Accreditation and State Liason (ASL) E-Recognition Web Site US Department of Education, Promoting educational excellence for all Americans.
Skip to main content | Home | OPE Home | ASL Home | NACIQI | NCFMEA | User Guide

Back

U.S. Department of Education

Staff Report
to the
Senior Department Official
on
Recognition Compliance Issues

RECOMMENDATION PAGE

1.
Agency:   American Osteopathic Association (1952/2016)
                  (The dates provided are the date of initial listing as a recognized agency and the date of the agency’s last grant of recognition.)
 
2.
Action Item:   Petition for Continued Recognition
 
3.
Current Scope of Recognition:   The accreditation and preaccreditation ("Provisional Accreditation") throughout the United States of freestanding, public and private non-profit institutions of osteopathic medicine and programs leading to the degree of Doctor of Osteopathy or Doctor of Osteopathic Medicine.
 
4.
Requested Scope of Recognition:   Same as above.
 
5.
Date of Advisory Committee Meeting:   June, 2016
 
6.
Staff Recommendation:   Continue the agency's recognition as a nationally recognized accrediting agency at this time, and require the agency to come into compliance within 12 months with the criteria listed below , and submit a compliance report due 30 days thereafter that demonstrates the agency's compliance.
 
7.
Issues or Problems:   It does not appear that the agency meets the following sections of the Secretary’s Criteria for Recognition. These issues are summarized below and discussed in detail under the Summary of Findings section.

-- The agency must clearly distinguish the differences between its preaccreditation and provisional accreditation status. The agency must also clearly identify which status (preaccreditation or provisional preaccreditation) comports to the Secretary’s definition of preaccreditation in 602.3, and amend all related standards policies and procedures associated with that status. [§602.11]

-- The agency must provide information and documentation to demonstrate that it is widely accepted by practitioners and employers in the professional/vocational fields within the agency's jurisdiction. [§602.13]

-- The agency must provide information and documentation to demonstrate that its site-visit teams include academics. The agency must also demonstrate that a single individual fulfills one defined category/role at a time on the site review teams. The agency policies and procedures must be amended to meet the requirements of the criteria. [§602.15(a)(3)]

-- The agency must provide additional clarity and evidence of the use of the self-study throughout the accreditation review process. The agency must also provide additional documentation of full cycles of review from other programs/institutions they accredit in order for Department staff to determine whether the agency consistently applies its policies, procedures, and accreditation standards. [§602.16(a)(1)(i)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide additional full cycles of review from other programs/institutions they accredit for the review of compliance and consistency with agency standards, policies and procedures as well as Department criteria for this section. [§602.16(a)(1)(ii)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide additional full cycles of review from other programs/institutions they accredit for the review of compliance and consistency with agency standards, policies and procedures as well as Department criteria for this section. [§602.16(a)(1)(iii)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide additional full cycles of review from other programs/institutions they accredit for the review of compliance and consistency with agency standards, policies and procedures as well as Department criteria for this section. [§602.16(a)(1)(iv)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide additional full cycles of review from other programs/institutions they accredit for the review of compliance and consistency with agency standards, policies and procedures as well as Department criteria for this section. [§602.16(a)(1)(v)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide additional full cycles of review from other programs/institutions they accredit for the review of compliance and consistency with agency standards, policies and procedures as well as Department criteria for this section. [§602.16(a)(1)(vi)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide additional full cycles of review from other programs/institutions they accredit for the review of compliance and consistency with agency standards, policies and procedures as well as Department criteria for this section. [§602.16(a)(1)(vii)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide additional full cycles of review from other programs/institutions they accredit for the review of compliance and consistency with agency standards, policies and procedures as well as Department criteria for this section. [§602.16(a)(1)(viii)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide additional full cycles of review from other programs/institutions they accredit for the review of compliance and consistency with agency standards, policies and procedures as well as Department criteria for this section. [§602.16(a)(1)(ix)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide additional full cycles of review from other programs/institutions they accredit for the review of compliance and consistency with agency standards, policies and procedures as well as Department criteria for this section. [§602.16(a)(1)(x)]

-- The agency must clearly distinguish the differences between its preaccreditation and provisional accreditation status. The agency must also clearly identify which status (preaccreditation or provisional preaccreditation) comports to the Secretary’s definition of preaccreditation in 602.3, and amend all related standards policies and procedures associated with that status. [§602.16(a)(2)]

-- The agency must provide a completed mid-cycle report and self-study of the same institution to demonstrate its use and review as outlined in the COM accreditation standards and procedures.
[§602.17(a)]

-- The agency must provide evidence of completed mid-cycle, annual reporting and commission actions taken on findings of these reports for the same institution(s) for Department staff to assess for compliance with the criteria for this section. [§602.19(b)]

-- The agency’s standards, policies and procedures must be amended to ensure that immediate action is taken when the Commission determines the COM is out of compliance with agency standards. The agency must also provide evidence of the full cycle of review in order for Department staff to assess for compliance with this criterion. [§602.20(a)]

-- The agency must revise its current policies and procedures to require notification to the entities required by this criterion when it places and institution on warning status. The agency must also provide documentation to demonstrate the application of its revised policy. [§602.26(b)]



EXECUTIVE SUMMARY

 
 

PART I: GENERAL INFORMATION ABOUT THE AGENCY

 
The Commission on Osteopathic College Accreditation (COCA) is a standing committee of the American Osteopathic Association (AOA). The COCA currently accredits 23 osteopathic colleges of medicine and provisionally accredits another six. Because these osteopathic medical education programs may be offered in either freestanding institutions offering only these programs or in larger institutions offering other educational programs, the agency is considered both an institutional and programmatic accreditor.

