Paper presented at a Medical Education Workshop held at the Faculty of Medicine University of Science and Technology Sana’a, Yemen 14-27 June 2007 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine at the Institute of Medicine Universiti Brunei Darussalam. WEB: http://omarkasule.tripod.com
ABSTRACT
This paper starts from the assumption that quality is from inner motivation and emanates from ihsan (excellence) which alongside Islam and iman is the third greatest fundamental of al diin al islami. The paper also asserts that principles of quality assurance and quality improvement used in management can apply to quality of medical education. The paper then discusses some of the approaches to quality in medical education.
1.0 CONCEPTS AND PRINCIPLES OF QUALITY ASSURANCE
1.1 Ihsan = Quality
Ihsan is the Culture of Islam
Islam sets quality work and excellent performance in all spheres of life as its culture. Quality must permeate all activities. Allah accepts the best of work, taqabbalu ahsan al ‘amal[i] and gives rewards for it, jazau ahsan al ‘amal;[ii] The prophet said that Allah loves ihsan in everything and advised Muslims to perfect every work that they undertake including the slaughter of animals.[iii] Humans in their earthly life are tested to see who performs the best, Ibtillai al naas ayyuhum ahsan ‘amalan.[iv]
Ihsan in the Qur’an
The importance of ihsan is shown by its mention in many places in the Qur’an: as verb in the Qur’an in the past tense,[v] as a verb in the present tense,[vi] in the imperative,[vii] as an adjective, and as a noun.
Enjoining ihsan
Islam enjoins excellence in all human endeavors for example ihsan for parents, ihsan al walidayn,[viii] excellence in greetings, ihsaan al tahiyyat,[ix] excellence in religion, ihsaan al ddiin,[x] excellence in arguments, ihsaan al mujadalat;[xi] excellence in interpretation, ihsaan al taawiil;[xii] excellence in speech, ihsan al qawl;[xiii] excellence in reactionary response, al dafa’u bi al ahsan;[xiv] excellence in fulfillment of duties, ihsaan al adau;[xv] excellence in divorce, tasriiuhu bi ihsaan;[xvi] excellence in following, ittiba’u bi ihsaan.[xvii]
Characteristics of excellent workers
The Qur’an presented Yusuf as a muhsin by testimony of his brothers[xviii] and fellow prisoners.[xix] It then describes his excellent performance as a Minister in the Egyptian government when he made economic reforms and saved the country from famine. It also describes the excellence of his character when he was generous and magnanimous towards his brothers who had mistreated him.
1.2 Management Tools in Quality Assurance
Principles of Quality Assurance
Continuous quality improvement (QI) is a management philosophy that is committed to continuous and consistent improvement in quality. It is consistent with the Islamic concept of ihsaan that calls for continuous human improvement. Quality assurance or quality improvement is a type of control.
Quality assurance (QA) is formal and systematic identification, monitoring, and overcoming problems. Quality indicators are statistical indices of work performance that are a bench-mark against which performance can be evaluated. QA review may be concurrent or retrospective. The QA reviewers may be independent clinical auditors from outside or may be part of the institution. The aim of QA review is to ascertain compliance with the given guidelines. If a deviation is found, it is documented as well as its surrounding circumstances. It is discussed at the departmental QA committee. The committee will suggest actions to be taken to alleviate the deficiency and map out an implementation plan. The QA review process is cyclical. Deficiencies found are corrected and the process is repeated.
The concept of quality in university education is more difficult to define than in industry. Unlike the factory, the university has no way of defining its output in a quantitative way. However the inputs and processes of the education process can be described and can be defined. The destiny of the graduates and their achievements can be used as a fairly objective outcome indicator but it occurs too late and we are not sure of what other factors contribute to the student outcome.
