በኢፌዲሪ የትምህርትና ስልጠና ባለሥልጣን

FDRE Education and Training Authority

Document Number: ACC017/2023

Review Number: First edition
Effective Date: Nov 10/2023

Medicine Program Accreditation Data Collection Tool (DCT)

November, 2023
Addis Ababa, Ethiopia

i
Contents

LIST OF ABBREVIATIONS.............................................................................................................. III

INTRODUCTION ................................................................................................................................. 1

1. PROGRAM OUTCOME .................................................................................................................. 2

1.1 PROGRAM DEVELOPMENT ............................................................................................................... 2

2. CURRICULUM .............................................................................................................................. 6

2.1 DESIGN AND ORGANIZATION ........................................................................................................... 6

2.2 CURRICULUM EVALUATION AND REVIEW PROCESS .................................................................. 11

3. LEARNING, TEACHING AND ASSESSMENT ........................................................................ 12

3.1 LEARNING AND TEACHING ............................................................................................................. 12

3.2 ASSESSMENT POLICY AND SYSTEM ............................................................................................. 17
3.3 ASSESSMENT METHOD ................................................................................................................... 19

4. STUDENTS................................................................................................................................... 23

4.1 STUDENT SELECTION AND ADMISSION POLICY ............................................................................. 23

4.2 STUDENT COUNSELING AND SUPPORT SERVICE .......................................................... 27

4.3 STUDENT PROGRESSION ...................................................................................................... 31

4.4 ALUMNI ....................................................................................................................................... 33

5. ACADEMIC STAFF .................................................................................................................... 34

5.1 STAFF RECRUITMENT AND SELECTION .......................................................................................... 34

5.2 STAFF SUPPORT AND RETENTION ............................................................................................... 37
5.3 STAFF PROFESSIONAL DEVELOPMENT ....................................................................................... 38

6. EDUCATIONAL RESOURCES.................................................................................................. 40

6.1 PHYSICAL FACILITIES .................................................................................................................... 40

6.2 PRACTICAL/CLINICAL TRAINING SITE ............................................................................ 45

i
6.3 FINANCIAL RESOURCE ......................................................................................................... 48

7. RESEARCH AND COMMUNITY ENGAGEMENT ................................................................. 49

7.1 RESEARCH ...................................................................................................................................... 49

7.2 COMMUNITY ENGAGEMENT........................................................................................................... 52

8. PROGRAM MANAGEMENT ..................................................................................................... 54

8.1 LEADERSHIP AND DECISION MAKING ............................................................................................ 54

8.2 ALLOCATION OF RESOURCES ...................................................................................................... 60

9. CONTINUAL QUALITY IMPROVEMENT .............................................................................. 61

9.1 CONTINUAL QUALITY IMPROVEMENT SYSTEM ............................................................................. 61

9.2 IMPLEMENTATION OF CONTINUAL QUALITY IMPROVEMENT ................................ 62

9.3 MONITORING AND EVALUATION OF CONTINUAL QUALITY IMPROVEMENT ................................. 64

9.4 DOCUMENTATION AND DISSEMINATION ..................................................................................... 66

ii
List of Abbreviations
AC Academic commission

AY Academic Year

CQI Continuous Quality Improvement

CrHr Credit hour

DC Department Committee

ECTS European Credit Transfer and Accumulation System

EQF Ethiopian Qualification Framework

ETA Education And Training Authority

HEI Higher Education Institute

HR Human Resource

ICT Information Communication Technology

MoA Memorandum of Agreement

SSS Student Satisfaction Survey

iii
INTRODUCTION
Data collection tool (DCT) is an instrument used to collect and analyze quantitative and/or
qualitative data that demonstrate the compliance of higher education program with accreditation
standards. With this tool, the program assesses its performance and achievement against the pre-
defined standards and indicators which are set for program accreditation.
This instrument has a narrative response and supportive document for each of the indicators that
the program need to provide. Narrative response is a written comment that the program are
required to state/describe for each of the indicators whereas supportive documents are various
forms such as letters, minutes, portfolios, certificates, guidelines, procedures, audio-videos or
other written documents that the HEIs are required to state/list for each of the indicators. The
written document or the evidence listed/stated needs to support and verify the narrative response.
Thus, the program seeking accreditation need to prepare a DCT report using this instrument. And
this document is considered as one of the requirements needed to apply for Program
accreditation.

1
1. Program outcome
1.1 Program Development
1.1.1. The program has policies, procedures, and processes for introducing new program and
periodically reviewing existing program.

Narrative response
a) Describe the procedures and process for introducing new programs.
b) Summarize the process for review of the program.
c) Discuss how often the program is reviewed and provide the date of the most recent
formal program review.

Supporting documentation
a) Needs assessment, program development committee minutes and reports.
b) Meeting minutes/reports of most recent formal program review.
c) Policy, Procedure for introducing new programs.
d) Policy and procedure for existing program review.

1.1.2. The program Identifies and addresses the national priorities, needs of the society, and
present and emerging role of the learner which is consistent with international standards
in addition to professional and legal requirements for practice and knowledge creation.

Narrative response
a) Describe how the program ensures the relevance of the program to the needs of the
society and national priority.
b) Summarize the program’s national priorities, needs of the society, and present and
emerging role of the learner
c) Describe the program’s consistency with national and international standards.
d) Describe the sustainability of the program based on national priorities and societal
needs
e) Indicate the professional and legal requirements of the program and show it’s
alignment with the program.

2
 Supportive documentation
a) Mission, goals, strategic plans identifying national priorities and society needs.
b) Program review/committee minutes and reports of program’s consistency with
national and international standards. Program review/committee minutes and reports
aligning the program with professional and legal requirements.
c) Program review/committee minutes and reports providing rationale and evidence of
the sustainability of the program based on national priorities and societal needs.

1.1.3. The program learning outcomes are clearly expressed and communicated to staff and
students; ensure principal stakeholders have reasonably participated in formulating and
reviewing processes.

Narrative response
a) Describe the process used by the program to develop its learning outcome and by
whom the program learning outcomes were formulated.
b) Describe the stakeholders involved in the development of program learning outcomes.
c) Describe the process, persons involved and frequency of review of the program
learning outcomes. When was the most recent date of program learning outcome
review?
d) Describe how the program learning outcomes are communicated to internal and
external stakeholders.

Supporting documentation
a) Program outcome document
b) Minutes of meetings and documentation of the most recent review of program
learning outcomes.
c) Evidence of communication of learning outcomes to stakeholders; syllabus, memos,
website postings, etc.
d) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with communication of learning outcomes (Indicator 1.1.3).

3
 Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

1.1.4. Considering the stated learning outcomes, the program indicates the career and further
studies options available to students upon program completion.

Narrative Response
a) Discuss how the program indicates the career and further studies options based on
stated learning outcome.
b) Describe how the students are made aware of the career and further studies options.

Supportive Documentation
a) Student handbook, career guidance and counseling documents
b) Tracer study report.
c) Minutes of program review based on tracer study report.

1.1.5. There is a systematic approach in place to obtain feedback from stakeholders to improve
the delivery of the study program and attainment of the program outcomes and update the
program accordingly in line with the current practice.

Narrative Response
a) Describe the mechanisms and frequency that are in place to obtain feedback from
stakeholders to improve the delivery of the study program.
b) List the various stakeholders and describe the type of feedback obtained from each
group.
c) Discuss how the program is updating based on the feedback obtained from the various
stakeholders and provide examples.

Supportive Documentation
a) Stakeholder feedback data; completed evaluation forms, survey result, focus group,
b) Analysis of feedback data with actions taken, minutes, reports.

4
1.1.6. The program is approved by appropriate governing body.

Narrative response
a) Describe the procedure used to approve the program.
b) Is the program approved by the appropriate governing bodies?

Supporting documentation
a) Program approval minute/(AC/DC)
b) The current Legislation

1.2 Alignment between Institutional Mission, program educational objective,

program outcome, and course learning outcome

1.2.1 The program has clearly defined educational objectives, program outcome and course
learning outcome that are aligned with institutional mission.

