በኢፌዴሪየትምህርትናስልጠናባለሥልጣን

FDRE Education and Training Authority

Medicine Program Accreditation Data Collection Toll (DCT)

July, 2023
Addis Ababa, Ethiopia

Program Accreditation Standards

Program accreditation is a systematic and thorough process of assessing the
performance of HEI’s program in accordance with the standards in this guideline and
enabling it to provide quality higher education. It looks at critical areas of program
development and performance that can be assessed objectively. The program
accreditation process will assess HEI’s program based on a set of nine standards
which are formulated through wide stakeholder consultations, research and
international best practice. Each standard has sub-standards and indicators that are
significant, relevant, measurable and achievable. The nine standards are:

1. Program Outcome
2. Curriculum
3. Learning, Teaching and Assessment
4. Students
5. Academic Staff
6. Educational Resources
7. Research, and Community Engagement
8. Program Management
9. Continual Quality Improvement

Each standard is identified by a number and name (e.g. standard 1: Program

Outcome). The sub-standards of each standard are numbered with two digits (e.g. 1.1
and 1.2 for 2 sub standards under standard 1). Each sub-standard has a set of
indicators numbered with three digits (e.g. sub-standard 1.1: Alignment with
institutional mission and vision has 3 indicators numbered 1.1.1 1.1.2, and 1.1.3
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.
The procedures and process for introducing new programs starts with conduction of need
assessment to understand the general needs and expectations of the stakeholders/society.
Information obtained can be used as input for launching and/or revising. Then, the economic
feasibility of the program is checked by preparing detailed business plan.
Any academic staff or the head of department/program/chair may initiate with specific
proposal in writing for curriculum development and its merit shall be discussed at the
department academic committee (DAC).
Curriculum development work shall commence with the official assignment of curriculum
taskforce by the head department. The curriculum taskforce shall comply with all applicable
formats and requirements for curriculum development. The curriculum task force shall make
a fair and balanced survey and assessment of the need for curriculum development. The
curriculum development document shall be presented for the DAC/School Academic Council
SAC/ College Academic Council (CAC)or approval in order. Then, it will be examined by
the academic program office and presented to academic standard and quality assurance and
relevance committee (ASQARC) with its recommendation. The decision of the ASQARC
shall be presented to the Senate for approval. The approved program/curriculum shall be sent
for license to Ethiopian Education and training authority (ETA) to the earliest time. The
program will be launched after the licensure process. (Annex 1, Annex 2)

b) Summarize the process for formal review of the program.

Any academic staff or the head of department/program/chair may initiate with specific
proposal in writing for curriculum review and its merit shall be discussed at the DAC.
Curriculum review work shall commence with the official assignment of curriculum
taskforce by the head department. The curriculum taskforce shall comply with all applicable
formats and requirements for curriculum review. The curriculum task force shall make a fair
and balanced survey and assessment of the need for curriculum review. The review document
shall be presented for the DAC/SAC/CAC for approval in order. (Annex 1, Annex 2)
 c) Describe the process for formal phasing out of the programs.
Any program under the school of medicine (SoM) will be closed under the following
circumstances:
 When the graduate is no more needed in the market.
 If the program fails to achieve (meet) its objectives upon serious evaluation by
stake holders.
 If the quality of education is affected and difficult to improve in any means.
In case program closure is mandatory, an official letter should be written to the
university senate for approval so that no more students are placed for the next
academic year. (Annex 1)
d) Discuss how often the program is reviewed.
The medicine program shall undergo periodic self-evaluation once a year so as to
assure the quality of education through the School academic standard and quality
assurance committee (SASQAC). The SASQAC will have yearly supervision to
academic programs and receive a feedback from external qualification examiners.
Based on the report of the self-evaluation and external evaluation made by ETA,
necessary measures will be taken timely so as to maintain academic quality and
standard. (Annex 1, annex 3, annex 4, annex 5, annex 6)

Supporting documentation
a) Need assessment, program development /review committee minutes and reports
b) Policy, Procedure and Curriculum guideline

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.
Having a healthy and productive community is a necessity, not a choice, for populous
countries like Ethiopia and population can be an asset or a liability depending on the national
priorities of the country. As a country with significant resource constraints, a fair and
efficient health priority setting should be at the cornerstone of Ethiopia’s commitment to
attain universal health coverage by 2030.
Through the Sustainable Development Goal (SDG) era, the main priorities of the health
sector that resulted in a significant improvement of the population health status and the
achievement of most of the health related SDG’s are:
1. Creating access to basic primary health care services and
2. Building community ownership
 On the process of creating access to basic primary health care services
there has to be adequate number of physicians with in each primary health
care unit so as to fulfill the societal health needs. (Annex 1)
b) Summarize the program’s national priorities, needs of the society, and
present and emerging role of the learner
 Ethiopia is one of the countries with very low doctor-patient ratio. Thus it
is highly relevant to open a program to produce medical doctors that would
meet the present and future priority health needs of the Ethiopian
population and fulfill international standards for medical education.
(Annex 1)
c. Show program’s consistency with national and international standards.
Arsi University SoM adapted the medicine curriculum from nationally Harmonized
Competency-Based Integrated, Modular Medicine Curriculum (CBIMMC). This CBIMMC is
designed so as to meet the standards set by World federation for medical education (WFME).
(Annex 7 and 8)

d. Describe the sustainability of the program based on national priorities and

societal needs
The school of medicine has graduated 6 batches of medical doctors under
ASTU. Later the school began to receive its own students with establishment
of Arsi University by 2014. The first batch of medicine graduated with the
name of Arsi University in 2020. Till 2022 School of medicine has produced
and graduated a total of 658 competent medical doctors with undergraduate
program for the nation and global community.

Arsi university school of Medicine

Medicine graduates by Year
YEAR OF GRADUATION
G.C E.C Male Female Total Remark Entry

2014/2015 2007 80 5 85 ASTU 2001

2015/2016 2008 97 7 104 ASTU 2002
2016/2016 2008 75 7 82 ASTU 2003
2018/2019 2011 90 19 109 ASTU 2005
2019/2020 2012 89 26 115 ASTU 2006
2020/2021 2013 45 15 60 ARSI 2007
2022/2023 2015 70 33 103 ARSI 2008
2023/2024 2016 ARSI 2009
TOTAL 546 112 658

e) Indicate the professional and legal requirements of the program and show
it’s alignment with the program.
 Any student of medicine will take Exit and licensure exams after
graduation to practice medicine in the country. The exam will be given by
ministry of health licensure directorate in collaboration with ministry of
education.
 Up on passing the exams, the medicine graduate will receive his/her
professional license from accrediting body of the country which is
education and training authority (ETA) and its respective regional
delegates.
 Only Medicine graduate who received his/her professional license up on
successful passing of licensure and Exit exam is allowed to practice
medicine.
 Those who failed to pass licensure and Exit exam will be given multiple
chances to sit for the exam till they pass unless otherwise limitation is set
by ministry of health. (Annex 1, Annex 9)
Supportive documentation
a) Program based legal practice documents
b) Program based policy indication document
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 by whom the program learning outcomes were formulated.
 The nationally developed curriculum were reviewed and discussed the
importance of the program at the school and college level involving
curriculum review committee, department heads, instructors, students
representatives, and the administrative bodies.
b) Describe the stakeholders involved in the development of program learning
outcomes.
 National curriculum task force, Curriculum review committee of the SoM,
department heads, instructors, and student representatives.

c) How often the program learning outcomes are reviewed?