Of the 29 colleges of osteopathic medicine accredited or provisionally accredited by AOA COCA, three are located in freestanding institutions. For these institutions, AOA COCA accreditation is a required element in enabling them to establish eligibility to participate in Title IV, HEA programs. During this recognition period, the Department has received no third party comments and no complaints for the American Osteopathic Association.

 
 
Recognition History
 
The AOA COCA, as previously configured, was first recognized by the U.S. Commissioner of Education in 1952 and has received periodic renewal of recognition since then. The agency was last reviewed for continued recognition in 2005. In 2006 the Secretary granted continued recognition to the AOA COCA for a period of five years and granted it a waiver of the separate and independent requirements. At this time, the Secretary also required the AOA COCA to submit an interim report on outstanding issues which the Secretary accepted in 2007. The agency's renewal petition is the subject of this analysis.


PART II: SUMMARY OF FINDINGS

 
§602.11 Geographic scope of accrediting activities.
The agency must demonstrate that its accrediting activities cover--

(a) A State, if the agency is part of a State government;
(b) A region of the United States that includes at least three States that are reasonably close to one another; or


(c) The United States.

 
The agency demonstrates accrediting activities across the United States. This is evidenced through the agency’s inclusion of a list of its accredited institutions and programs in 42 locations within the United States, which includes two additional schools in pre-accreditation status since the last recognition period. However, a review of the accreditation list and agency website reveals several institutions exceed the five year provisional accreditation status.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation in the form of pre-accreditation and provisional accreditation letters as evidenced in exhibits 1-5 of this section. However, after review of the evidence and follow-up communication with the agency, the agency definition for pre-accreditation status is inconsistent with the Department definition found within 602.3.

Alternatively, the agency definition of provisional accreditation coincides with the Department definition of pre-accreditation found in 602.3. However, COM accreditation standards and procedures do not reflect a clear distinction between the two terms and in some instances pre-accreditation and provisional accreditation are utilized interchangeably, thus deeming the agency non-compliant with the Department criteria for this section.
 

§602.13 Acceptance of the agency by others.
The agency must demonstrate that its standards, policies, procedures, and decisions to grant or deny accreditation are widely accepted in the United States by--

(a) Educators and educational institutions; and

(b) Licensing bodies, practitioners, and employers in the professional or vocational fields for which the educational institutions or programs within the agency's jurisdiction prepare their students.
 
The agency states that its standards, policies, procedures, licensure summary and decisions to grant or deny accreditation are widely accepted in the United States by educators/educational institutions and licensing bodies. The agency included a list of its accredited institutions and programs of which all 30 colleges of osteopathic medicine offering education leading to the degree of Doctor of Osteopathic Medicine (D.O.) or Doctor of Osteopathy (D.O.) within the U.S. have received accreditation from the AOA COCA.

In Section 602.15(a)(2), the agency has provided a list of educational evaluators including CV’s; and in 602.15(a)(3), the agency includes the evaluation manual and training materials for evaluators along with a description of a volunteer evaluator registry containing educators and practitioners in the field of osteopathic medicine.

The agency has also included the U.S. Osteopathic Licensure Summary which identifies the state-by-state licensing requirements, which acknowledges all states require graduation from an AOA-approved college for licensure. However, the agency does not demonstrate wide acceptance of its standards, policies, procedures, and decisions to grant or deny accreditation by practitioners, and employers in the professional or vocational fields for which the educational institutions or programs within the agency's jurisdiction prepare their students.


Analyst Remarks to Response:
In response to the draft analysis, the agency narrative explains the different individuals and groups in which wide acceptance of agency standards, policies, procedures, and decisions for accreditation are accepted by the aforementioned stakeholders. Examples of these groups include employers of graduates, stakeholders, Directors of Medical Education, etc. However, the agency has not provided any evidence supporting the narrative claims for review by the Department as no documentation was uploaded by the agency
 

§602.15 Administrative and fiscal responsibilities
(3) Academic and administrative personnel on its evaluation, policy, and decision-making bodies, if the agency accredits institutions;

 
The agency’s Handbook and Evaluation Manual identifies the composition of the academic and administrative personnel represented on its evaluation, policy, and decision-making bodies.

The agency’s Handbook details the backgrounds required for commission members that include two college deans, two educators from colleges of osteopathic medicine, a director of medical education, hospital administrator, three public members and eight members at large. Although not provided in this section, the curriculum vitae for these members are found in Section 602.15(a)(2). However, the site team composition does not include academic personnel which is a requirement for institutional accreditors. Since the agency serves as the institutional accreditor for freestanding schools or colleges of osteopathic medicine to establish eligibility to participate in Title IV programs, 602.15(a)(3) and (4) must be met.

