Skills for Health QA International best practice report October 2005

QA International Best practice Report

Executive Summary
‘Quality assurance’ (QA) means different things to different people
and so cannot unequivocally be defined. There is general
agreement however that in the case of the education and training of
the healthcare workforce, QA is intended to safeguard academic
standards through validating education providers and specific
programmes and ultimately to protect the public from incompetent
healthcare practitioners.

The United Nations Educational, Scientific and Cultural Organization

(UNESCO 1998: 7) provided a comprehensive definition of quality in higher
education: it is a 'multidimensional concept, which should embrace all its
functions, and activities: teaching and academic programmes, research and
scholarship, staffing, students, buildings, facilities, equipment, services to the
community and the academic environment. Internal self- evaluation and
external review, conducted openly by independent specialists, if possible with
international expertise, are vital for enhancing quality. Independent national
bodies should be established and comparative standards of quality,
recognized at international level, should be defined. Due attention should be
paid to specific institutional, national and regional contexts in order to take into
account diversity and to avoid uniformity. Stakeholders should be an integral
part of the institutional evaluation process'.

The World Health Organisation (WHO) global project ‘Towards Unity for
Health' (TUFH) is promoting collaborative efforts towards providing health
care services based on individual and community needs. They recommend
that education providers should ask whether newly qualified practitioners are
able to function competently in practice and whether the preparation they
received was fit for the purpose. They described proactive education
providers, which they applauded, as those who modify their training
programmes in response to the answers to such questions.

In May 2005 a consultation document, ‘The INQAAHE Guidelines of Good

Practice’ was published after collaboration from representatives from 65
countries. The guidelines have the potential to improve education
opportunities for everyone, from cradle to grave, across the world as they are
based on the premise that each country has its own cultural and historic
context, which must be considered and incorporated into any form of quality
assurance. The focus is on generally agreed principles and indeed the reader
is warned that the ‘guidelines should not lead to the dominance of one specific
view or approach, but promote good practices, while helping to eradicate bad
quality’ (INQAAHE 2005: 2).

During recent years there have been several changes within HE that have
challenged and impacted on quality assurance and enhancement. Some of
the factors include increased student access, the promotion of life-long
learning, new modes of delivery in teaching and learning (e.g. virtual

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education, distance learning), academic mobility and the trend towards

international or trans-national programmes (Middleton 2001; Lindeberg &
Kristoffersen 2002). The introduction of student fees in some European
countries has led them to adopt a much more customer orientated stance and
has increased their perceptions and expectations of how HE should be
managed, organised and delivered (Crozier 2004).

Quality assurance and quality enhancement in Higher Education has also

been influenced, indirectly, by The Bologna Declaration in 1999 and
subsequent key meetings. In order to achieve the goals of the declaration, the
Bologna Process recommended a convergence of quality assurance practices
across the signatory States. A Quality Convergence Study (Crozier et al,
2004) carried out by ENQA between September 2003 and October 2004 to
ascertain how Higher Education Institutions (HEI’s) within different countries
were functioning (e.g. the national dynamics and constraints) and how they
were working to achieve co-operation with each other. A key message from
the UK contribution to the ENQA convergence study is that ‘the UK has been
slow to address the implications of the Bologna Process’ (Crozier 2004: 1)

Key findings

The aim of this scoping study was to review and identify international best
practice in quality assurance and quality enhancement of healthcare
education and training. Our key findings are as follows:

 The philosophy of ‘one size fits all’, or a single model, is not appropriate
in quality assuring the education and training of the health care
workforce throughout the world. If a single model was to be adopted
then there are real concerns that ‘quality assurance will become a fixed
ritual, according to fixed procedures, with quality assurance appearing
to become an end rather than a means’ (Scheele 2004: 20).

 No generally accepted international agreement exists for the definition

of accreditation. In Europe the term ‘Quality Assurance’ (QA) seems to
mirror the process of Accreditation of the academic institutions and
programs in America. The terms QA and ‘accreditation’ are sometimes
used interchangeably depending on the country (and mother tongue)
from which a publication is generated.

 QA (or accreditation) and the costs it incurs should be seen as an

investment for the future. Both students and employers welcome
improvements in quality.

 Accountability and transparency are essential attributes of autonomy.

“Consistent with the principle of institutional autonomy, the primary
responsibility for quality assurance in higher education lies with each
institution itself and this provides the basis for real accountability of the
academic system within the national quality framework”. (ENQA 2005)

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 The value of peer review should not be underestimated and

consideration should be given to appointing younger, credible, staff
members to the panel instead of sticking with ‘higher ranking’
academics who may have lost interest in undergraduate education
(Scheele and Hämäläinen cited in Di Nauta 2004).

 The United Kingdom and The Netherlands are viewed by many as the
'front runners' in QA of healthcare education and training

 No consistency exists between countries about what occupational

groups constitute 'regulated professions'.

 European guidelines for QA in higher education (ENQA 2005) include

the principle that QA for purposes of accountability is fully consistent
with QA for enhancement.