 The new curriculum was started recently and two batches of students took
external pre-clinical examination after which preclinical part of the
curriculum has undergone mini revision. After graduation of 1 st batch of
new curriculum, the whole program outcome will be reviewed .Then after;
the curriculum will be reviewed every 3 years. (Annex 10)
d) Describe the process used by the program to develop its learning outcome.

The curriculum is designed and produced as an integrated, competency based,

modular approach in which the basic sciences are taught simultaneously with
clinical and community medicine. It is described in terms of learning outcomes,
which define the knowledge, skills and attitudes (behaviors) so as to produce
competent, compassionate, respectful caring and community oriented doctors for
Ethiopia with internationally accepted standard of excellence. The learning
outcomes that are listed in curriculum are initially developed by the nationally
established taskforces from different universities and disciplines which has
undergone 8 rounds of curriculum development workshop. Finally the approved
harmonized curriculum was sent to our university. Then after, the school has
established a team of curriculum review taskforce containing academic staffs of
 different discipline, academic leaders, and student representatives to review and
develop the learning outcomes. (Annex 4)

e) Describe how the program learning outcomes are communicated to internal and
external stakeholders.
 The learning outcomes communicated through student hand book,
curriculum, university website and brochure.
Supporting documentation
a) Curriculum design, development and revision guide /minutes /curriculum review/
validation workshop report
b) Syllabus

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 indicate the career and further studies options based on
stated learning outcome
 Medical Students who has completed their under graduate program in
medicine program shall have the career and further studies options
available to them based on their personal interest. So the graduates have an
option to continue as clinician by doing their specialty and subspecialty
certificates as a second and third degree respectively or may join public
health as masters and PhD consecutively. They can also grow in clinical
medicine while taking public health as masters and PhD programs so that
they can integrate both so that they can be clinicians and researchers at a
time. (Annex 11).
Supportive Documentation
a) Tracer study report
b) Minutes
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
 b. What mechanisms are put in place to obtain feedback from stakeholders to
improve the delivery of the study program?
 The mechanisms to obtained feedback from stakeholders includes student
satisfaction survey, tracer study, feedback from external examiners.
(Annex 5 & 12)
c. Show how the program is updating based on the feedback obtained from
stakeholders.
 Based on obtained feedback, the curriculum implementation will be
revised, updated and incorporated into the existing curriculum.(Annex 5)
Supportive Documentation
c) Tracer study report
d) Minutes
1.1.6. The program is approved by appropriate governing body.
Narrative response
a) Describe the procedure used to approve the program
 The final program approval occur in the following manner
 The academic affairs office shall present curriculum approval request to
the academic standard and quality assurance and relevance committee
(ASQARC) with its recommendation.
 The recommendation of the academic affairs office shall cover substantive
and technical review results of the proposed curriculum.
 The ASQARC shall notify its decision within two weeks. It may be
prolonged by additional two weeks if the senate standing committee
backlogs.
 The decision of the ASQARC can be appealed to the Senate for approval.

b) Does the program approved by appropriate governing bodies?

 The curriculum development and/or review document shall be presented by

school dean for the SAC/CAC/senate for approval in order.
 The approved program/curriculum shall be sent for accreditation to Ethiopian
Education and training authority (ETA) to the earliest time.
 The program will be launched after the accreditation process.
c) How often and by whom the program outcomes are reviewed?
  The program outcome will be reviewed regularly every three years by
curriculum review committee (Annex 2)
Supporting documentation
a. Program approval minute/ (AC/DC) …..Annex 13
b. The current Legislation
1.2. Alignment with institutional mission, vision and goals
1.2.1. The outcomes of the program align with the HEI’s mission, vision and strategy.
Narrative response
a) Provide the mission and vision statement of the institution
 Mission- Arsi University strives to bring sustainable development through
practice-based teaching-learning process and conducting problem-solving
research in collaboration with industries.
 Vision- Becoming one of the most known and chosen Applied Science
universities in East Africa by 2030. (https://arsiun.edu.et/vision-and-
mission/ )
b) State program outcomes set for the program.
 Clear, measurable and observable learning outcomes are stated at
program, module and rotation levels considering learning domains
(knowledge, skill and attitude) and learning hierarchy suitable for higher
order learning requiring application and problem-solving.(Annex 7)
c) Show the alignment of program outcomes with institutional mission and vision.
 The outcome of medicine program is to produce competent, compassionate
and committed medical doctors that would meet the present and future
priority health needs of the Ethiopian population and fulfill international
standards for medical education through our four fold mission; to teach, to
heal, to search, and to serve. This program outcome is in line with the
university’s mission and vision (Annex 1 &7)
Supporting documentation
a) The current strategic plan of the institutions
b) Program curriculum.

1.2.2. The program learning outcomes conform to academic requirements of the study
program and Ethiopian Qualification Framework (EQF).
Narrative Response
 a) Describe the alignment of program learning outcomes with academic
requirements of the study and EQF
 The ENQF is based on the outcomes-based education concept in that
programs leading to the award of qualifications should introduce
curriculum which state the outcomes expected from learners. The ENQF
has a built-in mechanism that evaluates whether learners are assessed to
predetermined learning outcomes and whether education and training
institutions have the proper institutional settings to enable learners to
achieve those outcome statements. In line to this, our new CBIMMC is
outcome based curriculum which would enable medical students with
seven core competencies. (Annex 7 and 14)
Supportive Documentation
a. EQF document
b. Syllabus
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) How does the HEI ensure that the curriculum is relevant to the expectations of the
national and international competencies?
 The curriculum is designed and produced as an integrated, competency based,
modular approach in which the basic sciences are taught simultaneously with
clinical and community medicine. It is described in terms of learning
outcomes, which define the knowledge, skills and attitudes (behaviors) so as
to produce competent, compassionate, respectful, caring and community
oriented doctors for Ethiopia with internationally accepted standard of
excellence. Annex 7 and 8

Supportive Documentation
a) Curriculum
2.1.2. The curriculum incorporates core contents of the discipline that are essential for
understanding the concepts, principles and methods that support the program
outcomes.
Narrative response
a) Indicate the core content (Course catalogue) of the discipline for
understanding the concepts, principles and methods that support the program
outcomes.
 The core contents (Course catalogue) of the discipline are organized into the
following academic years, namely Pre-medicine, pre-clerkship I, pre-
clerkship II, clerkship I, clerkship II and internship. Within each academic
year, there are modules with detailed course contents and learning outcome.
(Annex -7 and 11)
b) Current curriculum of the program (Annex -7)
c) Show how the core contents of the discipline support the program outcomes.
 Each module of the medicine curriculum has detailed course contents and
learning outcomes that are organized into seven core competencies.(Annex 7)
Supportive Documentation
a) Table on Course catalogue (copy the whole table)
List of Course Course ECTS/CrHr Pre- Remark
courses category code requisite

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) How does the program curriculum takes into account the appropriate professional
requirements, industry requirements and good practices in the discipline
 The Medical Expert Role is central to the function of physicians and draws
on the competencies included in the Intrinsic Roles (Communicator,
Collaborator, Leader, Health Advocate, Scholar, Manager and Professional).
So, the curriculum will ensure that each module of the medicine curriculum is
designed to meet the above mentioned core competencies. (Annex 7)
Supportive Documentation
 a) Curriculum of the program
2.1.4. Educational 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) Indicate the learning outcomes of the program.
 The learning outcome of the program is to produce competent,
compassionate, respectful, caring and community oriented doctors for
Ethiopia with internationally accepted standard of excellence. Annex 7

b) Show how the learning outcomes clearly articulate the required domains of
learning.
 The program outcome described in terms of learning outcomes, which define
the knowledge, skills and attitudes (behaviors) so as to produce competent,
compassionate, respectful, caring and community oriented doctors for
Ethiopia with internationally accepted standard of excellence. Annex 7
Supportive Documentation
a) Current curriculum of the program