The agency's evaluator manual defines the site team composition which consists of a team chair and the following types of evaluators: administration/finance, preclinical education, student services, two Clinical Education Evaluator in which one is a practitioner, evaluator trainee, and a team secretary. The agency has also established an evaluator’s registry that is maintained annually which includes former COCA members. The registry contains individuals with proficiency in administration/finance, student services, and preclinical and clinical education, as documented in Section 602.15(a)(2).

Although not included in the narrative of this section, the agency’s College of Osteopathic Medicine (COM) accreditation standards and procedures found in 602.15(a)(4) outlines the process for conducting appeals panels utilizing representatives with academic and administrative backgrounds. These panels are comprised of former COCA members who were not COCA members when the adverse decision under appeal was made. The COM accreditation standards and procedures also acknowledges that when the agency COCA is serving as an institutional accreditor of the COM, appeals include a member with an academic background and administrative background; if serving as the programmatic accreditor of the COM, the panel will include an educator and practitioner.

Department staff observed an on-site COM program review the agency conducted in March 2016, which included evaluators in the areas of administration, finance, preclinical education, student services, and clinical education along with a secretary for the site team from the agency. However, the department staff did not observe participation/attendance of an evaluator trainee as referenced in the site team composition within the agency’s Evaluator Manual (page 10). The agency must ensure that it consistently adheres to its written policy. In addition, the inclusion of an evaluator trainee is one of the methods used by the agency to train new site team members. Therefore, it is unclear to Department staff if this particular training method is widely and consistently used by the agency for training its site team members. Site team evaluators introduced themselves to the program COM program faculty, staff and students describing their areas of expertise and review areas for the site visit. The site teams qualifications met the requirements of the agency standards

Analyst Remarks to Response:
In response to the draft analysis, the agency narrative attests that site visit teams include individuals representing all stakeholder groups of the agency. However, the academic personnel required by the criteria is not clearly defined in the evaluator manual as well as the site visit compositions included as evidence. Also, it is unclear in the narrative and the evaluator manual if a single individual fulfills one defined category/role at a time on the site review teams.
 

§602.16 Accreditation and preaccreditation standards
(a) The agency must demonstrate that it has standards for accreditation, and preaccreditation, if offered, that are sufficiently rigorous to ensure that the agency is a reliable authority regarding the quality of the education or training provided by the institutions or programs it accredits. The agency meets this requirement if -
(1) The agency's accreditation standards effectively address the quality of the institution or program in the following areas:
(i) Success with respect to student achievement in relation to the institution's mission, which may include different standards for different institutions or programs, as established by the institution, including, as appropriate, consideration of course completion, State licensing examination, and job placement rates.

 
The agency's COM accreditation standards and procedures contain standards and guidelines for student achievement through the connection of learning outcomes assessment to mission, plans and objectives in order to continuously improve educational quality by incorporating formative and summative reviews of student achievement. Some of these reviews include COMLEX-USA Level 1 and COMLEX-USA Level 2 passage rates; licensure, geographic area of practice, obtainment and completion of a postdoctoral program, and board examination and certifications. The agency requires the COM to establish a system of assessment that clearly defines procedures for the evaluation, advancement and graduation of students providing feedback to each student and serving as a motivating factor in improving student performance.

The agency requires Colleges of Osteopathic Medicine (COMs) to submit annual reports that include questions on student achievement data, as demonstrated by the questions on the sample annual review which is then reviewed by the Commission for acceptance or rejection of the findings. The agency has established an evaluator's manual for on-site evaluators which outline the purpose, responsibilities, and questions regarding the assessment of the standards related to student achievement during the site visit. The agency provides the site team members with a documentation pad (referred to as "DOC Pad), with the agency standards and guidelines, bulleting key areas to review and verifying the collection and analysis of the preliminary data received by the COM. The results of the doc pad (e.g., standards met or not met) are than utilized to determine whether standards have been met as it relates to student achievement and reported in a site visit report. Department staff observed an on-site review of a COM, in which the review of student achievement standards and the utilization of the doc pad were observed by staff. However, the doc pad is not included or explained within the standards as the self study; which is explained and required 24 months prior to a site visit in chapter three of the COM accreditation standards and procedures, and not included as evidence for Department staff to assess.

To demonstrate the application of its student achievement standards the agency provided the on-site evaluation report (Doc Pad). However, this document is not complete and therefore does not evidence the agency’s actual review and assessment of its student achievement standards. The agency did provide a completed annual report to demonstrate the application of its policy. While the completed annual report does demonstrate that the agency has an active monitoring process and that student achievement is part of the fiscal viability review of an institution which is evaluated annually, this documentation does not demonstrate the review of a COM during an accreditation review.