Narrative response
a) Describe the mission and vision statement, the program educational objectives and
program outcome set for the program.
b) Has an alignment been established between the institutional mission and the program
educational objectives; between program educational objectives and program
outcomes and program outcome and course learning outcome?

Supporting documentation
a) The current strategic plan of the program
b) Program document
c) Document showing the alignment between the mission and the program
educational objectives; between program educational objectives and program
outcomes and between program outcome and course learning outcome.
1.2.2 The program learning outcomes conform to academic requirements of the study program
and Ethiopian Qualification Framework (EQF).
Narrative Response

5
 a) Describe the alignment of program learning outcomes with academic requirements
of the study and EQF.
Supportive Documentation
a) Alignment mapping of program learning outcome with EQF

2 Curriculum
2.1 Design and Organization

2.1.1 The curriculum design is based on national and international expectations of the academic
discipline/field of study.

Narrative Response
a) Explain the program curriculum design process and describe the general design of
the curriculum.
b) How does the HEI ensure that the curriculum is relevant to the expectations of the
national and international competencies?

Supportive Documentation
a) Analysis comparing curriculum with national and international expectations.

2.1.2 The curriculum incorporates core content of the discipline that are essential for
understanding the concepts, principles and methods that support the program outcomes.

Narrative response
a) Describe how the core content of the discipline were established
b) Explain how the core contents of the discipline support the program learning
outcomes.

Supportive Documentation
a) Table 2.1.2 Course Catalogue describing core contents of the discipline.

List of Course Course ECTS/CrHr Pre-

courses category code requisite

6
2.1.3 The curriculum takes into account the appropriate professional and industry requirements
as well as good practices in the field.

Narrative Response
a) Describe how the program curriculum is designed to meet the appropriate
professional requirements, industry requirements and good practices in the
discipline

Supportive Documentation
a) Curriculum of the program indicating professional requirements

2.1.4 The learning outcomes are competency based and clearly articulate the required
knowledge, skills, values, behavior and preparedness to become a professional healthcare
provider that is socially accountable.

Narrative response
a) Describe the required domains of learning, i.e. the knowledge, skills, values and
behaviors to become a professional healthcare provider.
b) Explain how the learning outcomes clearly articulate and are linked to the required
domains of learning.

Supportive Documentation
a) The competency based learning outcomes.
b) Learning outcomes linked to the required domains of learning.

2.1.5 The curriculum is designed in such a way that there are clear career pathways and
students are informed about the development of career pathways during their studies.

Narrative Response
a) Describe how the curriculum is designed with clear career pathways.

7
 b) How are students informed about the development of career pathways during their
studies?

Supportive Documentation
a) Curriculum design linked to career pathways.
b) Communications (syllabus, brochures, website, etc.) informing students of career
pathways.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with information about the career pathways (Indicator 2.1.5)

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

2.1.6 The curriculum has a coherence that ensures learning and teaching activities are
appropriately designed to achieve the learning outcomes.

Narrative Response
a) Describe how the coherence of the curriculum is ensured? How the curriculum is
vertically and horizontally integrated?
b) Describe how the learning and teaching activities in the curriculum are
appropriately designed to achieve the learning outcomes.
c) Discuss the alignment of the learning and teaching activities with learning
outcomes.

Supportive Documentation
a) Minutes/reports of review of teaching and learning activities

2.1.7 The learning and teaching activities encourage the active participation of students in their
learning process.

Narrative Response

8
 a) Describe how learning and teaching activities encourage the active participation of
students.
b) Provide specific examples of learning and teaching activities that encourage the
active participation of students in their learning process.

Supportive Documentation

a) List of courses with active student participation in learning.

2.1.8 The total duration of the training, credit hours per semester and duration are clearly
defined and consistent with the national standards.

Narrative Response
a) Describe the duration and credit hours in light of applicable national standards

Supportive Documentation
a) The current curriculum of the program indicating duration and credit hour.

2.1.9 The curriculum specifies outcomes related to engagement of the students in research and
community service.

Narrative Response
a) Describe learning outcomes and opportunities pertaining to student engagement in
research and community service.
b) Describe how students are informed about and supported in research and
community service activities.
c) Provide specific examples where students are engaged in research and community
service.

Supportive Documentation
a) The program learning outcomes
b) List of courses and activities with student engagement in research and community
service.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with engagement in research and community service (Indicator 2.1.9)

9
 Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

2.1.10 The program communicates the learning outcomes to students, staff and stakeholders.
Narrative Response

a) Discuss how learning outcomes are communicated to student, staff and stakeholders
Supportive Documentation

a) Communication of learning outcomes (syllabus, curriculum orientation, brochures,

website, etc.)
b) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with learning outcomes communicated to students (Indicator 2.1.10)

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

2.1.11 The program ensures the content, extent, sequence, duration of courses/modules, and
other curricular elements are appropriate, integrated and have appropriate coordination
between basic biomedical, behavioral, social, public health and clinical subjects.

Narrative Response
a) Describe the process for determining the following:
a) The content of courses/modules and other curricular elements.
b) The duration and placement in the curriculum and sequencing of courses/modules
and other curricular elements.
c) Coordination between basic biomedical, behavioral, social and public health subjects

10
 b) Discuss how the various curricular elements and phases of the curriculum are
integrated

Supportive Documentation
a) The current curriculum design of the program

2.2 Curriculum Evaluation and Review Process

2.2.1 There is a functional curriculum committee where students are represented with the
capacity to oversee, monitor and evaluate the curriculum to achieve the intended learning
outcomes.

Narrative Response
a) Describe the roles and responsibilities of the curriculum committee.
b) List the members and composition of curriculum committee.
c) Describe the function of the curriculum committee and how the committee oversees,
monitors and evaluates the curriculum
d) Describe the role of students in the curriculum committee.

Supportive Documentation
a) Letters of assignment for curriculum committee.
b) Curriculum committee minutes, report for the last 2 years
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with student representation on curriculum committee (Indicator 2.2.1)

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

2.2.2 There is a clearly defined process and mechanism, to regularly monitor and evaluate and
review/update the curriculum through data collection including student and stakeholder
feedback and use the results to improve.

11
 Narrative response
a) Describe how and how often the overall program curriculum is reviewed and how
courses and clerkships are reviewed.
b) Describe the outcome measures and data sources used by the curriculum
committee to evaluate the curriculum.
c) Describe the types of feedback data collected from students and stakeholders and
discuss how the feedback from stakeholders are considered in the review process
d) Give examples of improvements made based on evaluation.

Supportive Documentation
a) Minutes/report on curriculum review process
b) Student evaluation of courses and clerkship and other feedback data collected for
the last 2 years.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with inclusion of students’ feedback during curriculum monitoring and
review (Indicator 2.2.2)

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

3 Learning, Teaching and Assessment

3.1 Learning and Teaching
3.1.1 The learning and teaching activities are consistent with the curriculum and ensure that
there are varieties of learning-teaching methods aligned with learning outcomes to help
students take responsibility for their own learning.

Narrative response
a) Describe the process of selecting the learning and teaching activities with the
curriculum.
b) Describe the varieties of learning-teaching methods used for the program

12
 c) How do learning and teaching methods encourage the active participation of
students for their own learning?

Teaching and Learning Activity

Program Outcome

Supporting Documentation
a) The current Curriculum/ Course/module syllabus
b) Learning teaching manual.

c) Student Satisfaction Survey Indicator 3.1.1. Percentages of students who were

satisfied and very satisfied with teaching learning activities prepare and support
students to take responsibility (Indicator 3.1.1.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

3.1.2 The learning and teaching activities are appropriately designed to ensure that learning
outcomes are achieved.

Narrative response
a) How does the program review and evaluate that the teaching and learning activities
ensures the achievement of learning out comes?
b) Describe the outcome measures used to evaluate the teaching and learning methods
in achieving the learning outcomes.

Supportive Documentation
a) Minutes/reports of review of learning and teaching activities

13
 b) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with learning teaching activities are appropriately designed to achieve the
learning outcome (Indicator 3.1.2.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

3.1.3 The curriculum ensures that instructors provide a standardized syllabus for the course and
effectively plan and prepare for teaching, through regular use of session plans including
clinical practicum.