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) Explain the program curriculum design process.
The initiative to have harmonized competency based integrated curriculum was started in
2014 during the medical school’s consortium meeting facilitated by the Ministries of Health
and Education. The task force was nominated by the consortium in the meeting that was held
on August 2015 at Ghion hotel. The task force was represented by Medical Schools,
Ministries of Health and Education and Non-Governmental Organizations who are involved
in improving quality of medical education in the country including Jhpiego, ICAP and
CIRHT. This taskforce was mandated to develop an updated curriculum that has innovative
features while maintaining the strength from the conventional one.
The curriculum design process sought to assure that it meets the needs of the society and be
responsive to the expectation of the population. To achieve this, local morbidity and mortality
data were reviewed; National Health Policies and strategies were considered and National
Task Analysis survey findings were used.
Overall the curriculum development process took about 8 months with workshop-based
intense engagement and individual assignments completed by members before, in-between
and after workshops. Essentially, eight steps were followed:
 Preparation and desk review of documents and resource materials
 First curriculum development workshop
 Second curriculum development workshop
 Individual assignments
 Third Curriculum Development Workshop
 Compilation of draft curricula for review
 Curriculum review workshop
 Finalization of the curriculum
Annex 7
b) Discuss the way how the program curriculum design and development is
communicated to students.
 The program curriculum design and development is communicated to students
through student handbook, brochures and face to face orientation. Annex 11,
15

Supportive Documentation
a) Curriculum guideline
b) Minutes
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 learning and teaching activities in the curriculum are
appropriately designed to achieve the learning outcomes
 The curriculum model is competency (outcomes)-based with three
cardinal features.
i. Clear, measurable and observable learning outcomes are stated at
program, module and rotation levels considering learning domains
(knowledge, skill and attitude) and learning hierarchy suitable for
higher order learning requiring application and problem-solving.
 ii. Appropriate and experiential teaching and learning strategies that
are aligned with defined learning outcomes are selected to
maximize attainment of the desired competencies by all students.
iii. Assessment methods that are authentic and require students to
perform the tasks defined by the learning outcomes are suggested.
Annex 7
b) Discuss the alignment of learning and teaching activities with learning outcomes.
 In the current competency based curriculum, there is constructive alignment
among learning outcomes, teaching and learning strategies and assessment
methods. To achieve the learning outcomes (seven competencies), the SPICES
(student-centered, problem-based, integrated, community-based, elective and
systematic) model, innovative educational strategies are used in the
implementation of the curriculum.
(Annex 7)

Supportive Documentation
a) The current curriculum of the program
2.1.7. The learning and teaching activities encourage the active participation of students in
their learning process.
Narrative
a) Describe how learning and teaching activities encourage the active participation
of students.
 In the current competency based curriculum, students are given greater
responsibility for their own learning by integrating a more learner—centered
teaching and learning and assessment methods such as problem-based
learning, personal research and reflection exercise and portfolio-based
learning and assessment. This has the advantage of putting the emphasis on
the student, increasing students’ motivation and preparing them to become
lifelong learners. (Annex 7)

Supportive Documentation
a) The current curriculum of the program
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
a) Describe the duration and credit hours in light of applicable national standards
 The duration of the medical education is six and half years with the following
components: Pre-medicine (1year), pre-clerkship I & II (2years), clerkship I &
II (2 and half years) and internship (1year). The total credit hours for pre-
medicine are 21 and 23 in 1st and 2nd semester respectively over a total duration
of 40weeks.The total ECTS for pre-clerkship I and II are 89 and 60 over a total
duration of 58weeks and 50weeks respectively. Similarly during clerkship I and
II students will take 91 ETCS and 89 ETCS over a period of 62 weeks and
60weeks respectively. See the table below for the detail clarification.( reference
Medicine Student hand book 2023,CBIMMC 2021)
 Table showing summary of duration of stay and total ECTS to be taken at
school of medicine and national level. Annex 7

Academic Year Duration in weeks including vacations Total ECTS

Pre-medicine 40weeks 78
Pre-clerkship I 58weeks 89
Pre-clerkship II 50weeks 60
Clerkship I 58weeks 91
Clerkship II 62weeks 89
Internship 60weeks 105
Total 328weeks 512

Supportive Documentation

b) The current curriculum of the program

2.1.9. The curriculum Specify outcomes related to engagement of the students in research
and community service.
Narrative
a) Describe outcomes pertaining student engagement in research and community
 The curriculum specify importance of preparing doctors who are able and
willing to address priority health needs of their communities, community-based
 learning is added to complement the hospital-based learning. To this end,
students have scheduled visits to primary health care facilities and
communities, community-based training programs and a team training program
during internship. Advantages of community-based learning include providing
community-orientation to the curriculum, providing useful learning experiences
for competencies that may not be adequately developed in a hospital setting,
making use of untapped resources, encouraging active learning, exposing
students to patients that have not been seen by healthcare providers and
introduction to the healthcare system. ( Annex 7)

Supportive Documentation
a) The current curriculum of the program
2.1.10. The curriculum Communicate the educational outcomes to students, faculty, staff and
stakeholders.
Narrative
a) Discuss how educational outcomes are communicated to stakeholders
 The curriculum educational outcomes are communicated to stakeholders
through student’s handbook, curriculum orientation, brochures and university’s
website. Annex 11, 15
Supportive Documentation
a) Minutes/reports on curriculum orientation, brochures
2.1.11. The program Ensure 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
a) Discuss integration of the various components and phases of the curriculum
 Competency-Based, Integrated, Modular, Medical Curriculum (CBIMMC) is
designed based on the strengths of the traditional curriculum and incorporating
innovative features highlighted in the SPICES model and other global
recommendations on instructional design. It integrates the three arms of
medicine (biomedical science, clinical sciences and public health) both
horizontally and vertically starting from year two to final year of the academic
program. (Annex 7)
 Supportive Documentation
a) The current curriculum 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) List the members and composition of curriculum committee.
 The task force was represented by instructors, student representatives,
department heads, and administrative bodies. (Annex –16)
b) Describe how the committee oversee, monitor and evaluate the curriculum
 This committee has mandate to periodically oversee, monitor, evaluate and
update the curriculum through the following means:-
o Oversee matters directly pertinent to the curriculum of the School
of Medicine including, program objectives, process,
implementation integration, coordination and evaluation.
o monitoring curriculum content to identify gaps, redundancies, and
appropriate sequencing,
o ensuring integration of content within periods of study (horizontal
integration) and across years (vertical integration),
o monitoring student learning outcomes and approaches to student
assessment,
o Monitoring program evaluation data. Annex 17
c) Discuss the functionality of the curriculum committee.
 The committee members have reviewed the initial harmonized CBIMMC
and write a report and submit to the school of medicine for incorporation
and further approval at SAC/CAC/senate. The committee is still
undergoing mini revision for pre-clerkship modules following subsequent
step-1 qualification exam by incorporating feedback from external
examiners, students, and instructors. (Annex –4,5 and 18)
Supportive Documentation
a) Assigning letter for the committee
 b) Curriculum committee minutes, report

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
Narrative response
a) Describe how and how often the program curriculum is reviewed.
 The medicine program shall undergo periodic mini revision post step-1
qualification exam and major revision following graduation of first batch with
the curriculum after evaluating graduate outcome. Mini revision will continue
every three years then after when need arise.(Annex -2)
b) Discuss how feedbacks from stakeholders are considered in the review process.
 The curriculum committee will receive feedback from external examiners,
students, and instructors and incorporate valid and acceptable comments into
preexisting curriculum or modify the implementation of the already existing
practices. (Annex 5,18)