Department staff did observe a site visit in association with the analysis of the agency’s renewal petition, which demonstrates that the agency applies its standards. However, the agency must provide documentation such as a completed site visit report, self-study, and commission decision letter from several COM programs to demonstrate that it consistently applies its student achievement standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns related to student achievement as evidenced in Exhibits 14-15 and exhibits 16-24 in section 602.16(a)(1)(ii). However, the agency narrative describes the process of review by the site evaluators and the commissioners, but does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. The abbreviated version of the self- study is distributed to the site team in the form of a Doc Pad and once completed the separate parts are combined to formulate a site visit report. However, the narrative does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Additional explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria.

Also, in accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.
 

(a)(1)(ii) Curricula.
 
The agency evaluates colleges by the accreditation standards for curriculum contained in the COM accreditation standards and procedures standard six according to its mission. The agency standards and guidelines state that a COM must develop and implement a method of instruction and learning strategies designed to achieve its mission and objectives at a minimum of at least four academic years of the osteopathic medical curricula. A COM can implement their curriculum utilizing different curriculum models that should include biomedical sciences and disciplines related to osteopathic medicine; and establish clinical core competencies and a methodology to ensure they are being met. The COM must also have a process for ongoing review and evaluation of the curricula and, and demonstrate application of the findings towards improvement of the educational program (e.g. a curriculum committee of faculty and students).

The agency standards require graduates of COM programs should demonstrate basic knowledge of osteopathic philosophy and practice and osteopathic manipulative treatment; medical knowledge through various measures; interpersonal and communication skills with patients and other healthcare professionals; knowledge of professional, ethical, legal, practice management, and public health issues applicable to medical practice; and basic “basic support skills,” as assessed by nationally standardized evaluations.

The agency provided documentation to demonstrate the application of curriculum standards. Specifically, the agency provided documentation of the review process for COM programs for accreditation and preaccreditation, as well as the guidance provided to programs in addressing curricula in the self-study. The on-site evaluation report (Doc Pad) and the Department staff observation demonstrate that the program’s curricula was evaluated, as well as verified during the interviews for reliability of reported information per the evaluator manual instructions and COM accreditation standards and procedures. However, department staff is not able to clearly assess agency’s response to this standard without the COMs documentation submitted for assessment of the agency’s curriculum standards (self-study), a completed site visit report and commission decision.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns as evidenced in Exhibits 16-24 for Western University. Specifically, the agency has provided the Department with a full cycle of review for Western University including their self-study, completed Doc Pad reports submitted by the site team evaluators, final site visit report, and commission decision letter. In accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.

 

(a)(1)(iii) Faculty.
 
The agency's COM accreditation standards and procedures requires appropriately qualified, trained, and sufficient faculty to meet the mission and objectives within standard four. The standard also stipulates that COMs must have a statement of professional ethics, assessment-driven faculty development program, and faculty policies and procedures. The agency’s evaluator manual provides instruction to the site teams on the review of this standard.

The agency doc pad and Department observation demonstrate that its site evaluators interviewed faculty committees, verified the qualifications of faculty, evaluated faculty sufficiency and training, as well as the institution’s process for the hiring and promotion of faculty.

To demonstrate the application of its faculty standards the agency provided an on-site evaluation report (Doc Pad). However, this document is not complete and therefore does not evidence the agency’s actual review and assessment of its faculty standards for its COMs. The agency did provide a completed annual report to demonstrate the application of its policy. While the completed annual report does demonstrate that the agency has an active monitoring process and that faculty standards are part of the fiscal viability review of an institution which is evaluated annually, this documentation does not demonstrate the review of a COM during an accreditation review.

Department staff did observe a site visit in association with the analysis of the agency’s renewal petition, which demonstrates that the agency applies its standards. However, the agency must provide documentation such as a completed site visit report, self-study, and commission decision letter from several COM programs to demonstrate that it consistently applies its faculty standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns as evidenced in Exhibits 16-24 for Western University. Specifically, the agency has provided the Department with a full cycle of review for Western University including their self-study, completed Doc Pad reports submitted by the site team evaluators, final site visit report, and commission decision letter. In accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.
 

(a)(1)(iv) Facilities, equipment, and supplies.
 
Standard three of the agency’s COM accreditation standards and procedures state that a COM must have available sufficient and appropriate facilities for the program of instruction that enable students and faculty to successfully pursue the educational goals and curriculum with appropriate classroom, laboratory space and learning resources necessary to support and facilitate attainment of the curricular objectives. The COM must have and review assessment processes for all facility resources appropriate to achieve the COM’s mission and objectives to ensure delivery of the curriculum.

To demonstrate the application of its facilities, equipment, and supplies standards the agency provided an on-site evaluation report (Doc Pad). However, this document is not complete and therefore does not evidence the agency’s actual review and assessment of its facilities, equipment, and supplies standards for its COMs. The agency did provide a completed annual report to demonstrate the application of its policy. While the completed annual report does demonstrate that the agency has an active monitoring process and facilities, equipment, and supplies standards are part of the fiscal viability review of an institution which is evaluated annually, this documentation does not demonstrate the review of a COM during an accreditation review.