Narrative response
a) Describe the process for developing a standardized syllabus.
b) Is a standardized syllabus provided for each course/module and discussed with
students at the beginning of the course/module?
c) Describe how instructors plan and prepare for teaching. Are session plan used in
preparation for teaching?

Supportive Documentation
a) Module/course syllabus
b) Sample teaching session plan
c) Student Satisfaction Survey Indicator 3.1.3. Percentages of students who were
satisfied and very satisfied with course/module syllabi are shared and discussed at
the beginning of the course. (Indicator 3.1.3).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

14
3.1.4 Students of the study program are provided with sufficient learning resources, including
facilities, libraries, IT infrastructure and support, and academic guidance. The study
program takes place in an appropriate learning environment, including, in particular
counseling and other support services.

Narrative response
a) Describe the conduciveness of the learning environment for the effective
implementation of the program.
b) Provide details of the learning resources provided to students.
c) List the types of support services that are provided to students.

Supportive documentation
a) Report on student support services
b) Learning resource utilization report
c) Student Satisfaction Survey Indicator 3.1.4. Percentages of students who were
satisfied and very satisfied with access to and support for digital, blended or e-
learning (Indicator 3.1.4).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

3.1.5 The program has in place co-curricular activities that will enrich students’ experiences
and foster personal development and responsibility.

Narrative response
a) List program related co-curricular activities
b) Describe how these activities enrich students’ experiences, and foster personal

development and responsibility.

Supportive Documentation
a) Report on co-curricular activities

15
 b) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with co-curricular activities are available to support students’ achievement
Indicator (3.1.5).
Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

3.1.6 There is a systematic monitoring and review of teaching of the program to improve the
quality of teaching and learning. This monitoring and review includes the use of student
feedback on teaching quality, along with other evaluation mechanisms.

Narrative response
a) Describe how and how often the program monitors and reviews the learning and
teaching.
b) Describe how student feedback is used to monitor and review the quality of learning
and teaching.
c) Give examples of changes made to improve learning and teaching based on student
feedback and other evaluation mechanisms.

Supportive documentation
a) Learning teaching review report
b) Course/module and faculty evaluation for the last 2 years.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with feedback on teaching activities and feed-back based improvements.
(Indicator 3.1.6.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

16
3.2 Assessment Policy and System

3.2.1 The program has an assessment policy/ guideline/exam blueprint that clearly describes
assessment practices and principles including methods, frequency, scoring, marking,
remedial action and post-exam analysis procedures.

Narrative response
a) Discuss the assessment policy/guideline and its key components
b) Describe the assessment practices with respect to the following:
a. Determination of assessment methods, frequency and scoring for each type
of teaching/learning activity.
b. Development and utilization of exam blueprint.
c) Describe post exam analysis procedures.
d) Describe the remediation process and procedure.

Supportive Documentation
a) Assessment policy/guideline.
b) Exam blueprint examples.
c) Post exam analysis report examples.
d) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of assessment policy/ guideline/exam blueprint (Indicator
3.2.1)
Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

3.2.2 The program has in place mechanisms to ensure the validity and reliability of the student
assessment system.

Narrative response

17
 a) Describe the process used to create and generate student assessment systems.
b) Describe how the program ensures the validity and reliability of the student
assessment system.

Supporting Documentation
a) Reports on validity and reliability of assessments.
b) Assessment policy/guideline

3.2.3 The program has clear mechanisms for student appeal and dispute resolution are
regulated and fairly administered. The academic security and integrity of assessment,
confidentiality of assessment results and academic records are maintained in line with
HEI’s policy.

Narrative response
a) Describe the student assessment appeals policy.
b) Describe how the program regulates and administers student appeals and disputes
regarding assessment.
c) Discuss the alignment of academic security and integrity of assessment arrangements
with HEIs policy.
d) Describe the mechanism for ensuring confidentiality of assessment results and
academic records.

Supportive Documentation
a) The policies and procedures for disciplinary action and appeals
b) Minutes on disciplinary and appeal decisions
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of student appeal and dispute mechanisms for assessment
(Indicator 3.2.3.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5

18
% Satisfied and
very satisfied

3.2.4 The program has a system of assessment that measures course and program learning
outcomes and informs on progression and graduation.

Narrative response
a) Describe the assessment system used to measure course and program learning
outcomes.
b) Discuss how the assessment system informs academic progression and graduation.

Supportive Documentation
a) Outcome measures for courses and program learning outcomes.
b) Minutes/review reports of courses and program learning outcome review.
c) Minutes/academic progression and graduation report.

3.2.5 The program has a functional system to conduct item analysis and standard-setting and
use the results for decision-making.

Narrative response
a) Describe the system for exam item analysis and standard setting
b) Discuss how the exam item analysis result is used for decision making.

Supportive documentation
a) Assessment policy guideline showing policy and procedure on standard setting
and item analysis.
b) Exam item analysis report
c) Exam committee minutes/reports of decision making based on item analysis and
standard setting for courses and for progression and graduation.

3.3 Assessment Method

3.3.1 The program employs a variety of assessment methods and tools to assess learning
outcomes and competencies covering knowledge, skills and attitude.

19
 Narrative response
a) Describe the various assessment methods used for each learning outcome,
competency, knowledge and skills.
b) Describe how the assessment methods and tools assess the learning outcomes and
competencies.
c) Table 3.3.1. Learning outcomes, competencies, knowledge and skills and the
assessment methods used

Learning Assessment method

outcome/competency

Supportive documentation
a) Assessment policy/guideline determining type of assessment for each program
learning outcome.
b) Reports/minutes of review of assessment methods for program learning outcome.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with a variety of assessment methods/tools are employed for assessing
knowledge and skills (Indicator 3.3.1.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and

20
 very satisfied

3.3.2 The program’s approach to overall assessment activities is systematically and regularly
reviewed to ensure its effectiveness.

Narrative response
a) Describe how and how often the program reviews the effectiveness of overall
assessment activities.

Supportive Documentation
a) Assessment review report/minute.

3.3.3 The program has in place a system of assessment that regularly offers students timely,
specific, and actionable feedback that identifies their strengths and areas of improvement
and helps them to consolidate their learning.

Narrative response
a) Describe the feedback system for students in course and clerkships.
b) How often and how are formative and summative feedback provided?
c) Describe how students are provided with timely feedback to identify their strength
and areas of improvement.

Supportive Documentation
a) Assessment policy/guideline describing feedback to students.
b) Examples of actionable feedback provided to students.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with the system of assessment that regularly offers students timely, specific,
and actionable feedback (Indicator 3.3.3).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied
and very
satisfied

21
3.3.4 Information on the program’s approach to assessment is clearly provided to students. The
assessments within the study program are adequate to judge the achievement of the
learning outcomes and designed so that students are fairly assessed.

Narrative response
a) Describe how the program’s assessment approach is communicated to students.
b) Discuss the adequacy and fairness of the assessment to measures the achievement
of learning outcomes.

Supportive documentation
a) Assessment policy/guideline describing adequacy and fairness of the assessment
system to achieve learning outcome.
b) Exam committee reports reviewing adequacy and fairness of the assessment system
to achieve learning outcome.
c) Student Satisfaction Survey Indicator. Percentages of students who were satisfied
and very satisfied with information about the content, style and format of assessment
(Exam Blueprint)/fairness of assessment mechanism .(Indicator 3.3.4.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

3.3.5 The program provides special support to students with poor performance based on
assessment results.

Narrative Response
a) Describe remedial mechanisms for low performing students.
b) Describe academic advising, tutoring and other resources available to support low
performing students.

22
 Supportive Documentation
a) Minutes/reports and letters on remediation
b) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of targeted support for poor performing students (Indicator
3.3.5.).
Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

3.3.6 The program use performance feedback from external exams and national licensing
exams to improve instruction and in-school assessment practices.

Narrative Response
a) Describe how performance feedback from national licensure exams and external
exams are used for improvement.

Supportive Documentation
a) AC/DC Minutes/reports and letters
b) Results of national licensure and external exams with review and analysis
c) Action plans based on performance feedback on the national and external exams.