Supportive Documentation
a) Curriculum review workshop report
b) Student satisfaction survey report
c) Minutes/report on curriculum review process

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) Discuss the consistency of learning and teaching activities with the curriculum.
 The modules within the curriculum are designed in system based
approach, teaching methodology and assessment methods are consistent
across the academic year. (Annex -7)
b) Indicate the varieties of learning-teaching methods used for the program
  The major teaching and learning methods suggested to be used in the
implementation of the curriculum are:
o Interactive lecture
o Problem-based learning(PBL):
o Case study:
o Simulated practice (clinical skills lab) :
o Clinical practicum:
o Community-based learning
o Laboratory practice:
o Portfolio-based learning:
o Whole group session
o Journal club(Annex-7 & 11 )

c) Describe how the learning-teaching methods set in the curriculum are aligned with
learning outcomes.
 The selected methods are closely aligned with the intended learning
outcomes across the three learning domains (knowledge, skills and
attitude) and the expected level of performance by the learner thereby
maximizing the chances that learner will master the required knowledge,
skills and attitude

 One size does not fit all. What might be considered as the best teaching
and learning method for a certain learning outcome may not be so for
another learning outcome. In addition, using different methods is likely to
stimulate and motivate learners. Hence, a variety of teaching and learning
methods are suggested to be used in the curriculum. Where possible,
methods that encourage collaboration and cooperation among learners are
proposed. (Annex 7)

d) How do learning and teaching methods encourage the active participation of

students for their own learning?
  In teaching and learning activities students are given greater
responsibility for their own learning by integrating a more learner—
centered teaching and learning and assessment methods such as problem-
based learning, personal research and reflection exercise and portfolio-
based learning and assessment. This has the advantage of putting the
emphasis on the student, increasing students’ motivation and preparing
them to become lifelong learners. (Annex 7 & 12)

Supporting Documentation

a) The current Curriculum/ Course syllabus

b) Learning teaching manual
c) Student Satisfaction Survey
3.1.2. The learning and teaching activities are appropriately designed to ensure that learning
outcomes are achieved
Narrative response
a) Discuss how the teaching-learning activities are designed to ensure achievement
of learning out comes
 The curriculum model is competency (outcomes)-based with three cardinal
features. Firstly, clear, measurable and observable learning outcomes are
stated at program, module and rotation levels considering learning
domains (knowledge, skill and attitude) and learning hierarchy suitable for
higher order learning requiring application and problem-solving. Secondly,
appropriate and experiential teaching and learning strategies that are
aligned with defined learning outcomes are selected to maximize
attainment of the desired competencies by all students. Thirdly, assessment
methods that are authentic and require students to perform the tasks
defined by the learning outcomes are suggested. To the extent possible,
there is constructive alignment among learning outcomes, teaching and
learning strategies and assessment methods. Within the framework of the
SPICES Model, the following innovative educational strategies are used in
the development of the curriculum. Student-centered, problem-based,
integrated, community-based, elective and systematic) and other global
recommendations on instructional design. It integrates the three arms of
 medicine (biomedical science, clinical sciences and public health).(Annex
7 & 12).

Supportive Documentation
a) Curriculum
b) Module/course syllabus
c) Student Satisfaction Survey

3.1.3. The curriculum Ensure/verify 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) Discuss whether instructors provide syllabi and use session plans for
instruction
 The curriculum has a standardized course syllabus which will be
shared for the students. The instructors are well informed to prepare
effective session plan for teaching, including clinical practicum.
However, use of lesson plan is not consistent across all instructors.
Therefore, instructors are highly encouraged to use session plan
consistently.(Annex-19)

Supportive Documentation
a) Module/course syllabus
b) Sample session plan
c) Student Satisfaction Survey
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) Provide details of the learning resources are sufficiently addressed to students.
 There is a 24 hours open dedicated Medical Library, IT room which are
located in health science campus with access to electronic information
systems, broad band internet, Books, publications and materials.
  The main library located in Dinsho campus accessible for premedical and
pre-clerkship students for 24hrs accommodating more than 2000students
having sound proof floor.
b) Describe the conduciveness of the learning environment for the effective
implementation of the program.
 Lecture halls are smart rooms equipped with well-furnished seats, fixed
LCDs projectors, Desk top computer, white board with marker and Wi-Fi.
 Clinical skill dev’t Lab Center (SDL) is designed and arranged based on
the desired competencies and students are accessing it being with their
instructors or practice with colleagues at their convenient time.
 Basic science laboratories are well equipped and furnished for practical
teaching of pre-clerkship students.
 Student Dormitories and Study Space are convenient and located near
library.(Annex-20)
c) List the types of support services that are provided to students.
 University Student clinic
 Counseling and Psychological Services (CAPS)
 Students cafeteria service
 Financial Assistance
(Annex 12, 21)
Supportive documentation
a) Report on student support services
b) Learning resource utilization report
c) Student Satisfaction Survey

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
 Student council
 Football club
 Girls club
 GAASO club
 Student association( EMSA)
 b) Describe how these activities enrich students’ experiences, and foster personal
development and responsibility.
 These co-curricular activities are crucial in enriching the experiences of
students in leadership, management, communication, collaboration, and
conflict solving and culture development.
Supportive Documentation
a) Student satisfaction survey result on co-curricular activities
b) Report on co-curricular activities
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.
 The module coordinator for preclinical students and undergraduate coordinator
for clinical students monitor and review learning and teaching, which is done
at the end of each modules.

b) Describe how student feedback is used to monitor and review the quality of learning
and teaching.
 Feedback of the students is collected, reviewed and used to identify gaps in the
curriculum then finding will be incorporated into ways of implementation.
 Item analysis reports, student feedback on test items, and other statistical
reports for all assessments shall also be forwarded to the Assessment
committee for review and evaluation.(Annex 18)

Supportive documentation
a) Student Satisfaction Survey
b) Learning teaching Feedback report