Control
Control is assuring that plans are carried out effectively and efficiently. It provides a systematic and methodological approach to ensuring compliance. It enables early detection and correction of mistakes. It may be internal (due to taqwa and thawaab) or external (due to rewards and punishment). It may be pre-action, concurrent, or post implementation. A good control system must be flexible, timely, accurate, cost-effective, understandable, acceptable, and objective. The steps of the control process are (a) setting standards, criteria, or objectives; (b) measurement of actual performance; (c) comparing actual to expected standards; (d) and taking corrective action. Base plans can be changed as a result of control activities. The control program can fail due to resistance, inaccurate information, rigid bureaucracy, negligent management, too rapid changes, and an overstretched organization.
Evaluation
The objectives of evaluation are assessing whether objectives were achieved, assessing efficiency, assessing effectiveness, and learning from experience. Its benefits are: Identification of success and reinforcement, helping the management see areas of weakness and improvement, reassuring workers that they are moving well, reassuring stake-holders, and gaining the confidence of supporters and donors. If the results of an evaluation process are not used to improve future performance, the evaluation has not achieved its purpose. Evaluation may be process evaluation or outcome evaluation. It may be internal or external. It may be during project implementation or at the end of implementation. The basis for evaluation in the Qur'an and sunnah is the individual accountability as well as the reward and punishment. Data for evaluation can be collected by direct observation, questionnaire, interview, end-product, records review, and performance/knowledge tests. Self-evaluation is very difficult but yet is very important. Only the most mature, most self-confident, and most sincere people are capable of looking at themselves in mirror and deal objectively with their performance, negative or positive. Projects are evaluated on the criteria of keeping the schedule, finishing within budget, meeting all project objectives, and meeting stakeholder expectations.
2.0 CONCEPTS AND PRACTICE OF QUALITY IN MEDICALEDUCATION
2.1 Why Quality in Medical Education
Globalization has led to more competition in all fields of endeavor including medical education. The competitors are global and are no longer confined within national boundaries. Winners of the competition are those with the highest quality in terms of products and services. Governments and medical professional bodies have set up programs for quality assurance these include accreditations requirements and monitoring faculties if medicine with requirements for regular reports. Since in the globalized economy people seek work outside their country of birth, it is very important to ensure that medical qualifications of the mother country are accepted by other countries. This acceptance will occur only if the highest international standards of quality are maintained. Universities and faculties of medicine sometimes cooperate to formulate common quality assurance guidelines. These criteria also provide a framework for benchmarking.
2.2 Setting up a Quality Assurance System
Each University should have a QA unit whose job is to train lecturers and administrators from individual faculties on QA systems. They should therefore play a supporting role rather than becoming a supreme authority directing QA systems. QA programs succeed most when they are controlled at the faculty or even departmental levels by people with intimate knowledge of what is going on. A big bureaucratic centralized system will create instead of solving quality problems. The QA system must be documented in detail. The details set out QA objectives and the methodology of QA implementation. Specific QA criteria must be formulated for the various activities of the faculty. These must be quantifiable as much as possible.
2.3 Implementing a QA System
Successful implementation of a QA system requires political will from the highest authorities in a university. This is followed by identifying academic and administrative staff that has the motivation to lead the QA process. They are given the necessary training and support. Then QA procedures are formulated as a consensus of several rounds of discussion involving all stakeholders. The procedures are published in a QA manual. The manual must include clear quantitative and qualitative QA indicators. Budget and time must be made available for the QA process. It is important to maintain motivation all through. QA sub-committees are set up at various levels: units, department, faculty, and university. Provision must be made for internal and external assessment of the QA system. Internally every sub-committee has to carry out assessment at its level. Reports of both internal and external assessment are written and are discussed to identify ways of improving the QA process. Measures taken to remedy any deficiencies are treated as part of the QA report. For maximum efficiency these reports should be widely available within the institution because transparency is one of the major factors for the success of the QA process.
2.4 Evaluation of a QA System
The performance of the QA system must be monitored continuously. QA systems must be audited by both internal and external auditors. Self-assessment by members of the department remains the cornerstone of quality assurance and quality improvement. It is the best form of assessment and should be carried out on a continuous basis. Self evaluation is a more detailed process than external evaluation. It involves SWOT analysis. Assessment can also be by internal or external assessors. Scores can be given for each QA indicator so that a total score can be generated. This total score should not be over interpreted as it may not be perfect reflection of total quality. The scoring system is based on existence of documentation for that indicator: 1= very little, 2=little, 3=below average 4=average 5=above average 6=large amount 7=very large amount. The assessment should end with listing of outstanding / unresolved issues as well as recommendation for improvement.