4 Students

The school has appropriate student admission policies and practices and systems in place for
student support including academic, career, Psychosocial and financial support services.

4.1 Student Selection and Admission Policy

4.1.1. Student selection and admission practices for the program are clear, efficient, explicit and
fair, and in accordance with the HEI’s policies and regulations.

Narrative response
a) Describe the student selection and admission policies and practices of the program.
b) How does the program ensure the admission practices are clear, efficient, and fair?

23
 c) Describe the roles, responsibilities and composition of the committee making
admission decisions
d) Discuss the alignment of student selection and admission practice with HEIs policy
and regulations.

Supportive document
a) Student selection and admission policy
b) Student handbook
c) Registrar manual
d) Student Satisfaction Survey Indicator. Percentages of students who were satisfied
and very satisfied with clarity and fairness of student selection and admission policy
(Indicator 4.1.1.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

4.1.2. The criteria and processes of student selection and admission are published, disseminated
and publicly accessible.

Narrative Response
a) Describe the minimum requirements for admission to the program.
b) Describe the principle, criteria and process of admission to the program.
c) Describe how student selection and admission criteria is disseminated for internal
and external stakeholders.

Supportive Documentation
a) Student selection and admission criteria and guideline
b) Student handbook
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with student selection and admission policy are communicated (Indicator
4.1.2.).

24
 Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

4.1.3. The program defines and periodically reviews the size and route of entry (direct entry vs
graduate entry) of student intake in line with available resources to ensure effective
implementation of the program.

Narrative response
a) Describe how often and by whom the size of student intake capacity is defined and
reviewed.
b) Describe the various routes of entry (direct vs graduate entry).
c) Explain how the program ensures student intake capacity is aligned with available
resources for effective implementation of the program.
d) Table 4.1.3. Provide the number of active batch student enrollment capacity of the
program
Academic year Enrolled students Remark
F M
2023 # #
2024 # #

Supportive documentation
a) Student intake capacity review documents and communication letter
b) Current annual plan of the program

4.1.4. The program has established well-defined policies and mechanisms to facilitate student
mobility which may include student transfer within and between institutions nationally
and internationally.

Narrative response
a) Describe the student transfer and exchange policy.

25
 b) Describe the practice and procedure of the program on student transfer and
exchange.
c) Table 4.1.4. Provide the number of transferred/exchange students for each indicated
academic year (3 consecutive years student active batch).

Transfer/exchange -AY -AY -AY Remark

students
Transferred students that # # #
entered into the second
year

Supportive documentation
a) Student transfer and exchange policy
b) Student handbook/Student transfer Guideline Registrar manual.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with presence of well-defined mechanisms to facilitate student mobility
(transfer) across institutions nationally and internationally (Indicator 4.1.4)
Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5

% Satisfied and
very satisfied

4.1.5. Promote diversity in admission, including gender mainstreaming, and consideration of

disadvantaged groups and persons with disabilities, where applicable

Narrative Response
a) Describe the inclusiveness’ of the admission policy
b) Describe the program’s processes and practices that promote and ensure diversity
in admission.

Supportive Documentation
a) Student selection and admission policy
b) Review/ data/report on student body diversity

26
 c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with presence of inclusive (gender) admission policy and practices
(Indicator 4.1.5.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5

% Satisfied and
very satisfied

4.1.6. Entry standards for the program are regularly reviewed based on student performance and
other relevant internal and external reference points.

Narrative response
a) Describe how, by whom and how often the admission requirements are reviewed.
b) Describe the outcome data and other sources used to review the admission
requirements and entry standards.
c) Indicate the date of the last review of the admission requirements and entry
standards.

Supportive document
a) Minutes/reports on reviewing admission requirements.

4.2 Student Counseling and Support Service

4.2.1 There are appropriate and adequate student support services such as physical, social, and
financial support, recreational and online facilities, academic, non-academic and career
counseling, and health services.

Narrative response
a) Describe the types of student support services available to students.
b) Explain how and by whom the following services are provided:
a. Academic support
b. Career counseling

27
 c) Describe how the program supports the physical, social, and financial needs of
students.
d) Describe the recreational activities available to students.
e) Describe the health services available to students.
f) Evaluate the adequacy and appropriateness of student services.

Supportive Documentation
a) Student support services manual/guidebook.
b) Student academic and career counseling manual.
c) Student support service yearly report.
d) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of student support service (Survey Indicator 4.2.1.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

4.2.2 The program has a comprehensive student handbook that indicates students’ support
systems and makes it accessible to students.

Narrative response
a) Indicate the availability of student handbook with inclusion of student support
services and systems.
b) How is the student handbook with student support services made available to
students?

Supportive Documentation
a) Student handbook with student support services.
b) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of comprehensive student handbook with student support
services (Indicator 4.2.2.).

Academic Academic Academic Academic Academic

28
 Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

4.2.3 There is an effective orientation program to new students about the program and the
available support mechanisms. Academic, non-academic and career counseling are
provided by adequate and qualified staff.

Narrative response
a) Describe the process of orientation provided to new students regarding the program
and available support mechanisms.
b) When and how often is orientation provided to students?
c) Describe the qualification of staff and how often academic counseling is provided to
students.
d) Describe the qualification of staff and how often career counseling is provided to
students.

Supportive Documentation
a) Student handbook.
b) Orientation to program and support services schedule.
c) Student academic and career counseling manual indicating qualification of staff.
d) Student Satisfaction Survey Percentages of students who were satisfied and very
satisfied with availability of effective orientation system for new students about the
program and support services (Indicator 4.2.3.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied
and very
satisfied

4.2.4 The program has effective mechanisms to identify and support students with special
needs including those who are at risk of not progressing academically.

29
 Narrative response
a) Describe the mechanism to identify students with special need and the types of
support provided.
b) Describe how and when students that are at risk of not progressing academically
identified?
c) Describe the academic support provided to academically at-risk students.
d) Describe strategies used to minimize attrition.

Supportive Documentation
a) Number of supported special need students for the last 2 academic years.
b) Tracking report of academic at-risk students.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of support system for students with special needs and
academically at-risk students (Indicator 4.2.4.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

4.2.5 The program evaluates student support services regularly to ensure their adequacy,
effectiveness, and safety.

Narrative Response
a) Describe how and how often student support services are evaluated to ensure
adequacy, effectiveness, and safety.
b) How is student feedback data on adequacy and effectiveness of student support
services obtained and used in evaluation?

Supportive documentation
a) Student support service yearly report with evaluation and minutes.
b) Student evaluation data of support services.

30
 4.2.6 There is an active mechanism for students to voice their grievances and seek resolution
on academic and non-academic matters. The program has clearly defined and
documented processes and procedures for handling student disciplinary cases.

Narrative response
a) Describe the policy, processes, and procedures for handling student disciplinary
cases.
b) Describe how student’s grievances and appeals are handled regarding academic and
non-academic matters.
c) How students are made aware of the policy, processes, and procedures for handling
student disciplinary cases?

Supportive Documentation
a) Policy on disciplinary procedures, grievance, and due process.
b) Minutes/reports on disciplinary decision.
c) Student handbook.
d) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of appeals and grievance handling mechanisms (Indicator
4.2.6.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

4.3 Student Progression

4.3.1 The program has appropriate strategies to improve the retention, progression, and
completion rates of students in the program.

Narrative response

31
 a) Describe strategies used to improve students’ retention, progression, and completion
rate.
Supportive documentation
a) Student progression and retention plan and strategies.
b) Student progression report, review, and minutes

4.3.2 The program ensures that more than 50% of the graduates pass the exit exam.

Narrative response
a) Describe the availability of a comprehensive/ exit/qualification examination to check
student’s final competency.
b) Describe the program’s strategy and plans to ensure success of the graduates on the
exit exam.

Supportive Documentation
a) Comprehensive/exit qualifying exam performance and review report.
b) DC & AC minutes.

4.3.3 The program regularly reviews the effectiveness of its strategies and mechanisms to
ensure appropriate student attrition, retention, progression, and completion rates are
maintained.