3.2. Assessment policy and system

3.2.1. The program has an assessment policy/ guideline that clearly describes assessment
practices and principles including methods, frequency, scoring, marking, remedial
action and post-exam analysis procedures.
 Narrative response
a) Discuss the policy/guideline and its key components
 The assessment policy has different components with detail description
of assessment methods which include direct observation of clinical
skills (DOCS, objective structured examination, Structured long cases,
Written assessments, standardized oral exam, Logbook, Portfolio,
global Rating, PBL /case study, tutorials progressive assessment,
Additionally the policy has incorporated Assessment Policy and its
scope, rules for the undergraduate examinations, General Provisions on
Remarking of Final Examinations, Grading system and promotion
criteria and Graduation Requirements are well mentioned in the
guideline. (Annex 22)
b) Describe post exam analysis procedures.
 Post examination, student feedback on test items, item analysis and other
test statistical reports will be reviewed by the relevant
course/module/rotation coordinator and/or teaching faculty, in conjunction
with the Assessment committee, prior to final determination of student
scores. Any modifications made as a result of this analysis will be applied
to the entire class. These data will also be used to inform future item
development and reuse (from exam bank).(Annex-22 & 23)
Supportive Documentation
a) Assessment policy/guideline
b) Post exam analysis report
3.2.2. The program has put in place mechanisms to ensure the validity and reliability of the
student assessment system including exam blue print, item analysis and exam bank.
Narrative response
a) Describe how the program ensures the validity and reliability of the student
assessment system
 The Assessment committee is responsible for oversight of the submitted
assessment documents, and will review any items flagged by the
assessment coordinator, committee chair or other course faculty.
 Each course/module coordinator will report annually to the Assessment
committee on the performance of the course/module/rotation
 examination(s), (reliability, adherence to blueprint) and course evaluations
as they relate to assessment procedures.
 Item analysis reports, student feedback on test items, and other statistical
reports for all assessments shall also be forwarded to the assessment
committee for review and evaluation.
 Any adverse assessment performance report, such as low (<70%) course
evaluation scores on assessment, high numbers of poorly performing
questions, or significant concerns arising from qualitative student
feedback, will require a review of the course/module/rotation assessment
framework. The Assessment committee will work with the course team in
revising the assessment framework for any course where problems are
identified.
 The committee will report annually to the Curriculum Committee on the
performance of the assessment process.(Annex-22)
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.
Narrative response
a) Describe how the program regulate and administrate student appeals and disputes
regarding assessment.
 As per modified Arsi University legislation 2018 with a duties and
responsibilities given for college under section of 140.2 duties and
responsibilities subsection “d” the presence of a system for disciplinary
and appeal process for assessment results has been stated with a statement
which said “Examines and decides on issues of graduate students’
academic appeal; readmission, make up examinations.” School of
medicine shares that duty; it has its own disciplinary and appeal process
for assessment results(Annex 2 & 22)
b) Discuss the alignment of academic security and integrity of assessment
arrangements with HEIs policy.
  As per modified Arsi University legislation 2018 on Article 208: rights of
student subsection “L) Enjoy the benefits of a carefully considered policy
of confidentiality regarding the information that should be part of their
permanent educational record and as to the conditions of its disclosure”,
the school of medicine is maintaining confidentiality and security of
student assessment processes, assessment results and well documented
academic records and are maintained in line with HEI’s policy (Annex- 2
&22)
Supportive Documentation

a) The policies and procedures for disciplinary action and appeals

b) Minutes on disciplinary and appeal decisions
c) Assessment policy/guideline.

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 how the assessment mechanisms used to measure the course outcomes.
 In the competency- based, integrated, modular medical curriculum of Arsi
University, assessment methods are supposed to assess the three domains
of learning.
 These assessment methods can be either formative or summative
assessment. Summative assessment methods for pre-clerkship I and II with
an aim to determine the attainment of educational outcomes which are
described on page 40 – 41, 43 as: “Both OSCE/OSPE will be part of the
summative assessment and will be implemented during premedical, pre-
clerkship I and II as well as clerkship I and II to assess psychomotor
domain of learning. Oral exam will be part of the summative assessment in
qualification exams at the end of pre-clerkship and clerkship modules.
PBL /case study tutorials progressive assessment method will be part of
both formative and summative assessment during pre-clerkship I and II
and clerkship I and II. Written assessments, include multiple-choice
questions, matching, true-false, essay and short answer, would be used as
parts of both as formative and summative assessment in premedical, pre-
 clerkship and clerkship. Global rating will be also used as part of both
formative and summative assessment of students throughout the duration
of the medical curriculum 3600 evaluation which consists of measurement
tools completed by multiple people in a student’s sphere of influence.”
(Annex 7)
b) Discuss how the assessment ensures academic progression and graduation.
 In the competency- based, integrated, modular medical curriculum of Arsi University,
there is general promotion criteria and criteria for pre-clerkship and clerkship to
decide promotion for students to next academic year which is well articulated and has
also graduation requirement stated as;
 A student should pass successfully in all modules obtaining a minimum grade of
“C”.
 A cumulative Grade Point Average (CGPA) of 2.00 must be obtained
 A Student should successfully pass step 2 qualifying examination Successful
completion of internship attachments.” the school of medicine has a system of
assessment that measures course outcome and informs decisions on progression
and graduation.” (Annex-7 & 22)
Supportive Documentation
a) Assessment policy/guide
b) 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
 There is mechanism at each department for exam analysis with standard
setting discussion
b) Show how the exam item analysis result is used for decision making
 Using computerized system questions missed by high scorers and
answered by low scorers might be by chance and cancelled from total
summation.
Supportive documentation
a) Exam item analysis report
b) Minute for Decision making item analysis.
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.
Narrative response
a) What assessment methods and tools are used?
 direct observation of clinical skills (DOCS)
 Objective structured clinical examination (OSCE)
 Structured long cases
 Written assessment
 standardized oral examination
 logbook
 portfolio
 global rating
 PBL/ case study progressive assessment (Annex 7 & 22)
b) Describe how the assessment methods and tools assess the learning outcomes and
competencies.
 Assessment activities contribute significantly to student learning by giving each
student ongoing feedback about their performance. Assessments in all parts of the
curriculum are designed to promote deep learning, critical thinking, and habits of
inquiry aligned with the School of Medicine competencies and objectives so that
students attain the knowledge, skills, and attitudes at a level of mastery necessary
to pass licensing exams and to ultimately provide high-quality patient care.
(Annex 7, 12 & 22)

Supportive documentation
a) Student assessment guideline
b) Current curriculum
c) Student Satisfaction Survey (SSS)
3.3.2. The program’s approach to overall assessment activities are 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.
 The Assessment committee is responsible for oversight of the
submitted assessment documents, and will review any items flagged
 by the Assessment coordinator, committee chair or other course
faculty.
 Each course/module coordinator will report annually to the
Assessment committee on the performance of the
course/module/rotation examination(s), (reliability, adherence to
blueprint) and course evaluations as they relate to assessment
procedures.
 Item analysis reports, student feedback on test items, and other
statistical reports for all assessments shall also be forwarded to the
Assessment committee for review and evaluation.
 The committee will report annually to the Curriculum Committee on
the performance of the assessment process. (Annex 7 & 22)
Supportive document
a) Assessment review report/minute
b) Student assessment guideline

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) Discuss the system of assessment that regularly offers students with actionable
feedback
 Students receive constructive formative feedback (i.e. feedback beyond a
numerical grade value) on their performance during each required
preclinical course/module in order to allow sufficient time for remediation.
For courses/modules of less than 4 weeks duration, alternative methods of
formative assessment may be used to allow students to reflect on their
learning.(Annex-7 & 22)
b) Describe how students are provided with timely feedback to identify their strength
and areas of improvement.
 Feedback must include written narrative description of performance
whenever teacher-student interaction permits this form of assessment. Any
student who fails a major internal summative assessment may request to
review his/her assessment by contacting the appropriate course, module or
 rotation coordinator. In most cases this will be accommodated. However,
in some instances it cannot due to issues of exam security. Students
considering an appeal should refer to the appeals process (Annex- 7,12 &
22)

Supportive Documentation
a) Student satisfaction survey report
b) Assessment policy/guideline
c) Exam committee minute and report

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
 Students are provided with national Harmonized Competency-Based Integrated,
Modular Medicine Curriculum (CBIMMC) and student handbook on program
assessment (Annex 7 & 11).