Department staff did observe a site visit in association with the analysis of the agency’s renewal petition, which demonstrates that the agency applies its standards. However, the agency must provide documentation such as a completed site visit report, self-study, and commission decision letter from several COM programs to demonstrate that it consistently applies its facilities, equipment, and supplies standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns as evidenced in Exhibits 16-24 for Western University. Specifically, the agency has provided the Department with a full cycle of review for Western University including their self-study, completed Doc Pad reports submitted by the site team evaluators, final site visit report, and commission decision letter. In accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.
 

(a)(1)(v) Fiscal and administrative capacity as appropriate to the specified scale of operations.
 
The agency’s standards for fiscal and administrative functions are found in standard two- governance, administration, and finance of the COM accreditation standards and procedures. The standard includes requirements that the COM develops and implements bylaws, or equivalent documents that clearly define the governance and organizational structure as well as financial resources and reserves to achieve and sustain its educational mission and objectives. The COM’s must also have a governing body that will confer degrees for students who have satisfactorily completed the requirements and recommended by faculty for graduation; a Chief Academic Officer responsible for fiscal management of the COM and ensuring compliance with COCA Standards; and a Chief Financial Officer acting as controller for free-standing, single degree-program institutions for which the COCA is the institutional accreditor.

To demonstrate the application of its fiscal and administrative capacity standards the agency provided an on-site evaluation report (Doc Pad). However, this document is not complete and therefore does not evidence the agency’s actual review and assessment of its fiscal and administrative capacity standards for its COMs. The agency did provide a completed annual report to demonstrate the application of its policy. While the completed annual report does demonstrate that the agency has an active monitoring process and the fiscal and administrative capacity standards are part of the fiscal viability review of an institution which is evaluated annually, this documentation does not demonstrate the review of a COM during an accreditation review.

Department staff did observe a site visit in association with the analysis of the agency’s renewal petition, which demonstrates that the agency applies its standards. However, the agency must provide documentation such as a completed site visit report, self-study, and commission decision letter from several COM programs to demonstrate that it consistently applies its fiscal and administrative capacity standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns as evidenced in Exhibits 16-24 for Western University. Specifically, the agency has provided the Department with a full cycle of review for Western University including their self-study, completed Doc Pad reports submitted by the site team evaluators, final site visit report, and commission decision letter. In accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.

 

(a)(1)(vi) Student support services.
 
The agency's requirements for student support services under standard five within the COM accreditation standards and procedures include the COM’s delivery of services devoted to student affairs, financial aid, academic counseling, mental health care, and administrator and faculty access. Other services include transfer credit and waiver policies and procedures in accordance with its educational mission and objectives.

To demonstrate the application of its student support services standards the agency provided an on-site evaluation report (Doc Pad). However, this document is not complete and therefore does not evidence the agency’s actual review and assessment of its student support services standards for its COMs. The agency did provide a completed annual report to demonstrate the application of its policy. While the completed annual report does demonstrate that the agency has an active monitoring process and that student support services standards are part of the fiscal viability review of an institution which is evaluated annually, this documentation does not demonstrate the review of a COM during an accreditation review.

Department staff did observe a site visit in association with the analysis of the agency’s renewal petition, which demonstrates that the agency applies its standards. However, the agency must provide documentation such as a completed site visit report, self-study, and commission decision letter from several COM programs to demonstrate that it consistently applies its student support services standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns as evidenced in Exhibits 16-24 for Western University. Specifically, the agency has provided the Department with a full cycle of review for Western University including their self-study, completed Doc Pad reports submitted by the site team evaluators, final site visit report, and commission decision letter. In accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.
 

(a)(1)(vii) Recruiting and admissions practices, academic calendars, catalogs, publications, grading, and advertising.
 
The agency's requirements under standard five and eight within the COM accreditation standards and procedures for recruiting and admissions practices, academic calendars, catalogs, publications, grading, and advertising require COM’s to develop and implement a student recruitment process that attracts and maintains a qualified applicant pool. The COM is also to report publicly annually on its website, in its catalog, and in all COM promotional publications that provide information about the COM’s education for prospective students the first time pass rates and the number of students from each graduating class that successfully and unsuccessfully obtained placement in a graduate medical education program accredited by the American Osteopathic Association or the Accreditation. The COM’s also publish, via paper document or on its website, information on policies and procedures on academic standards, grading, attendance, tuition fees, refund policy, student promotion; retention and other information.

To demonstrate the application of its recruiting and admissions practices, academic calendars, catalogs, publications, grading, and advertising standards the agency provided an on-site evaluation report (Doc Pad). However, this document is not complete and therefore does not evidence the agency’s actual review and assessment of its recruiting & other practices standards for its COMs. The agency did provide a completed annual report to demonstrate the application of its policy. While the completed annual report does demonstrate that the agency has an active monitoring process and that recruiting & other practices standards are part of the fiscal viability review of an institution which is evaluated annually, this documentation does not demonstrate the review of a COM during an accreditation review.

Department staff did observe a site visit in association with the analysis of the agency’s renewal petition, which demonstrates that the agency applies its standards. However, the agency must provide documentation such as a completed site visit report, self-study, and commission decision letter from several COM programs to demonstrate that it consistently applies its student recruiting and admissions practices, academic calendars, catalogs, publications, grading, and advertising standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns as evidenced in Exhibits 16-24 for Western University. Specifically, the agency has provided the Department with a full cycle of review for Western University including their self-study, completed Doc Pad reports submitted by the site team evaluators, final site visit report, and commission decision letter. In accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.