Narrative response
a) How and how often does the program review the effectiveness of its strategy and
mechanism on student attrition, retention, progression, and completion rates?
b) Describe the types of data reviewed and analyzed regarding student achievement,
retention, attrition rates, progression, and completion.
c) Table 4.3.3. Provide student data for attrition, progression, and graduation (3
consecutive year’s active batch).

Year of entry Registered Drop Dismiss Withdrawal Attrition Progression No of Graduati

out rate rate Graduat on rate
ed
students

32
AY1 # # # # # #
AY2 # # # # # #
AY3

Supportive Documentation
a) Report on student achievement, retention, attrition rates, progression, and completion.
b) Academic or senate minutes of graduation.

4.4 Alumni
4.4.1 There is an active mechanism to trace employability and satisfaction of graduates and
employers and use the findings to improve the educational program.

Narrative response
a) Describe how and how often tracer studies are used to track employment of
graduates.
b) Describe the mechanism used to trace the satisfaction of graduates and employers.

Supportive documentation
a) Tracer study report.
b) Graduates’ satisfaction survey.

4.4.2 There is an effective use of formal system and process for managing and maintaining
relationships with its alumni database.

Narrative response
a) Describe the process and system of managing and maintaining graduates with alumni
database.
b) Describe how the program creates a formal link with the alumni.

Supportive Documentation
a) Registrar manual.
b) Updated database information of program alumni.
c) Tracer study report.

33
5. Academic Staff
5.1 Staff Recruitment and Selection
5.1.1. The program has clearly stated and well-defined system in place for the appointment and
promotion of staff with appropriate qualifications, competences and skills guided by
considerations which are in line with institutional, national policy and international best
practices.

Narrative response
a) Discuss the system used for academic staff appointment and promotion with
appropriate qualifications, competences, and skills.
b) Are the requirements for appropriate qualifications, competences and skills of
academic staff positions defined?
c) Are the promotion criteria and timeline for academic staff defined?
d) Describe the alignment of the staff appointment and promotion system with
institutional, national policy and international best practices.

Supportive Documentation
a) Policy and procedure for appointment and promotion of academic staff.
b) Examples of qualification criteria for the various academic staff appointment.
c) Criteria for promotion of academic staff.
d) HR manual.
e) Academic staff handbook.
f) Minute/letter for appointment and promotion.

5.1.2. The program implements a strategic approach to the planning and management of human
resources which is aligned to its mission and strategic objectives. The recruitment
strategy seeks a balance between senior and junior academic staff, between academic and
non-academic staff, between academic staff with multidisciplinary backgrounds and
specializations.

Narrative response

34
 a) Describe the strategic approach of the planning and management of human
resources.
b) Describe the alignment of strategic approach with program mission and strategic
objectives.
c) Discuss the effectiveness of the human resource strategic planning with respect to
ensuring the following.

a. Appropriate balance between senior and junior academic staff.

b. Appropriate balance between academic and non-academic staff.
c. Appropriate balance of academic staff with multidisciplinary backgrounds and
specialization.

d) Table 5.1.2. List of academic and non-academic staff composition and qualification

Name of Composition Qualification Name of Qualification Remark

academic Specify degrees, non-
staff specialty, Academic
subspeciality, staff
achieved with
specific field of
study
Junior Senior

Supportive Documentation
a) Human resource strategic planning document.
b) HR manual.
c) Legislation.

5.1.3. The program has an adequate number of qualified full-time academic staff for each study
program.

35
 Narrative response
a) Describe the balance of full time and part time teaching staff to ensure the effective
delivery of the program.
b) Table 5.1.3 List of part time and full-time academic staff.

No List of Academic Qualification Full time Part time Remark

staff

Supportive documentation
a) Human resource management review reports, planning minutes.

5.1.4. The staff to student ratio of the program is appropriate to the teaching-learning methods
and comply with the program discipline standards.

Narrative response
a) Describe the appropriateness of staff to student ratio to the teaching-learning
methods.
b) Discuss the staff to student ratio with respect to the program standards.
c) Table 5.1.4, Staff to student ratio (3 consecutive years active batch).

Active No of Academic No student Ratio Remark

batch staff
AY1
AY2
AY3

Supportive Documentation
a) The program discipline standard regarding staff to student ratio.

36
5.2 Staff Support and Retention

5.2.1 The program utilizes the appraisal data to provide timely and constructive feedback,
improve the performance of staff, and inform decisions, benefits, and awards.

Narrative response
a) Describe how and how often the program provides feedback for staff.
b) Discuss how the program utilizes appraisal data to improve the performance of staff,
and inform decisions, benefits, and awards.
c) Describe the benefits and awards provided for academic staff based on performance
appraisal data.

Supportive documentation
a) Staff performance appraisal report.
b) Academic staff handbook.
c) Appraisal data-based benefits and awards report.

5.2.2 The program has transparent staff appraisal system addressing the roles of the academic
staff in teaching, research, community services and administrative functions and leading
to action.

Narrative response
a) Describe the policies, procedures, and mechanism of staff appraisal system.
b) Explain how the staff appraisal system addresses the roles of academic staff in
teaching, research, community services and administrative functions.
c) How are academic staff made aware of their expectations in teaching, research,
community service and administrative functions in their promotion and retention?
d) Describe the types and frequency of data collected for faculty performance
assessment in teaching, research, community services and administrative functions.
e) How does the program support and encourage academic staff to achieve the
promotion expectations and describe the remedial actions in place to ensure success.

Supportive document
a) Staff appraisal policy.

37
 b) Academic staff handbook.
c) Academic staff evaluation forms.
d) Staff performance appraisal report.

5.3 Staff Professional Development

5.3.1 Have mechanisms in place for the promotion of staff to leadership positions and academic
ranks.

Narrative response
a) Describe the policy and requirements for the promotion of staff to academic ranks.
b) Describe the mechanisms for staff promotion to leadership positions.

Supportive Documentation
a) Policy of academic staff promotion.
b) HR manual.
c) Academic leadership manual.

5.3.2 The program has an effective academic staff development program and offers
professional development of its staff based on appropriate needs assessment.

Narrative response
a) Describe the professional development programs for academic staff in the following.
a. Teaching and assessment skills
b. Research and scholarly activity
c. Community service
d. Leadership
b) Describe the effectiveness of academic staff development program and professional
development practice based on need assessments.

Supportive Documentation
a) List of academic staff professional development activities.
b) Staff development plan and report.
c) Need assessment for staff and professional development.

38
5.3.3 The program provides mentoring and formative guidance for new academic staff as part
of its staff development program.

Narrative response
a) Describe the mechanism used for mentoring of new academic staff as part of the staff
development program.
b) How is formative guidance and feedback provided to new academic staff?

Supportive Documentation
a) Staff development report.
b) Induction manual and report.
c) Academic staff handbook.

5.3.4 The program provides the academic staff with the necessary training, tools and
technology for self-learning, technical update training in the field of instruction and
access to information and for communication.

Narrative response
a) Describe how the program provides the necessary and continuous training for the
academic staff.
b) Discuss the technology and communication tools for instruction, information, and
communication available for the academic staff.

Supportive Documentation
a) Academic staff continuous training reports.
b) ICT utilization and access for staff report.

5.3.5 The program supports and encourages the research activities of its academic staff and
ensures their academic freedom.

Narrative response
a) Discuss how the academic staff members are supported to undertake research.
b) Discuss how the program ensures academic freedom.

39
 Supportive Documentation
a) Incentive package for research.
b) Research manual.
c) Legislation.
d) Academic Staff handbook pertaining to research.

5.3.6 The program has national and international linkages for enhancement of academic and
professional development and scholarly activities.

Narrative response
a) Describe the mechanisms in place for supporting national and international linkage
of the program.
b) Discuss how the linkages enhance professional development and scholarly activities.

Supportive Documentation
a) List of national and international linkages with professional development activities
and scholarly work for the last 2 academic years.

6. Educational Resources
6.1 Physical Facilities
6.1.1. The program has clearly stated and well-defined system in place for procuring and
utilization of educational resources in line with the HEI policy.

Narrative response
a) Describe the system of procuring and utilization of educational resources.
b) Discuss how the procuring and utilization of educational resources align with the
HEI policy.