b) Discuss the adequacy and fairness of the assessment to measures the achievement of
learning outcomes
 Each course/module/rotation director is responsible for standard setting
assessments, and will use an appropriate standard setting procedure in order to
determine the passing grade or cut score for each major assessment (OSCE or
written exams). This score will represent the minimal level of competence deemed
acceptable for that assessment at that level of training. Assistance with choice and
implementation of appropriate standard setting procedures is available from the
Assessment committee. When test centered methods are used, participants will
include course faculty. Cut scores is a fixed scale as it is stated in curriculum.
(Annex 7 & 22)
Supportive documentation
a) Curriculum
b) Assessment policy/guideline
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
 Students who are identified as being in academic difficulty may be offered
remediation and supplemental assessment.
 The course/module coordinator will determine the specific type of
remediation and supplemental assessment needed for each individual
student based on the rules stated in the curriculum.
 The supplemental assessment may be in the form of the original
assessment or in another form as appropriate for reassessing the student’s
area(s) of academic difficulty.
 The supplemental assessment may be cumulative or non-cumulative, and
either overrides a portion of, or the entire course/module mark. (Annex 7
& 22, a?).
Supportive Documentation
a) Minutes/reports and letters on remediation
3.3.6. 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
 External examiners will give feedback based on student exam performance
at the end of exam completion where instructors, department heads, school
dean and relevant administrative staff members.
 Based on assessments of national exam result and feedback from the
external examiners action plan will developed and implemented
accordingly (Annex a? and b?)
Supportive Documentation
a) AC/DC Minutes/reports and letters
b) Action plans based on performance feedback

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. Have updated and publicly accessible student selection and admission policy, tailored
to local and national workforce requirements which sets out the aims, principles,
criteria, processes, appeal procedures
Narrative Response
a) Describe how student selection and admission criteria is disseminated for internal
and external stakeholder
b) Describe the principle, criteria and process of admission to the program.
c) Describe the mechanisms of appeal system to admission process.
Supportive documents
a) Current Curriculum
b) Student handbook
c) Student selection and admission guideline
d) Student Satisfaction Survey report
4.1.2. Student selection and admission practices for the program are clear, efficient, explicit
and fair, and in accordance with the HEI’s policies and regulations.(This is indicator
4.1.1. in original document)
Narrative response
a) Describe thestudent selection and admission practices of the program.
b) Discuss thealignment of student selection and admission practice with HEIs policy
and regulations.
Supportive document
a) Student selection and admission policy
b) Student Satisfaction Survey
c) Student handbook
d) Registrar manual
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 reviewed
b) Explain how to ensure student intake capacity is in lined with available resources for
effective implementation of the program.
Supportive documentation
a) Student intake capacity communication letter
b) Current annual plan of the program
C) Summarize the active batch student enrollment capacity of the program
Academic year Enrolled students Remark
F M
2023 # #
2024 # #

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 policy which state about transfer and exchange of students nationally
and internationally
b) Describe the practice and procedure of the program on student transfer and
exchange
c) 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) Legislation
b) Registrar manual
c) Current curriculum
d) Student Satisfaction Survey
e) Student handbook/Student transfer Guideline
4.1.5. Promote diversity in admission, including gender mainstreaming, and consideration of
disadvantaged groups and persons with disabilities, where applicable
Narrative Response
a) Indicate theInclusiveness’ of admission policy
b) Describe the minimum requirements for admission to program
Supportive documents
a) Student selection and admission policy
b) Report on student placement
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) Indicate the admission requirements of the program.
b) Describe how and how often the admission requirements are reviewed.
Supportive document
a) Admission policy
b) Registrar manual
c) Minutes/reports on reviewing admission requirements
4.2. Student counseling and support service
4.2.1. The program has a comprehensive student handbook that indicates student`s support
systems and makes it accessible to students. There is an effective induction
orientation program to new students about the program and the available support
mechanisms
Narrative response
a) Describe the effectiveness of induction program provided to new students regarding
the program and available support mechanism.
b) Explain how and by whom the academic, non-academic and career counseling are
provided for students
c) Describe how student hand book accessible to students
d) Explain the availability of student hand book with inclusion of student support
systems.
Supportive Documents
a. Current curriculum
b. Legislations
c. Student Hand book
 d. Student satisfaction survey
4.2.2. 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.(This is 4.2.1.in the original document)
Narrative response
a) Explain how and by whom the academic, non-academic and career counseling are
provided for students.
b) Describe types of student support services delivered to students
c) Evaluate the adequacy and appropriateness of student services
Supportive Document
a) Student Hand book
b) Student counseling manual
c) Student Satisfaction Survey
4.2.3. The program has effective mechanisms to identify and support students with special
needs including those who are at risk of not progressing academically.
Narrative response
a) Describe the mechanism to identify students with special need
b) Describe how to support students with special need
c) Describe strategies used to minimize attrition
Supportive documentation
a) Student support service yearly Report
b) List of supported special need students
c) Student Satisfaction Survey
4.2.4. The program evaluates student support services regularly to ensure their adequacy,
effectiveness and safety.(This is 4.2.5.in the original document)
Narrative Response
a) Describe how and how often student support services are evaluated to ensure adequacy,
effectiveness and safety.
Supportive documentation
a) Student Satisfaction Survey
b) Student support guide
c) minutes/report on evaluation
4.2.5. 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.
(This is 4.2.6.in the original document)
Narrative response
a) Describe how student’s grievances and appeals are handled regardingacademic and
non-academic matters
b) Narrate how the program defined and documented processes and procedures for
handling student disciplinary cases.
Supportive document
a) Minutes/reports on disciplinary decision
b) Student handbook
c) Student Satisfaction Survey
4.2.6. Implement strategies and programs to broaden professional horizon of students, and
enhance their performance in various disciplines and in areas such as scientific
inquiry, scholarly concern for the profession, and the relevance and value of research
Narrative response
a) Describe the strategies used to broaden professional horizon of students
b) Explain how the students can involve in scientific inquiry and research
Supportive Documents
a) Minutes/reports on disciplinary decision
b) Student handbook
c) Student Satisfaction Survey
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
a) Describe strategies used to improve students’ retention, progression and completion
rate.
Supportive documentation
a) Program plan and strategies.
b) Progression report
4.3.2. 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 the program reviews the effectiveness of its strategy and
mechanism on student attrition, retention, progression and completion rates.
b) Narrate periodic recorded data and analysis regarding student achievement, retention,
attrition rates, progression and completion.
Supportive Document
a) Academic or senate Minute of graduation
b) Student Satisfaction Survey
c) Provide student data for attrition, progression and graduation (3 consecutive years
active batch)
Year of Registered Drop Dismiss Withdrawal Attritio Progressio No of Graduati
entry out n rate n rate Graduat on rate
ed
student
s
AY1 # # # # # #
AY2 # # # # # #
AY3

4.3.3 Check final qualifications achieved by the graduates are in line with the program’s
educational outcomes
Narrative response
a) Describe the presence of comprehensive/ exit/qualification examination to check
students final competency
b) Describe ways of evaluation graduates quality
Supportive Documents
a) Curriculum
b) department report on examination
c) DC & AC minute
d) interview of students and faculty
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 trace the employability
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 create a formal link with the alumni
Supportive documentation
a) Registrar manual
b) Updated Database information program alumni
c) Tracer study report

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 of staff with
appropriate qualifications, competences and skills
b) Describe the alignment of the system with institutional, national policy and
international best practices.
Supportive Document
a) HR manual
b) Legislation
c) Academic staff hand book
d) 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
a) Narrate 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) Explain the balance between senior and junior academic staff.
d) Explain the balance between academic and non-academic staff.
e) Explain the balance between academic staff with multidisciplinary backgrounds and
specialization.
Supportive document
a) HR manual
b) Legislation
c) List of academic and non-academic staff composition and qualification
Name of Composition Qualification Name of Qualificatio Remark
academic non- n
staff Academic
staff
Junior Senior