3.0 QUALITY ASSURANCE CRITERIA
3.1 QA Criteria for Teaching and Learning
Curricula must be fully documented. They should reflect a stated underlying vision and mission of the faculty. They should cover knowledge, skills, and attitudes. They should have horizontal and vertical integration. They should be benchmarked against the best faculties of medicine in the region and internationally. They should also be accredited by the national medical licensing authority to make sure that graduates will be registrable and employable in the local hospitals. Recognition of the final qualification by other universities especially overseas is a good indicator of quality. Denial of recognition does not necessarily indicate poor quality because political factors are often invoked. The curricula should be reviewed every 3 years in view of the rapid growth of knowledge and methods of teaching and learning. These reviews should result in refining, redirecting, and restructuring the curriculum. The process of curriculum review should be evolutionary and not revolutionary. Revolutionary changes cause a lot if dislocation and confusion and in the process do not last long.
Academic staff must be qualified. Appointment and promotion of academic staff should depend only on academic merit and character. Good staff means high quality. The minimum qualification for basic medical science lecturers is a doctoral degree. Clinical teachers must have the professional specialist qualification for that discipline. All academic staff must undergo training in teaching methodology including writing course descriptions, writing learning objectives, lesson planning, effective use of audio-visual aids, and assessment systems. The teacher to student ratio should vary by department and nature of discipline but must be fixed and documented in the QA manual. The university must have personnel policies that motivate the academic staff to produce their best. A staff handbook should spell out administrative and financial procedures. It should also explain disciplinary measures. All lecturers must upgrade their knowledge and skills by attending conferences or special training courses.
Assessment of students takes place before admission, during the course, and at the end of the course. It must be systematic and the faculty must have written policies and guidelines for examinations. These should include what to do when students fail or when students cheat in the examinations.
Learning resources must be adequate. Quality starts from the facilities and management. If those are done well only vision and qualified teachers are needed to ensure quality products. These include library books, digital libraries, and internet access.
3.2 QA Criteria for Research
Research committees must exist at the university and faculty levels. The university must allocate funds for research. The research budget should not be less than one percent of the university operational budget. Academic staff must be given incentives for good research. They must be given time for research. This requires careful balancing of teaching and research which may be difficult when there is a shortage of teaching staff. The research strategy should be closely linked with the postgraduate strategy because academic staff undertakes research by directing and supervising postgraduate students.
Research distinguishes a university from a secondary school. It also enhances the academic standards by making the medical teachers producers of knowledge instead of being only consumers of knowledge who just pass it on to the students. Teachers who engage in research have up to date knowledge. The faculty should have a strategic plan for research spelling out what is to be achieved in 2, 5, or 10 years. The faculty should find a research niche and work on it in a multi-disciplinary approach. Even if the research undertaken is simple, it can yield useful results if it is focused.
Research output shall be judged for each individual lecturer as well as for the faculty as a whole. The start should be publication in the local faculty journal with attempts being made to publish in refereed international journals. The faculty should have a research ethics committee. Another academic product that must be encouraged is producing teaching materials. Lecturers should be encouraged to write up each lecture given. These can be accumulated over the years and can be published as a book.
Conference attendance is useful for purposes of presenting research results and getting feedback from other researchers. Just attending a conference without any paper presentation is not very useful.
3.3 QA Criteria for Consultancy
The faculty should have a policy on consultancy specifying how much time a lecturer can spend on consultation and also specifying financial rights.
3.4 QA Criteria for Community Service
A university cannot be an ivory tower isolated from the community. It must give back to the community by undertaking community service. This should be in the form of programs that have direct benefits for the community.