Supportive document
a) Resource utilization manual.

40
 b) Procurement policy.

6.1.2. The program has sufficient and appropriate resources, including equipment and facilities
for training, to ensure effective delivery of the curriculum. Educational resources are
distributed according to the educational needs of the study program and are well
maintained.

Narrative response
a) Describe the available educational resource related to the program.
b) Discuss the appropriateness and adequacy of educational resources to ensure
effective delivery of the curriculum.
c) Describe how educational resources are distributed according to the needs of the
program.
d) Describe the process and mechanism for maintenance of the educational resources.
e) Table 6.1.2. Educational resources list.

Number and holding Remarks

Facilities capacity
No Capacity
1 Lecture Halls
2 Basic Science Labs

Clinical Skill Lab

PBL Discussion Rooms
Morning Session Rooms

Supportive Documentation
a) Resource utilization manual.
b) Resource review and progress report.
c) Inventory report on facilities.

6.1.3. The program ensures that learning and teaching resources and facilities are appropriate
and adequate to meet the needs of its study programs.

41
 Narrative response
a) Describe the appropriateness and adequacy of educational resources to meet the
needs of the program.

Supportive Documentation
a) Minutes/reports reviewing adequacy of resources and facilities.
b) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of sufficient and appropriate resources to ensure the
delivery of the curriculum (Indicator 6.1.3.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

6.1.4. The physical facilities comply with the relevant laws, and with health and safety
regulations including accessibility to people with disabilities.

Narrative Response
a) Describe how the program ensures that the physical facilities conform with relevant
laws, health, and safety regulations.
b) Describe how the program ensures accessibility of physical facilities to people with
disabilities.

Supporting Documentation
a) Facilities review/report of compliance with health and safety regulations.
b) Physical facility health and safety manual/guideline.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of physical facilities that comply with laws and safety
regulation (Indicator 6.1.4.).

42
 Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

6.1.5. The program has a risk management strategy and conducts risk assessment of its
educational resources and teaching facilities.

Narrative response
a) Discuss the program’s risk management strategy with respect to educational
resources and teaching facilities.
b) Describe how the program conducts risk assessment.

Supportive Documentation
a) Risk management strategy of educational resources.
b) Risk assessment report of educational resources.

6.1.6. The program has a functional library accessible to students and staff with adequate
capacity.

Narrative Response
a) Discuss the functionality and adequate capacity of the library.
b) Describe when the library is accessible to students and staff.

Supportive Documentation
a) Library manual.
b) Student Satisfaction Survey. Percentages of students who were satisfied and very
Satisfied with availability of functional and adequate capacity library (Indicator
6.1.6.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and

43
very satisfied

6.1.7. The library has adequate and appropriate current references, electronic resources and
databases, qualified staff and other facilities including appropriate information and
communication technology mediated reference materials, to support academic programs
and research activities.

Narrative response
a) Describe the database system used in the library.
b) List the number of staff in the library and their qualifications.
c) Describe resource sharing and access mechanisms that are available to extend the
library’s capabilities.
d) Discuss the organization of the library and the availability of adequate supply of up-
to-date textbooks and reference materials of both hard and softcopy.

Supportive Documentation
a) Library manual describing the database system, textbook and reference materials.
b) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of digital library, up to date text and reference and database
management system (Indicator 6.1.7.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

6.1.8. The program has information and communication technology infrastructure appropriate to
the program that are required for the study program.

Narrative response
a) Describe the type of information and communication technology infrastructure
available to support the program.
b) Discuss the appropriateness and adequacy of information and communication
technology infrastructure of the program.

44
 Supportive Documentation
a) Information technology strategic planning and review document.
b) Website and corporate email.

c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with presence of information and communication technology infrastructure

(Indicator 6.1.8.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

6.1.9. The program regularly reviews resources to ensure they are appropriate and effectively
support mechanism for learning and teaching.

Narrative response
a) Describe how, how often and by whom the appropriateness and effectiveness of
resources are reviewed.
b) Provide examples of changes implemented based on review of program resources.

Supportive Documentation
a) Educational resource inventory and review report.
b) Minute /report on review.

6.2 Practical/Clinical Training Site

6.2.1 The program has access to various clinical and community attachment (training) sites to
provide adequate clinical and community learning experiences for students.

Narrative Response
a) Provide a list of the community attachment (training sites) sites.

45
 b) For each attachment site, describe the type of training provided, the resources
available and services provided, the timing of training in the curriculum and the
duration of time spent at the site by the students.
c) Describe the process (MOU, etc.) by which access of the resources for the students is
ensured.

Supportive Documentation
a) MOU.
b) Schedule of training.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with engagement of students at various clinical and community attachment
(training) sites (Indicator 6.2.1.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

6.2.2 The program has practical sites that are accessible with adequate patient number and mix
per the core competencies.

Narrative Response
a) For each practical training site, describe the patient flow and case mix that supports
the learning outcomes of the program.

Supportive Documentation
a) Assessment Checklist.
b) Student documents (notes, portfolios, and reports).
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with adequacy of facilities in the practical training sites (Indicator 6.2.2.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5

46
% Satisfied and
very satisfied

6.2.3 The program provides educational resources including national service delivery
guidelines, personal protective equipment, learning tools (checklists, logbook, SOP) and
other essential equipment.

Narrative Response
a) Describe the various educational resources available to students as listed in element
6.2.3 and any additional learning tools that are provided.
b) How and when are these resources provided to students?

Supportive Documentation
a) SOP.
b) Evidence of resource provision to students (receipt forms, etc.).
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of educational resources including national service delivery
guidelines, personal protective equipment, learning tools (Indicator 6.2.3.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

6.2.4 The program has a dedicated coordinator for facilitating community/clinical training.

Narrative Response
a) Describe the process used to ensure facilitation of the community/clinical training.
b) Is there a dedicated coordinator for the training sites? Describe the roles and
responsibilities of the coordinator and who they report to.

Supportive Documentation
a) Assignment/appointment Letter.

47
 b) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with presence of dedicated coordinator for facilitating community/clinical
training (Indicator 6.2.4.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

6.2.5 The program engages adequate instructors and supervisors in the required range of
clinical and community settings.

Narrative Response
a) For each practical training site, describe the instructors and supervisors available for
student training including total number, professional and expertise mix for the
attachment.

Supportive Documentation
a) Official list of instructors and supervisors at the training sites.
b) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with availability of assigned instructors and supervisors in the practical
centers (Indicator 6.2.5.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

6.3 Financial Resource

6.3.1 The program has financial resources sufficient to undertake its operations and implement
the strategic objectives.

Narrative response

48
 a) Discuss the adequacy of financial resources of the program for its operation and
implementing the strategic objectives.

Supportive documentation
a) Report on budget utilization.
b) Financial plan of the program.
c) Budget breakdown.

7. Research and Community Engagement

7.1 Research
7.1.1 The program has a policy and procedure that identifies the priorities, and researcher
recognition of research outputs.

Narrative Response
a) Describe the program’s goals, strategic objective, and plan for research.
b) Describe the policy and procedure that identifies the research priorities.
c) Discuss the mechanisms for researcher recognition and commercialization of research
output.

Supportive Documentation
a) Research strategic objective.
b) Research policy/manual.
c) List of researcher recognition and research output.
d) List of commercialization of research output.

7.1.2 The program provides adequate budget and sufficient facilities and equipment for the
research activities of its staff in line with its strategies to promote research activities.

Narrative response
a) Discuss the adequacy of facilities, equipment and budget allocation for research work
and dissemination.

49
 Supportive documentations
a) Annual research plan.
b) Budget request approval report.

7.1.3 The program encourages national and international research collaboration and
cooperation.

Narrative response
a) Describe how the program supports research collaboration and cooperation across
the institutions and externally, nationally, and internationally.
b) Provide examples of research collaborations with the various institutions internally
and externally.

Supportive Documentation
a) MOA between the program and internal and external institutions.
b) Research annual plan /report on research collaborations.

7.1.4 The program ensures that its research activities conform to internationally accepted
quality standards. The program ensures that misconduct, including plagiarism, is
prevented and complies with ethical standards.