5.1.3. The program has an adequate number of qualified full-time academic staff for each
study program.
Narrative response
a) Provide the list of part time and full time teaching staff.
b) Show the balance of full time and part time teaching staff to ensure the effective
delivery of the program.
Supportive documentation
a) List of part time and full time staff.
b) Table on part time and full time staff
No List of Academic Qualification Full time Part time Remark
staff
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) Narrate 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.
Supportive documents
a) The program discipline Standard regarding staff to student ratio
b) Table on Staff to student ratio (3 consecutive years active batch)
Active No of Academic No student Ratio Remark
batch staff
AY1
AY2
AY3

5.1.5. The program has clearly defined roles and responsibilities for staff and has an
academic code of conduct with efficient and fair procedures for discipline,
complaints, and disputes resolution.
Narrative response
a) Discuss the procedures for discipline, complaints, and disputes resolution
Supportive documentation
a) HR manual
b) Minutes/reports on compliant and disputes resolution.
5.1.6. The program regularly reviews the effectiveness of its strategies and mechanisms of
staff recruitment, promotion and retention to maintain conducive learning and
teaching environment.
Narrative response
a) Narrate how and how often the program reviews the effectiveness of strategies and
mechanisms regarding staff recruitment, promotion and retention.
b) Describe how the strategies and mechanisms maintain conducive learning and
teaching environment
Supportive document
a) Minutes/report on review
b) Staff development report
c) HR manual

5.2. Staff support and retention

5.2.1. 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 mechanism to develop and implement staff appraisal system
b) Narrate how staff appraisal system address the roles of academic staff in teaching,
research, community services and administrative functions
Supportive document
a) Academic staff hand book
b) Students satisfaction survey
c) Staff performance appraisal report
5.2.2. The program utilize 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 utilized the 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 appraisal
data/performance.
Supportive documentation
a) Staff appraisal report
b) Academic staff hand book
c) Appraisal data based benefits and awards 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) Narrate mechanism of academic promotion and leadership positions.
Supportive document
a) Legislation
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 effectiveness of academic staff development program and professional
development practice based on need assessments
Supportive document
a) Staff development report
b) Need assessment for staff and professional development
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 and guidance of new academic staffs as
part of the staff development program
Supportive document
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, access to information and for communication.
Narrative response
a) Describe how the program provides necessary continuous trainings for the academic staff
b) Discuss the technology and communication tools accessed for the academic staff
Supportive documentation
a) 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 researches
 b) Narrate how the program ensures academic freedom.
Supportive document
a) Published researches
b) Incentive package for research
c) Research manual
d) Legislation
e) Academic Staff handbook
5.3.6. The program has national and international linkages for enhancementof academic and
professional development and scholarly activities.
Narrative response
a) Describe the national and international linkage of the program to involve renowned
academics and professionals
b) Narrate how the linkages enhance the scholarly activities.

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) Narrate how the procuring and utilization of educational resources aligned with the
HEI policy
Supportive document
a) Resource utilization manual
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) List all the educational resource related to the program
b) Describe the appropriateness and adequacy of educational resources to ensure
effective delivery of the curriculum
 c) Describe how educational resources are distributed according to the need of the
program
Supportive document
a) Resource utilization manual
b) Progress report
c) Inventory report on facilities
d) Student Satisfaction Survey
e) Table on educational resources lists

Number and holding Remarks

Facilities capacity
No Capacity
1 Lecture Halls
2 Basic Science Labs

Clinical Skill Lab

PBL Discussion Rooms
Morning Session Rooms

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.
Narrative response
a) Describe the appropriateness and adequacy of educational resources to meet the need
of the program
Supportive Document

a) Resource utilization manual

b) Progress report
c) Inventory report on facilities
d) Student satisfaction survey
 e) Table on educational resources lists
6.1.4. the program has adequate offices for teaching and administrative staff with
adequate space and equipped with computers and internet access and accessible to
people with disability
Narrative response
a) Describe the adequacy, fulfillment, accessibility, and safety of the staff offices.
Supportive document
a) Office and equipment inventory (verified by Site visit)
6.1.5. The physical facilities comply with the relevant laws, and with health and safety
regulations including accessibility to people with disabilities.
Narrative Response
a) How the physical facilities confront with relevant laws, health and safety regulations.

b) Describe the inclusiveness of the available physical facilities to people with

disabilities.
Supporting Document
a) Resource utilization manual and report
b) Health and safety manual/guideline
c) Student satisfaction survey
6.1.6. The program has a functional library accessible to students and staff with adequate
capacity.
Narrative Response
a) Narrate the functionality and adequate capacity of the library.
Supportive Document
a) Student Satisfaction Survey
b) Library manual
6.1.7. The library has adequate and 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) State 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 library and the availability of adequate supply of up-to-date
textbooks and reference materials of both hard and softcopy.
Supportive document
a) Library manual
b) List of Library staff
c) Student Satisfaction Survey
d) Table on reference materials supporting the program
Resources supporting the
program (e.g., books, online Number of Journals State other facilities such as
resources, etc) CD ROM, Video and
Title Publish Number of Title Publish date Number of electronic reference
date Collection Collection material

6.1.8. The program has information and communication technology infrastructure

appropriate to the program including computer laboratories that are required for
the study programs.
Narrative response
a) Describe the appropriateness of information and communication technology
infrastructure to the program
Supportive documents
a) Student satisfaction survey
b) Website and corporate email
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 and how often the appropriateness and effectiveness of resource are
reviewed
Supportive documents
a) Educational resource inventory 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) Describe and mention community attachment (Training Sites) sites
Supportive Document
a) MOU
b) Schedule (Verified by Site Visit)
6.2.2. The program has practical sites that are accessible with adequate patient number
and mix per the core competencies
Narrative Response
Describe the patient flow and case mix as to the learning goal
Supportive Document
a) MOU
b) Schedule
c) Assessment Checklist
d) Student documents (Notes, portfolios, reports)
6.2.3. The program provides educational resources including national service delivery
guidelines, personal protective equipment, learning tools (checklists, log book,
SOP) and other essential equipment
Narrative Response
a) Describe/mention available resources
Supportive Document
a)delivery guidelines, personal protective equipment, learning tools (checklists, log
book, SOP) verified by Site visit
6.2.4. The program has a dedicated coordinator for facilitating community/clinical
training
Narrative Response
a) Mention the coordinator and the process.
Supportive Document
b) Assignment/appointment Letter
6.2.5. The program engages adequate instructors and supervisors in the required range of
clinical and community settings
Narrative Response
a) Describe the professional and expert mix for the attachment
Supportive Document
a) Attachment schedule
6.3. Financial Resource
6.3.1. The program has financial resources sufficient to undertake its operations and
implement the strategic objectives.
Narrative response
a) Discuss the adequacy of financial resources of the program to its operations
and implement 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, researcher
recognition and commercialization of research outputs.
Narrative Response
a) Narrate the policy and procedure that identifies the priorities, researcher recognition and
commercialization of research output
Supportive Document
a) Research policy/manual
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
works and disseminations
Supportive documentations
a) Annual plan of the research
b) Annual plan of the program
c) Budget request approval report
7.1.3 The program encourages research collaboration and cooperation across the institution
and externally.
 Narrative response
a) Describe how the program support research collaboration and cooperation across
the institutions and externally
Supportive documentation
a) MOA between the program and eternal institutions
b) Research annual plan /report
7.1.4 The program ensures that its research activities conform to internationally accepted
methodological standards, comply with ethical standards. The program ensures that
academic misconduct, including plagiarism, is prevented.
Narrative response
a) Narrate how the research activities comply with international accepted
methodological standards and ethical standards
b) Describe the mechanisms to prevent academic misconduct
Supportive documents
a) Research policy/manual
b) Plagiarism checker system
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 planning and management
b) Narrate how the program ensure the achievement of research output and outcome
Supportive documentation
a) Minute/report on research conference
7.1.6 The program has dedicated resource and budget for research and community
engagement.
Narrative response
a) discuss the resource and budget allocation for research works and disseminations
b) discuss the resource and budget allocation for community engagement
Supportive documentations
a) annual plan of the research and community unit
b) annual plan of the program
c) 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 outcome aligned with learning and teaching activities
Supportive documentation
a) Research annual report
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) Narrate the system and process for planning, implementing, monitoring and
evaluating community engagement
b) Describe the alignment of community engagement with HEI policy
Supportive documents
a) Community engagement policy/manual
b) Reports on community engagement activities
7.2.2 The program defines the community/communities it serves for assesses their
needs and requirements and takes these in to consideration for its activities.
Narrative response
a) Describe the mechanism to identify the need and requirements of the community
Supportive documentation
a) Need assessment for community engagement activities
b) Reports on community engagement activities
7.2.3 The program has a well-defined, coordinated approach to the identification of,
and engagement with, industry, employers, professions and the community at
large.
Narrative response
a) State the approach to identify and engage with industry, employers, professions
and the community at large
Supportive documentation
a) Community engagement manual
b) MOA
c) Reports on community engagement activities
 7.2.4 The program encourages and supports staff and students to engaged in
industry and community engagement activities that lead to productive
relationship.
Narrative Response
a) Describe how the academic staff and students are involved in industry and community
engagement.
b) State any initiatives taken by the program to involve students and staff in industry and
community engagement.
Supporting Document
a) Community engagement policy/manual
b) Community engagement report
c) Student satisfaction survey
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 governance structure of the program.
b) Discuss the alignment of the governance structure with program goals.
c) Availability of recognized office with authority and accountability
Supportive Documentation
a. Organizational structure /organogram
b. Public announcement (letter, website, social media, printed media…)
c. Strategic plan/Legislation