 Within the United Kingdom (UK), the decision by the QAA to halt
external ‘Academic Reviews’, which originally combined academic
audit, and subject reviews to reduce the workload and consequent
pressure on the staff in Higher Education Institutions is to be applauded.
HEIs however, in exchange for this capitulation, are expected to
demonstrate that their own ‘internal processes for quality assurance are
robust and that their quality cultures are strong’ (Crozier 2004).

 Devolution within the UK has increased the complexity of QA in

education and training not least because of differing (and not always
complementary) policies that can be divisive, the student fees issue
being a case in point.

 Increasing autonomy of HEI's means there is even more need to

establish QA processes with an external review built in.

 There has been some resistance to the concept of Europe wide

accreditation process and it will be difficult to marry these up with needs
of the labour market.

 For academic staff in a number of countries (including the UK) there are
on-going tensions between fulfilling their teaching responsibilities and
the expectation to undertake research and publish their findings, the
quality and quantity of which influences the amount of funding an HE
attracts. (Crozier et al 2004).

 The value of student engagement and their representation on external

and internal QA activities should not be underestimated. In some
countries students are mandated to participate in QA activities while in
others it is voluntary. Although there is written evidence, from some
countries, on the mandatory numbers of students participating in QA
activities, it has not been possible to ascertain whether this is actually

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achieved in practice and so the ‘evidence’ should be treated with

caution.

 Students have become more mobile during their education as a result of

successful transfer systems being implemented. There is evidence that
the number of student exchanges for both the theory and practice
components will continue to increase. Students from European
countries are likely to apply in increasing numbers for exchange or
transfer to the UK as for many, English is their second language.

 The issue of student retention and attrition is an important component of

many quality assurance policies; indeed in some countries student
completion numbers is the only method of assessing quality of courses.
Ellis (1993) in part justifies this by the assertion that 'quality in education
is that which satisfies the student' and it is not unreasonable to suggest
that a link may exist between student satisfaction and retention and
attrition rates. Indeed there is evidence that, for overseas students in
HE the satisfaction with quality of life correlates positively with their
evaluation of course quality (Harris 1997).

 The need to link theory and practice cannot be overemphasised within

health education and training and this helpful list complements the
thinking of the Towards Unity for Health (TUF) paper which calls for
much more pro-activity in the education sector towards meeting the
ever changing needs in the workplace (WHO 2000).

 The Qualifications Curriculum Authority (QCA) and Scottish

Qualifications Authority (SQA) develop the standards, which relate to
the National Occupational Standards (NOS). The QCA can co-ordinate
education and training effectively as it facilitates use across academic
qualifications. However, work remains to be done on clarifying the
differences between performance criteria in NOS and learning
outcomes in Higher Education academic and vocational qualifications.

 The structure of benchmarking statements include: defining principles,

nature and scope of the subject, subject knowledge, subject skills and
general skills, teaching, learning, assessment and standards. This has
been criticised by some as being too prescriptive. According to Harvey
(2004) subject benchmarks can restrict the subject content and he
likens them to 'a national curriculum at higher education level'.

 There is recognition of the importance, particularly through UNESCO of

the benefits of high quality Technical Vocational Education & Training
(TVET) programmes can bring to support employment in the home
country and also its relevance to globalisation of world markets.

 High level quality learning experience can be achieved for learners in

the workplace where:

- there is proactive development of lifelong learning strategies;

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- there is evidence of good practice and high standards of work;

- staff are committed, enthusiastic and able teachers;
- there are effective communication links with the HEI(s) to
facilitate clear understanding of the needs of the learner, the
learning outcomes of the programme, the relationship between
theory and practice and criteria for teaching and assessment;
- students are appreciated and the contribution of staff to clinical
learning valued;
- the staff have an appropriate range of experience and skills.
(Klem et al 2004)

 Key questions for accreditation of professional courses with a high

vocational content (based on those devised by Martin (2004) for
engineers) could be adapted for the health sector.

- What does this health professional do?

- What training should this health professional receive?
- What should be the course content?
- How long should the course be?
- What are suitable training placements and where are they?
- What should the ratio of HE and practice based learning be?
- How much project based learning should there be?
- How should new technologies be included?
- How can ‘registered professionals’ be attracted to teach in
Higher Education thus making it possible to transmit their
professional competence?

Recommendations

The following recommendations are offered for consideration:

 Skills for Health (SfH) would benefit from forging closer links with the
following agencies and organisations:

- National Academic Recognition Centre (NARIC) in the UK

- The National Reference Point (NRP) for Vocational
Qualifications
- European Consultative Forum for Quality Assurance in Higher
Education
- International Network of Quality Assurance Agencies in Higher
Education (INQAAHE)
- European Network for Quality Assurance (ENQA)

 SfH should adopt a more systematic means of student feedback and

should consider the model of good practice devised for physiotherapy
students at the University of Dublin (2003) where formal student
feedback is built into the quality assessment of clinical placement sites.

 The existing links between SfH, HEI’s, the Government Departments

for Health and Education in each home country, need to be

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strengthened so that a meta framework can be designed that ensures

there is consistency between performance criteria in NOS, the
forthcoming Framework for Achievement (FfA) and learning outcomes
in HE academic and vocational qualifications.
 More work needs to be done to bring clarity in the area of accreditation
and the role it should play within quality assurance and enhancement
in health care education and training.

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