 

(a)(1)(viii) Measures of program length and the objectives of the degrees or credentials offered.
 
The agency's requirements for program length are found in standard six-curriculum of the COM accreditation standards and procedures. The agency requires the minimum length of the osteopathic medical curricula to be at least four academic years or its equivalent as demonstrated to the COCA. The guidelines for this standard further outline that the curriculum of the COM should provide at least 130 weeks of instruction. Standard six also outlines the learning strategies and core competencies COM’s are to use to meet the program length requirements and achieve its educational program mission and objectives.

To demonstrate the application of its program length standards the agency provided an on-site evaluation report (Doc Pad). However, this document is not complete and therefore does not evidence the agency’s actual review and assessment of its program length standards for its COMs. The agency did provide a completed annual report to demonstrate the application of its policy. While the completed annual report does demonstrate that the agency has an active monitoring process and the program length standards are part of the fiscal viability review of an institution which is evaluated annually, this documentation does not demonstrate the review of a COM during an accreditation review.

Department staff did observe a site visit in association with the analysis of the agency’s renewal petition, which demonstrates that the agency applies its standards. However, the agency must provide documentation such as a completed site visit report, self-study, and commission decision letter from several COM programs to demonstrate that it consistently applies its program length standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns as evidenced in Exhibits 16-24 for Western University. Specifically, the agency has provided the Department with a full cycle of review for Western University including their self-study, completed Doc Pad reports submitted by the site team evaluators, final site visit report, and commission decision letter. In accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.

 

(a)(1)(ix) Record of student complaints received by, or available to, the agency.
 
The agency addresses student complaints in standard five of the COM accreditation standards and procedures. In particular, standard 5.8 requires the COM, and/or its parent institution, to publish policies and procedures regarding student complaints related to accreditation standards and procedures, and maintain records of the receipt, adjudication, and resolution of such complaints. Standard guidance advises COM’s to utilize student complaints in its ongoing performance improvement processes, as appropriate. Standard 5.7 further requires the publication via paper document or on its website, academic freedom; students’ rights and responsibilities, including a grievance policy and appeal procedures; and other information pertinent to the student body. However, the agency has not provided a compliant example as evidence, but has included a compliant log maintained by the agency.

To demonstrate the application of its student complaint standards the agency provided an on-site evaluation report (Doc Pad). However, this document is not complete and therefore does not evidence the agency’s actual review and assessment of its student complaint standards for its COMs. The agency did provide a completed annual report to demonstrate the application of its policy. While the completed annual report does demonstrate that the agency has an active monitoring process and that student complaint standards are part of the fiscal viability review of an institution which is evaluated annually, this documentation does not demonstrate the review of a COM during an accreditation review.

Department staff did observe a site visit in association with the analysis of the agency’s renewal petition, which demonstrates that the agency applies its standards. However, the agency must provide documentation such as a completed site visit report, self-study, and commission decision letter from several COM programs to demonstrate that it consistently applies its student complaint standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns as evidenced in Exhibits 16-24 for Western University. Specifically, the agency has provided the Department with a full cycle of review for Western University including their self-study, completed Doc Pad reports submitted by the site team evaluators, final site visit report, and commission decision letter. In accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.

 

(a)(1)(x) Record of compliance with the institution's program responsibilities under Title IV of the Act, based on the most recent student loan default rate data provided by the Secretary, the results of financial or compliance audits, program reviews, and any other information that the Secretary may provide to the agency; and
 
The agency attests there have been no instances of identified difficulties with default rates in programs that the AOA COCA accredits. Department staff observed an agency site visit and the site evaluators did inquire about Title IV responsibilities at the institution. The agency's COM accreditation standards and procedures chapter three –self-study requires that the COM must include evidence that it is in compliance with its responsibilities under Title IV of the Higher Education Act of 1965 as most recently amended within its self-study .However, the agency must provide documentation such as a completed site visit report from several institutions/ programs to demonstrate it applies its standards consistently at several institutions/programs.

To demonstrate the application of COMs compliance with Title IV responsibilities the agency provided an on-site evaluation report (Doc Pad). However, this document is not complete and therefore does not evidence the agency’s actual review and assessment of its Title IV responsibilities for its COMs. The agency did provide a completed annual report to demonstrate the application of its policy. While the completed annual report does demonstrate that the agency has an active monitoring process and that Title IV responsibilities standards are part of the fiscal viability review of an institution which is evaluated annually, this documentation does not demonstrate the review of a COM during an accreditation review.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concerns as evidenced in Exhibits 16-24 for Western University. Specifically, the agency has provided the Department with a full cycle of review for Western University including their self-study, completed Doc Pad reports submitted by the site team evaluators, final site visit report, and commission decision letter. In accordance with the June 3, 2013 Department memo, agencies are required to submit documentation for a variety of types of programs/institutions they accredit in exchange for the lighter burden of criteria requiring a response in exhibiting compliance. With that said, the agency must provide additional information and documentation to evidence its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies.
 