Narrative response
a) Describe how the research activities comply with international accepted
methodological, quality, and ethical standards including review board approval,
conflict of interest, integrity of research, etc.
b) Describe the policies and procedures and mechanisms to prevent academic
misconduct.

Supportive Documentation
a) Research policy/manual.
b) Minutes/reports of review boards.
c) Conflict of interest disclosure forms.
d) Plagiarism checker system.

50
7.1.5 The program regularly reviews the effectiveness of its approach to research and
community engagement planning and management in order to ensure quality research
outputs and outcomes are achieved.

Narrative response
a) Describe how and how often the programs reviews the effectiveness of its approach
to research and community engagement planning and management.
b) Explain how the program ensures the achievement of research output and outcome.

Supportive Documentation
a) Minute/report on research effectiveness review.
b) Annual list of research and scholarly productivity and output.
c) Annual research report.
d) Annual community engagement report.

7.1.6 The program has dedicated resource and budget for research and community engagement.

Narrative response
a) Describe the resource and budget allocation for research and dissemination of
output.
b) Describe the resource and budget allocation for community engagement.

Supportive documentations
a) Annual plan of the research and community engagement budget.
b) Budget request approval report.

7.1.7 The program ensures that the outcomes of research are appropriately integrated into the
learning and teaching activities and community engagements.

Narrative response
a) Describe how the research goals and outcome are aligned with and integrated with
the learning and teaching activities of the program.
Supportive Documentation
a) Research annual report.

51
 b) Examples of learning activities and community engagement where research
outcomes were integrated.

7.2 Community Engagement

7.2.1 The program has a system and process for planning, implementing, monitoring, and
evaluating community engagement in line with HEI policies.

Narrative response
a) Describe the system and process for planning, implementing, monitoring, and
evaluating community engagement.
b) Describe the alignment of community engagement with HEI policies.
c) Describe how the program identifies and prioritizes the community engagement
activities.

Supportive Documentation
a) Community engagement policy/manual.
b) Reports on community engagement activities.

7.2.2 The program defines the community it serves, assesses its needs and requirements, and
takes these into consideration for its activities.

Narrative response
a) Describe how the program defines and identifies the community it serves.
b) Describe the process to identify the needs and requirements of the community.
c) Explain how the community engagement activities are aligned with the needs of the
community.

Supportive documentation
a) Need assessment for community engagement activities.

7.2.3 The program has a well-defined, coordinated approach to the identification of, and
engagement with, industry, employers, professional organizations, and the community.

52
 Narrative response
a) Describe the process and procedure to identify and engage with industry, employers,
professional organizations, and the community at large.
b) Explain the process to ensure the engagement process and procedures are well-
defined and coordinated.
c) Describe the tracking system used to monitor these engagements.

Supportive documentation
a) Manual/process and procedure for engagement with, industry, employers,
professional organizations, and the community.
b) MOA.
c) Tracking reports on engagement activities with industry, employers, professional
organizations, and the community.

7.2.4 The program encourages and supports staff and students to engaged in industry and
community engagement activities that lead to a productive relationship.

Narrative Response
a) Describe how the staff and students are involved in industry and community
engagement.
b) Describe how staff and students are made aware of the opportunities to engage in
industry and community.
c) State any initiatives taken by the program to involve students and staff in industry and
community engagement.
d) Describe how the program ensures that the community and industry engagements lead
to a productive relationship.

Supporting Documentation
a) Community and industry engagement policy/manual.
b) List of activities with community and industry engagement and evidence of output
and productivity.
c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with participation of students in community engagement (Indicator 7.2.4.).

53
 Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

7.2.5. There is an effective industry linkage for program delivery and periodically reviewing the
effectiveness of the linkage.

Narrative Response
a) Discuss the effectiveness of industrial linkage for program delivery.
b) Describe how often the industrial linkages are reviewed.

Supporting Documentation
a) Industry engagement policy/manual.
b) Industry engagement report.

8. Program Management
8.1 Leadership and Decision Making
8.1.1. The program has administrative structure and adequate staff that are qualified to support
the implementation of the educational program.

Narrative Response
a) Describe the administrative structure of the program that supports the
implementation of the educational program.
b) Describe the administrative offices and the qualification and adequacy of leaders
and support staff with recognized authority and accountability over the educational
program.

Supportive Documentation
a. Organizational structure /organogram.
b. Public announcement (letter, website, social media, printed media, etc.) of the
administrative structure and leaders.
c. Strategic plan/Legislation.

54
8.1.2. The program has policies, procedures, and mechanisms for regularly reviewing and
updating its, functions, strategies, core activities and resources to ensure continual quality
improvement.

Narrative Response
a) Describe how and how often the program reviews and updates its structure,
functions, strategies core activities and resources.
b) Describe policy, procedures, and mechanism to ensure continual quality
improvement.
c) Describe how the program seeks feedback from staff, students, and stakeholders for
continual quality improvement.
d) Provide examples of changes made to improve the program based on review reports.

Supportive Documentation
a) Program performance report.
b) Continual quality improvement review report and minutes.

8.1.3. The program has a transparent governance structure that aligns with the program goals to
realize teaching learning, research, and community engagement.

Narrative Response
a) Discuss the alignment of the governance structure with program goals.
b) Describe how the governance structure of the program supports teaching/learning,
research, and community engagement goals.
c) Explain how the program ensures transparency of its governance structure.

Supportive Documentation
a) Program organizational structure aligned with teaching/learning, research, and
community engagement.
b) Strategic plan/Legislation.

8.1.4. The program has effective regular reporting procedures about teaching-learning, research,
community engagement.

55
 Narrative Response
a) Describe the system for reporting about teaching-learning, research, and community
engagement activities.
b) Describe the offices and persons involved, frequency of reporting and persons
receiving the reports of the core activities of the program.
c) How are these reports disseminated to staff, students, and other stakeholders?

Supportive Documentation
a) DC Minutes.
b) Reports on core activities.

8.1.5. The program ensures creating institutional memory through the use of proper archives,
institutional emails, for a smooth transition of academic leaders.

Narrative Response
a) Describe how the program creates and preserves institutional memory.
b) Describe conventional and digital documentation for smooth transition of academic
leaders.

Supportive Documentation
a) Process and documentation of handover of academic leaders.
b) Institutional email system.
c) Archive of reports, minutes, decisions, and communications.

8.1.6. The program ensures the representation and role of the academic staff, students and other
principal stakeholders in committees and decision making at program level.

Narrative Response
a) Describe how the program ensures representation and participation of academic staff,
students and other principal stakeholders in decision making with respect to the
following.
i. Criteria for selection and terms of services.
ii. Role in the committees/working groups in decision making.

56
 b) Table 8.1.6. List of Committees with academic staff, students, and stakeholders’
participation.

List of No. of Academic No. of student members. No. of Stakeholders.

Committees staff voting
Voting or non-voting Voting or non-voting
members

Supportive Documentation
a) DC minutes.
b) Legislation.

c) Student Satisfaction Survey. Percentages of students who were satisfied and very
satisfied with participation of students in decision making (Indicator 8.1.6).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

8.1.7. There is a periodic review of the program which includes consideration of the
effectiveness of the management arrangements for the program.

Narrative response
a) Describe the process and frequency of how the program reviews the effectiveness of
the management.
b) Describe the types of data used to review the effectiveness of the management.
c) Describe any changes made to improve the effectiveness of the management based on
review.

Supportive documentation
a) DC minutes.
b) Reports on management effectiveness review.

57
8.1.8. The governing body of the program is an effective decision-making body with an
adequate degree of autonomy.

Narrative Response
a) Describe the decision-making body, its role and responsibilities, membership, and
frequency of meetings.
b) Describe how the program ensures the effectiveness of decision making with an
adequate degree of autonomy.

Supportive Documentation
a) DC minutes.
b) Legislation.
c) Program performance report.

8.1.9. The program provides accurate, relevant, and timely information about the program
which are easily and publicly accessible, especially to prospective students.

Narrative response
a) Describe how accurate, relevant, and timely information is provided regarding the
program.
b) How is the information disseminated to students and other stakeholders?

