The Five W’s of Self-Assessment

As presented by Medea Valdez, Ph.D.

From her webinar, “Consultants and Accreditation Support”

At the conclusion of a consultant’s work, the goal is that the whole program and the institution have a deeper understanding and appreciation of accreditation. It is exciting to see a stronger, more collaborative relationship between the administration and the program.

In that vein, let’s review the 5-Ws of the Self-Assessment Process. These underpin everything we do together to ensure sufficient understanding for an ongoing process in your program.

Why: Self-assessment provides evidence of compliance with C1.01, ensuring program improvement.

We all want to provide program excellence. This process provides evidence of what you think are strengths or problem areas. The self-assessment process allows us to test hypotheses and determine if they can be accepted or rejected.

Hypothesis Example: “Our program has an effective admissions process.” Self-assessment allows us to test that hypothesis and find the answer. If the answer is “yes,” great! If it is “no,”  we can do further analysis, triangulating data to see if this is an area needing improvement.

What: Data Collection, Both Direct and Indirect

• Data collection answers the question: Are we compliant with C1.01a through C1.01g?

• Use the Accreditation Manual

• Look at your data collection tools to ensure they include all the components that need assessment.  For example, programs often forget to evaluate their Medical Directors!

• Consider your direct data: outcomes, course grades, attrition counts, exam scores, remediation counts, etc.  Ensure you capture everything that is being asked for.

• Consider your indirect data: surveys (quantitative and qualitative) from the appropriate stakeholders.

When: You have Appropriate Timing for Data Collection – Collation – Review – Analysis

Is the cadence of your timeline appropriate for your program? 

Is time built in to accommodate each of these components? 

Do you have time to turn data into a meaningful exhibit that illustrates a relevant factor?

Is there time to move through the committee structure?

Are meetings scheduled and on the calendar? (Get them on the calendar now! Experience has taught me that unscheduled meetings are easy to push back until it's too late!)

Consider adding annual retreats to examine the big picture and include everyone.

Who: Determine Individual and Committee Responsibilities

Individual Responsibilities. Who collects and collates data? Who keeps the minutes? Who prepares the reports and sends them to the appropriate stakeholders or committees?  Who implements action plans? Who monitors results?

Committees. What do they receive? In what form? Who does the analysis, the triangulation, the action plans, and the approvals?

How: Determining the Particulars

What particulars need to be specified?

• Data Collection – what platforms are used? Is the collection internal or external? Do you want to add extra questions, beyond those required by ARC? 

• Data Collation – who takes the pile of data and makes it usable to be critically analyzed?  (I will add that this is probably one of the most overwhelming areas for PA programs.  Once they have collected all their data, transforming it into an applicable, meaningful exhibit is a common hurdle.)

• Data Analysis

• Benchmarks – have they been defined?

• Triangulation – do we understand what data truly aligns?

Conclusion

Self-assessment gives your program a 360-degree view, so that you can

a.     Make data-driven decisions for change

b.     Avoid getting lost in the “rabbit hole” of data that doesn’t impact the overall program.

c.    Understand and cope with negative factors, such as a rise in attrition, by creating an action plan that can correct the problem.

d.    Avoid becoming overly confident – you can detect potential problems before they become serious. You may avoid being blindsided by an unexpected issue.

It is rewarding when a program director becomes more confident in their role. Seeing a PD step up and grow in confidence is gratifying. It’s also rewarding to see the whole team on board with supporting accreditation in a myriad of ways: through depth and understanding of the program on multiple levels, and learning why things are done to be in compliance, rather than just “doing something because I was told to do it!”

Finally, it is gratifying to see that the program has implemented processes and procedures. They are able to build on what has been learned through this process, effectively review compliance, and maintain an effective assessment process. It becomes ongoing and sustainable no matter what comes!  

Thank you so much for joining me these past few weeks!

Best regards,

Dr. Medea Valdez