(a)(2) The agency's preaccreditation standards, if offered, are appropriately related to the agency's accreditation standards and do not permit the institution or program to hold preaccreditation status for more than five years.
 
The agency has attested that there has been no changes to the policies or practices since its last review before the NACIQI. However, the Department review and analysis revealed several institutions exceed the five year provisional accreditation status as evidenced by the agency’s list of accredited Colleges of Osteopathic Medicine and website.

Analyst Remarks to Response:
In response to the draft analysis and follow up communication with the agency, the agency definitions for pre-accreditation and provisional accreditation are inconsistent with the Department's definition for pre-accreditation in 602.3. The agency standards, policies and procedures must identify a clear distinction between the two terms consistent with the Department's criteria and the approved scope of recognition for the agency. Thus, the agency is non-compliant with the criteria for this section and 602.11.
 

§602.17 Application of standards in reaching an accrediting decision.
The agency must have effective mechanisms for evaluating an institution's or program's compliance with the agency's standards before reaching a decision to accredit or preaccredit the institution or program. The agency meets this requirement if the agency demonstrates that it--

(a) Evaluates whether an institution or program--
(1) Maintains clearly specified educational objectives that are consistent with its mission and appropriate in light of the degrees or certificates awarded;

(2) Is successful in achieving its stated objectives; and

(3) Maintains degree and certificate requirements that at least conform to commonly accepted standards;

 
The agency provided as evidence a licensure summary, COM accreditation standards and procedures, and a site visit Doc Pad demonstrating that it has requirements to evaluate whether a COM program maintains clearly specified educational objectives that are consistent with its mission and appropriate in light of the degrees awarded from the program. The agency’s standards further stipulate within the core competencies that schools are required to specify these educational objectives consistent and appropriate for the Doctor of Osteopathic medicine (DO) degree.

The agency outlines COM program processes to ensure the institution's performance by collecting required information and analyzing this information to assess whether the institution is successful in achieving its objectives through self-assessments via mid-cycle reporting and self-studies. Improvement plans based upon the analysis of the educational program are also outlined in these reports. The agency provided instructions of how it assesses the institution's success of this criterion with the inclusion of the COM mid-cycle report instructions for the institution and the COM mid-cycle report reviewer as well as Chapter three of the COM accreditation standards and procedures outline of the requirements for a self-study. However, the agency did not provide a self-study or completed mid-cycle reports from an institution and a reviewer to deem them compliant for these criteria.

Within the provided state-by-state licensure requirements for graduation from an institution accredited by the agency and the COM accreditation standards and procedures, the agency indicates that it evaluates whether a COM program maintains degree and certificate requirements conforming to commonly accepted standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation to address the previous concern as evidenced in exhibits 31-34 and exhibits 16-24 in section 602.16(a)(1)(ii). However, the agency still has not submitted the completed mid-cycle review and self-study for the same institution for review of their use as described in the COM accreditation standards and the criteria for this section.
 

§602.19 Monitoring and reevaluation of accredited institutions and programs.

(b) The agency must demonstrate it has, and effectively applies, a set of monitoring and evaluation approaches that enables the agency to identify problems with an institution's or program's continued compliance with agency standards and that takes into account institutional or program strengths and stability. These approaches must include periodic reports, and collection and analysis of key data and indicators, identified by the agency, including, but not limited to, fiscal information and measures of student achievement, consistent with the provisions of §602.16(f). This provision does not require institutions or programs to provide annual reports on each specific accreditation criterion.


 
The agency provided documentation to support their current monitoring processes. Annual and mid-cycle reporting is required by COMs either to determine whether there is credible information to cause the COCA to further investigate whether or not a COM remains in compliance with the standards (annual) or report on their success in meeting their mission (mid-cycle). The agency provided as evidence a sample annual report review, template, process, supplemental report template and instructions as well as mid-cycle report and reviewer instructions.

In addition to the aforementioned annual and mid-cycle reporting, the agency's monitoring processes include a progress report when standard(s) are determined as not met; interim progress review responds to the findings of a an on-site visit in which deficiencies were noted and requirements for compliance with the accreditation standards were stated; and focused visitation resulting from problems noted in a Provisional, Comprehensive, or Interim Progress Review site visit not or deemed necessary by the agency.

Action on the annual and mid-cycle reports, are taken by commission members who are identified as primary and secondary reviewers on a report review. The review team conducts the annual report review utilizing a standards crosswalk which links each question report questions to COM accreditation standards. The mid-cycle review questions are directly related to mission standards for reviewers. The commission member deemed as primary reviewer provides written feedback of the primary and secondary reviewer discussion for the COM report presented at the COCA meeting. The predoctoral education staff compiles the report contents for the commission meeting review in which the annual and mid-cycle reviews are discussed separately. However, the agency has provided annual reporting templates and instructions, but needs to provide evidence of a report and information or documentation of commission actions based on the findings from such reporting to demonstrate its review and assessment of institutions/programs for compliance with its standards.

