprehensive information regarding long-term career progression as required by ACCM Institutional Self-Study (Exhibit 12).
 
Analyst Remarks to Narrative
The ACCM has provided documentation of pass rates for the Step 2CK, Step2CS examination and graduates who obtained residencies. As noted in the narrative ACCM may need to describe how it uses the outcome information in deciding whether to grant the school accreditation status. The ACCM has not established any student performance benchmarks, but collects the information from the schools annually to determine whether the school has made improvements.

The NCFMEA may wish to request additional information explaining how or if student outcomes affect ACCM’s accreditation decisions and if ACCM plans to establish any student performance benchmarks.
 
Country Response
Student outcome very clearly affects Accreditation decisions.
If the student body does not have a greater than 85% pass rate in USMLE Examinations, withdrawal of accreditation is seriously considered and would occur if this took place over a number of years.
 
Analyst Remarks to Response
In addition to the review of the annual database submission, the country is very clear that the student outcomes impact their accreditation decisions. It is stated that if the 85% pass rate for the USLME does not occur that the withdrawal of accreditation is a serious consideration.
 
Staff Conclusion: Comprehensive response provided
 
Accrediting/Approval Decisions, Question 4
 
Country Narrative
ACCM has incorporated ACCM accreditation Elements (standards) and Protocol (Exhibit 1 & 2) in all of the steps involving the evaluation and decision-making process of colleges of medicine for the countries it represents.

ACCM requires the colleges to provide specific information that is keyed into the accreditation elements in the annual survey/data reports. The Annual Database (Exhibit 4) and the Institutional Self-Study (Exhibit 15) requires colleges to provide extensive and specific information based on the Elements. The structured on-site inspection is based on ACCM Elements and uses predetermined questions found in ACCM Protocol to ensure that the on-site review is consistent at every college reviewed by the ACCM (Exhibit 7 & 9, 24 & 25).

The decisions made by ACCM consider outcomes based on the performance of students on licensure examinations, residency acceptance, and graduate employment. For example, all students who enter the fifth semester of study must pass the USMLE Step 1, before entering the clinical science semesters. First time takers during 2013-2014 had 94% pass rate of the USMLE Step 1 (Exhibit 15 p.20). SMU Annual Database Report 2013-2014 reveals the importance of the insistence of the ACCM on the necessity of St Matthew’s to pass Step 1 prior to entering clinical science semesters and the improvement in the standard of reporting the employment status of graduates. The latter will continue to be a priority and lead to improvements in the relevant section of the questionnaire.

ACCM collects data on the pass rates for the Step 2CK (92%) and Step2CS (89%) examination and graduates who obtained residencies (Exhibit 15 p.21). Despite the emphasis on participation by graduates in various post graduate activities such as residencies and employment, ACCM may need to describe how it uses the outcome information in deciding whether the grant the school accreditation status. ACCM requires first time candidates for USMLE part 1 to have an 85% pass rate or greater.
 
Analyst Remarks to Narrative
The country has provided a summary of how it has evaluates outcomes based on the performance of students on licensure examinations, residency acceptance, and graduate employment. As previously stated, the country has provided documentation of pass rates for the Step 2CK, Step2CS examination and graduates who obtained residencies.

In the country's narrative they state ACCM may need to describe how it uses the outcome information in deciding whether to grant the school accreditation status. The ACCM has not established any student performance benchmarks, but collects the information from the schools annually to determine whether the school has made improvements.

The NCFMEA may wish to request additional information explain how or if student outcomes affect ACCM’s accreditation decisions and if ACCM plans to establish any student performance benchmarks.
 
Country Response
Student outcome very clearly affects Accreditation decisions.
If the student body does not have a greater than 85% pass rate in USMLE Examinations, withdrawal of accreditation is seriously considered and would occur if this took place over a number of years.
 
Analyst Remarks to Response
In addition to the review of the annual database submission, the country is very clear that the student outcomes impact their accreditation decisions. It is stated that if the 85% pass rate for the USLME does not occur that the withdrawal of accreditation is a serious consideration.
 
Staff Conclusion: Comprehensive response provided