4.0 GENERAL QUALITY APPROACHES IN MEDICAL EDUCATION
4.1 Student Feedback
Students are the most important customers in the educational process. Therefore their satisfaction is very important. We have to listen to them and address their concerns. We can get student feedback from the examinations. It is however also necessary to get their feed-back by use of questionnaires. These questionnaires are more effective if administered regularly usually at the end of each unit or module. Students should be asked to indicate their degree of satisfaction with each individual learning objective. If there are too many objectives we may group them into natural categories and choosing 1-2 objectives from each category for inclusion in the questionnaire. These formal means of getting student feedback are not a substitute for informal means of getting student views on the curriculum. The students may be more honest and forthcoming in informal settings.
4.2 External Examiners
Examiners are set and are marked internally. To maintain quality medical educators from other institutions should be involved as external examiners. Their involvement should include comments on the examination questions as well as marking a sample of the answer sheets to make sure that internal marking standards are comparable to external ones.
4.3 Benchmarking
The curricula in the faculty should be compared with curricula in other faculties. This process has now become easier because many universities put their curricula on their websites. The purpose of benchmarking is not to copy or be like everybody. It serves the purpose of indicating whether in general we are ‘moving with the crowd’. If a curriculum differs in major ways from comparable institutions a rational explanation must be found otherwise there is some problem.
Another approach to benchmarking is registering students to take international medical examinations. The Americans have the MCAT and USMLE examinations. The MCAT examination is taken by pre-medical students. The USMLE I examination is taken by students who have completed the medical sciences curriculum. The USMLE II is taken at the end of clinical training. There are equivalent UK and Australian examinations.
4.4 Student Tracer Studies
An identifiable product of an educational system is the students. After graduation they take the knowledge and skills learned to the outside world. Their job performance and character reflect to a certain extent the quality of the education that they received. Thus a faculty of medicine should follow up and trace its graduates to find out how they are performing. The tracing can be by using questionnaires or telephone interviews.
4.5 Exchange of Students And Staff
Exchange of students and staff with sister faculties for short periods of time 1-2 months can be very helpful. The students can join classes in other faculties and the lecturers can give some lectures. In the process they get to make comparisons with other faculties. They may learn new approaches and methods that can improve their own faculty.
4.6 Faculty Board
The faculty board meeting monthly should play an important role in quality assurance by reviewing reports of ongoing academic activities, reviewing examination questions, and reviewing minutes of monthly departmental meetings.
4.7 Performance Appraisals
Academic staff should have annual performance appraisals of their work. Any deficiencies detected should then be corrected.
4.8 Good Students
Admitting good students means high quality. Only the best should be admitted. Besides the academic grades, consideration should be given to character and motivation to study medicine. Experience has shown that diversity improves quality. The proportion of internationals should be at least 10% for good quality. Student counseling services should be provided for all students. There must exist mechanisms for identifying and counseling failing students as early as possible.
4.9 English Proficiency
English has become an international language of scientific and professional communication. The internet information highway is predominantly in English. Therefore quality teaching and quality learning require mastery of the English language. Both academic staff and students must be proficient in English at the highest levels. To achieve this continuing education English language courses must be provided in the faculty for both students and staff. It also may make sense to have an English language unit in the faculty. The unit should focus on using English for medical purposes and not acquiring general competence in English.
NOTES
i 6:16
ii 29:7, 39:35
iii inna al llaaha yuhibbu al ihsaan fi kulli shay…idha dhabahtum fa ahsinu al dhabhat..
iv 11:7
v 18:30, 17:7, 3:172, 5:93, 10:26, 16:30, 39:10, 53:31
vi 18:104
vii 28:77, 2:195, 2:83
viii 29:8, 6:151, 17:23, 46:15
ix 4:86
x 4:125
xi 16:125, 29:46
xii 17:35
xiii 41:33, 17:53
xiv 41:34
xv 2:178
xvi 2:229
xvii 9:100
xviii 12:78
xix 12:36
____________________________________
© Professor Omar Hasan Kasule June 2007
© Professor Omar Hasan Kasule June 2007