Analyst Remarks to Response:
In response to the draft analysis, the agency provided additional information and documentation as evidenced with exhibits 31-37. The agency provided mid-cycle report documents for Lincoln Memorial University DeBusk College of Osteopathic Medicine (LMU DCOM) and annual report documents for Campbell University Jerry M. Wallace School of Osteopathic Medicine (CUSOM). However, the agency must provide the subsequent actions for these COMs for review. Specifically, the agency must provide the mid-cycle review documents for CUSOM and the annual report documents for LMU DCOM along with both COMs commission decision letters for review and adherence to the criteria for this section.
 

§602.20 Enforcement of standards

(a) If the agency's review of an institution or program under any standard indicates that the institution or program is not in compliance with that standard, the agency must--

(1) Immediately initiate adverse action against the institution or program; or

(2) Require the institution or program to take appropriate action to bring itself into compliance with the agency's standards within a time period that must not exceed--

(i) Twelve months, if the program, or the longest program offered by the institution, is less than one year in length;

(ii) Eighteen months, if the program, or the longest program offered by the institution, is at least one year, but less than two years, in length; or

(iii) Two years, if the program, or the longest program offered by the institution, is at least two years in length.

 
The agency accredits 4-year educational programs, and allows COMs 24 months to address cited deficiencies and still be in compliance with the requirements of 602.20(a)(2)(iii) for this criterion. The agency outlines the policies and status of the COMs during the 24 month in the COM accreditation standards and procedure. Specifically, the agency timeframe requirements for programs to correct cited deficiencies are outlined in Chapter V of the COM accreditation standards and procedures.

The agency identifies in the COM accreditation standards and procedures, accreditation standard(s) that are to be met by the COM. If standards are not being met, the agency notes the deficiencies, and specifies the procedures for monitoring the COMs Accreditation with warning statuses which are kept confidential between the agency and the COM. The agency publically identifies the COM's status as "Accreditation" or "Provisional accreditation." The agency requires COMs to provide documentation of standards compliance within one year or less as determined by the agency and undergo an on-site visit within one year of the agency's decision of Accreditation with Warning. A condition which places an institution or program out of compliance with an agency standard must be reported to the Department. Placing an institution on a warning must be made available to the Department and the public. The Department and Federal Student Aid must know if accreditation is effected, since no prior notification that Title IV dollars going to students are being put in jeopardy is available to the Department (see 602.26b).

The agency submitted a warning status notification from a Commission meeting sent to a COM program placed on warning as evidence. However, the response to the notification was not submitted as evidence . The full cycle of the accreditation action (notice of deficiency, response, final commission action, etc…) must be provided to demonstrate compliance with this section. The agency stated that no probation or denial action have been taken since the last review before the NACIQI.

Analyst Remarks to Response:
In response to the draft analysis, the agency acknowledges that "Warning" is a status associated with non-compliance of its accreditation standards and indicates the agency’s non-compliance with 602.26 (b), as the agency does not currently notify the department when this status is applied to a COM. The issue confronting the agency’s non-compliance with this criterion is that placing a COM on ”Warning” allows the COM to still be publicly described as having "Accreditation" or “Provisional accreditation” (per the agency’s current standards). Thus, it is unclear to the Department what enforcement timelines are being adhered to by the COM while correcting their adverse action(s) based upon the agency standards, policies, procedures and the Department’s requirements for this criterion.

The agency did provide a warning status notification from a Commission meeting as evidence. However, the subsequent action was not submitted as evidence. The full cycle of the accreditation action (notice of deficiency, response, final commission action, etc…) must be provided in order for Department staff to ascertain if the enforcement timelines required by this criterion are being applied appropriately.
 

§602.26 Notification of accrediting decisions

(b) Provides written notice of the following types of decisions to the Secretary, the appropriate State licensing or authorizing agency, and the appropriate accrediting agencies at the same time it notifies the institution or program of the decision, but no later than 30 days after it reaches the decision:

(1) A final decision to place an institution or program on probation or an equivalent status.

(2) A final decision to deny, withdraw, suspend, revoke, or terminate the accreditation or preaccreditation of an institution or program;

(3) A final decision to take any other adverse action, as defined by the agency, not listed in paragraph (b)(2) of this section;

 
The agency has attested that there has been no changes to the policies or practices since its last review before the NACIQI. However, based upon the agency response for 602.20(a) Enforcement Timelines, the Department has determined that the agency must review current policy and procedures for institutions placed on warning status. Currently, if agency standards are not being met, the agency notes the deficiencies, and specifies the procedures for monitoring the COMs accreditation with the issuance of a warning status, which is kept confidential between the agency and the COM. The confidentiality of this information is non-compliant with this standard. The agency must provide these warning statuses to the Department and amend the agency policies to reflect the requirements of this criterion.

Analyst Remarks to Response:
The agency acknowledges their lack of transparency and has been found non-compliant, because it has not previously notified the Department when placing an institution on warning, which in accordance with its standards means that an institution or program is out of compliance with accreditation standards. While this information was previously kept confidential by the agency, moving forward the agency will be notifying the Department of their revised standards, policies and procedures adhering to the Department notification requirements.

 
 

PART III: THIRD PARTY COMMENTS

 
The Department did not receive any written third-party comments regarding this agency.