8.1.2. The program has policies, procedures and mechanisms for regular 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 review and update of its structure,
functions, strategies and core activities
b) Describe policy, procedures and mechanism to ensure continual quality improvement.
Supportive Documentation
a) Program performance report
 b) Review report
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
c) Describe the governance structure of the program.
d) Discuss the alignment of the governance structure with program goals.
Supportive Documentation
a) Program organizational structure
b) Strategic plan/Legislation

8.1.4. The program has effective regular reporting procedures about teaching-learning,
research, community engagement.
Narrative Response
a) Describe how and how often the core activities of the program are reported.
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 institutional memory.
b) List conventional and digital documentation for smooth transition of academic
leaders.
Supportive Documentation
a) Institutional email
8.1.6. The program describes 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 transparency and participation of academic staff,
students and other principal stakeholders in decision making.
Supportive Documentation
a) DC minutes
b) Student satisfaction survey
 c) Legislation
8.1.7. There is a periodic review of the program which includes review of effectiveness
of the program management.
Narrative response
a) Describe how and how often the program is reviewed
b) How and how often the program reviews the effectiveness of the management
Supportive documentation
a) DC minute
b) Reports on Core activities

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 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) How accurate, relevant and timely information provided regarding the program?
b) How the information disseminated to students and other stakeholders?
Supportive documentations
a) Student satisfaction survey
b) Student hand book
c) Social media of the program
8.1.10. The program has a risk management strategy and ensures risk assessment
Narrative Response
a. Ensure the presence of risk management procedure
Supportive Documentation
a. Legislation
 b. Interviews
c. Minutes
d. Incidence reports
8.1.11. Have clear policies, guidelines and strategies to prevent and manage sexual
harassment and gender-based violence (GBV)

Narrative Response
a. Ensure the presence of effective sexual harassment prevention and
management guideline
Supportive Documentation
a. Senet legislation
b. Student handbook (guide)
c. Discipline guideline
d. Discipline committee – interview
e. SSS
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 breakdown
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) Report on purchase request and procurement
9. Continuous Quality Improvement
9.1. Continuous quality improvement system
9.1.1. The program has a system for monitoring, evaluating and reviewing the attainment of
learning outcomes and program’s mission and goals.
Narrative Response
a) Describe the existing quality assurance system
b) Describe the curriculum revision process
Supportive Documentation
a) Observing organogram and QA office
b) Availability of revised curriculum
c) Curriculum review committee minutes
d) Participant attendance sheet
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) Presence of qualified and responsible person
b) Describe the quality assurance policy and procedure
c) How the policy and procedure are publicly available
d) Discuss how often internal quality assurance activities are reviewed and
updated
Supportive documentation
a) Quality assurance policy/manual
b) Legislation
c) Review reports
d) Website/social media channel
e) HR, dedicated person in office,
f) Committee membership letter
9.1.3. The program has a system to ensure effective monitoring and continuous quality
improvement of the program through adoption and implementation of the updated
national accreditation standards and guidelines
Narrative Response
 a) Describe how the program is implementing the updated national accreditation
standards
Supportive Documentation
a) Self-assessment report based on the updated national accreditation standards
9.2. Implementation of Continuous Quality Improvement
9.2.1. The program has a mechanism for continuous and need-based staff capacity building.
Narrative Response
a) Discuss the mechanism used for continuous and need-based staff capacity
building.
b) Staff development based on need assessment
Supportive Documentation
a) Staff development plan
b) Staff capacity building report
c) Capacity building need assessment (need assessment analysis document)
d) Training attendance, pictures, certificates, sponsorship letters
9.2.2. The program’s continuous 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) State the units and area of operations covered by the program continual quality
improvement.
b) Describe how quality assurance activities provide relevant information and
data
c) How the relevant information and data support the program management and
development?
d) How the quality assurance activities output aligned with the achievement of
institutional goals?
Supportive document
a) Continual quality assurance manual/Guideline
b) Annual quality assurance report
c) Program level self-study document
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
continuous quality improvement.
Narrative response
a) Describe how the quality assurance activities focused on quality enhancement and
culture
b) How the quality assurance activities involved academic and support staff and
students for operational process
Supportive documentation
a) Student satisfaction survey
b) Annual quality assurance report
c) Program level self-study document
9.2.4. The program has a mechanism to evaluate educational outcomes 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 performance evaluation system
b) Discuss the activities of the Career center/similar office
Supportive Documentation
a) University industry linkage office [Career Center/Office]
b) Document found in department /school vision of the program, rate of
employment)
c) Tracer study,
d) Employee satisfaction rate/study report
9.3. Monitoring and evaluation of Continuous 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.
Narrative Response
a) Describe the mechanism to gather and use feedbacks from students, instructors
and other stakeholders
Supportive Documentation
a) Minutes
b) Feedback report/letter
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) Describe the availability of program monitoring and review committee with a
designated head
b) Who are participating on monitoring and review of the program?
c) How the committee ensures the current and relevance of the program?
Supportive documentation
d) Committee Minutes/ review report
e) Annual quality assurance report
f) Designation letter
9.3.3. The program periodically reviews its quality assurance system for its effectiveness
and impact.
Narrative response
a) How and how often the program review its quality assurance system
b) Describe the effectiveness and impact of quality assurance system
c) Narrate at what level the quality assurance system is reviewed
Supportive documentation
a) Review report
b) Annual quality assurance report
9.4. Documentation and dissemination
9.4.1. The program has a mechanism to identify and disseminate good practices to the
stakeholders and wider community
Narrative Response
a) Describe the mechanism used to disseminate good practices to the stakeholder
and wider community
Supportive Documentation
a) Sample published/disseminated good practices