Supportive documentations
a) Student handbook
b) Social media, brochures, publications of the program
c) Student satisfaction survey. Percentages of students who were satisfied and very
satisfied with communication of accurate, relevant, and timely information about the
program (Indicator 8.1.9.).

Academic Academic Academic Academic Academic

Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

58
8.1.10. The program has a risk management strategy and conducts risk assessment.
Narrative Response
a. Describe the program’s risk management strategy and procedure.
b. Describe the risk areas assessed and types of data reviewed.

Supportive Documentation
a) Risk management policy and procedure.
b) Risk assessment reports.
c) Incident reports.

8.1.11. Have clear policies, guidelines, and strategies to prevent and manage sexual harassment
and gender-based violence (GBV).

Narrative Response
a. Describe the sexual harassment and GBV prevention and management guideline.
b. Describe the process and procedures for preventing and identifying sexual harassment
and GBV.
c. Describe the process of reporting, investigating, and managing sexual harassment and
gender-based violence (GBV).
d. How are staff, students and stakeholders made aware of the process?

Supportive Documentation
a. Senate legislation.
b. Student handbook (guide) pertaining to sexual harassment and GBV.
c. Faculty handbook pertaining to sexual harassment and GBV.
d. Discipline guideline.
e. Discipline committee hearings and minutes.
f. Student satisfaction survey. Percentages of students who were satisfied and very
satisfied with clear policies, guidelines, and strategies to prevent and manage sexual
harassment and gender-based violence (GBV) (Indicator 8.1.11.).

59
 Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

8.2 Allocation of resources

8.2.1 The program ensures a balanced and transparent budget and educational resource allocation
for the core functions.

Narrative Response
a) Discuss how the program ensures balanced and transparent budget allocation for core
functions.
b) Discuss how the program ensures educational resource allocation for core functions.

Supportive Documentation
a) Budget break down.
b) Annual plan.

8.2.2 The program ensures resources are sufficient, utilized efficiently and responsibly to
achieve the objectives of the program.

Narrative Response
a) Discuss how the program ensures the sufficiency of resources allocated for the
program.
b) Describe how the program utilizes resources efficiently and responsibly.

Supportive Documentation
a) Resource utilization manual.
b) Budget planning for resources.
c) Report on purchase request and procurement.

60
9. Continual Quality Improvement
9.1 Continual Quality Improvement System
9.1.1. The program has a system for monitoring, evaluating, and reviewing the effectiveness of
the governance structure.

Narrative response
a) Discuss the system of monitoring, evaluating, and reviewing the effectiveness of
program governance structure.
b) Describe the types of data collected and reviewed including frequency and personnel
and offices involved.

Supportive documentation
a) Legislation.
b) Effectiveness of governance structure review reports.

9.1.2. The program has a publicly available quality assurance policy and procedure including
adequate staffing and support, regular reviewing and updating of its internal quality
assurance activities to ensure continuous quality improvement.

Narrative response
a) Describe the quality assurance (QA) policy and procedure.
b) Describe the QA system for the following.
i. Presence of a qualified and responsible person with senior level reporting.
ii. Resources available including budget, adequate staff, and IT systems.
iii. Quality assurance manual with defined processes for monitoring and evaluating.
iv. Persons/committees responsible for QA activities.
c) Discuss how often internal QA activities are reviewed and updated.
d) Provide examples of changes made to ensure continual quality improvement based on
QA review.

Supportive documentation
a) Quality assurance policy/manual.
b) Legislation.

61
 c) QA review reports

9.2 Implementation of continual Quality Improvement

9.2.1 The program has a mechanism for continuous and need-based staff capacity building.

Narrative Response
a) Discuss the mechanism for continuous and need-based staff capacity building.
b) Describe staff development based on need assessment.

Supportive Documentation

a) Staff capacity building need assessment (need assessment analysis document).

b) Staff capacity building plan and report.

c) Evidence of staff development (training, attendance, certificates, and sponsorship

letters).

9.2.2 The program’s continual quality improvement covers all units and areas of operations.
The quality assurance activities provide relevant information and data to support the
institution in its management and development and linked with the achievement of the
institutional goals.

Narrative response

a) Describe the QA process and procedure for the following.

a. The program areas monitored including teaching and learning, research,
community engagement and strategic planning and management.
b. How QA activities are integrated across all areas monitored.
c. The types of data collected and analysis with defined frequency and
benchmark.
b) Describe how quality assurance activities provide relevant information and data for
continual quality improvement.
c) How does the relevant information and data support the program management and
development?

62
 d) How does the quality assurance activities align with and ensure the achievement of
institutional goals?

Supportive Documentation

a) QA manual describing types and frequency of data collected.

b) Annual quality assurance report.
c) Program level self-study document.
d) Examples of QA data reviewed and analyzed for each area of program activity and
changes made based on reports.

9.2.3 The program places the focus of its quality assurance activities on the enhancement of
quality and the development of a quality culture. The program ensures the active
involvement of academic and support staff and students in the operational process of
continual quality improvement.

Narrative response

a) Describe how the quality assurance (QA) activities are focused on quality
enhancement.
b) Describe how the program creates, encourages, and supports the development of a
quality culture.
c) How are academic and support staff and students involved in quality assurance
activities?
Supportive documentation

a) Quality assurance activities and data publication and dissemination.

b) QA activities discussion at department and other units’ level.
c) Awareness and educational discussion forums on QA policies, procedure, and
processes.
d) Publication and dissemination of program level self-study report.
e) Student satisfaction survey. Percentages of students who were satisfied and very
satisfied with the participation of students in the continual quality improvement
activities (Indicator 9.2.3.).

63
 Academic Academic Academic Academic Academic
Year 1 Year 2 Year 3 Year 4 Year 5
% Satisfied and
very satisfied

9.2.4 The program has a mechanism to evaluate program educational objective and program
outcome using a variety of outcome data (graduation and attrition rates, feedback from
clients, tracer study, employment rates, pass rates, mean scores and performance
breakdown on national licensure exam)

Narrative Response

a) Describe the system and process for evaluation of the educational outcomes.
b) Describe the types of data collected, describe how the benchmark is set for each and
how often and by whom the data is analyzed and reviewed.
c) Table 9.2.4 Program Outcomes Data.
Outcome Data AY 2021-2022 AY 2022-2023 AY 202

1. National licensing
exam pass rate
2. National licensing
exam mean score

Supportive Documentation

a) Educational outcome review process and procedure/ guideline.

b) Performance breakdown on national licensure exam.
c) Tracer study.
d) Employment rate.
e) Employer satisfaction rate/feedback from clients.

9.3 Monitoring and Evaluation of Continual Quality Improvement

9.3.1 The program has a mechanism to periodically gather and analyze a variety of data
(including feedback from students, instructors, and other stakeholders), and use results for
program improvement.

64
 Narrative Response
a) Describe the mechanism to gather and use feedback from students, instructors and
other stakeholders.
b) Describe the type of data collected and the frequency.
c) Provide an example of program improvement based on analyzed data.

Supportive Documentation
a) Examples of feedback data with analysis
b) Program improvements report/minutes based on feedback data.

9.3.2 The program has an internal program monitoring and review committee with a designated
head responsible for continual review of the program to ensure its currency and
relevancy.

Narrative response
a) Is there a program monitoring and review committee with a designated head?
b) Describe the role and membership of the program review committee?
c) Explain how the program review committee ensures that the program is current and
relevant?

Supportive documentation
a) Committee Minutes/ review report.
b) Annual quality assurance report.
c) Designation letter for committee members.

9.3.3 The program periodically reviews its quality assurance system for its effectiveness and
impact.

Narrative response
a) Describe the effectiveness and impact of the quality assurance system.
b) Describe how often and by whom the program reviews its quality assurance system.

Supportive Documentation
a) Quality assurance review report

65
9.4 Documentation and Dissemination
9.4.1 The program has a mechanism to identify and disseminate good practices to the
stakeholders and the wider community.

Narrative Response
a) Describe the mechanism used to identify and disseminate good practices to the
stakeholder and the wider community.

Supportive Documentation
a) Sample published/disseminated good practices.

66