Abstract
Accreditation is a significant facet of higher education that is aimed at improving public accountability and academic quality. It is intended to demonstrate to the general public that a given institution has met and is operating within the standards set by the accrediting organization. The primary responsibility of health care education is to produce practitioners who possess relevant knowledge and skills for the delivery of high-quality health care to populations. Accreditation is intended to ensure that these schools achieve this outcome. This paper will analyze the legal aspects of accreditation on higher education institutions offering health care and medical programs. It will explore some of the legal requirements and standards expected of these schools by accrediting agencies. The paper will also analyze a case study involving Hampton University and ACPE, an accrediting body and the ethical implications involved in decision-making. It will begin with an introduction, which will provide a general overview of the topic. The paper will also provide the legal aspects of accreditation from the perspective of a school leader or a director. In this section, various legal aspects across many jurisdictions will be explored. Much focus will be placed on the central role played by the healthcare education school director in making decisions amidst accreditation requirements. In deciding on what accreditation criteria to choose from, a school head is faced with myriad options. In many cases, this gives rise to ethical dilemmas that the school leader must juggle through. This paper will analyze how an accreditation issue involving an accreditation body and Hampton University set a jurisprudence on the ethical implications of the subject. The paper will discuss the ethical dilemma involved in the case and the options available for the healthcare institution head to address the issue at hand.
Keywords: accreditation, health care, education, school, school head, ethical, legal, decision-making.
Introduction
Accreditation is a significant facet of higher education that is aimed at improving public accountability and academic quality. It intends to demonstrate to the general public that a given institution has met and is operating within the standards the accrediting organization sets. Accreditation is usually assessed by non-governmental and private organizations that have been specifically created to review the education programs and institutions offering them. It is a voluntary process in many jurisdictions, including the United States, where it is managed by the U.S. Department of Education and the Council for Higher Education Accreditation (CHEA). Accrediting agencies expect to encourage institutional improvement and processes and offer continual assessment mechanisms by setting academic standards. Based on this observation, accreditation is a significant vehicle for enhancing the health profession’s diversity and promoting institutional change.
Although accreditation is important in all learning fields, it is in healthcare education that it is most recognized. This is partly based on the sensitivity of the sector in terms of the provision of health care to patients. Therefore, every aspiring healthcare practitioner would want to attend schools that have been approved by relevant accrediting agencies. Based on the multiplicity of healthcare schools’ accrediting agencies, institutions may approach healthcare material differently. However, it is imperative for them to stick to standard quality to assure their students that the education they are providing will adequately prepare them for their professions.
The profession of health care demands that practitioners are highly qualified and competent. Indeed, the success and failure of any healthcare institution are largely determined by how well the practitioners are prepared for the field. Undoubtedly, the success or failure of any healthcare institution has a huge impact on the overall health of a country. Therefore, much focus must be given to healthcare education and training for the successful development of the sector. Accreditation agencies play a significant role in ensuring that students churned out of healthcare institutions are competent enough to tackle the challenges of the profession. Even though accreditation has a huge potential to enhance the quality and diversity of education, there are several legal issues surrounding it. There are several accrediting institutions, particularly for health care training. Various cadres of health care are accredited differently. There are specific accreditation agencies for doctors, nurses, pharmacists, clinical officers, physical therapists, and nutritionists.
Legal Aspects from the Perspective of the School Director
The leader or director of a higher education healthcare school is at the center of all accreditation exercises. Therefore, his or her perspective on the same is of utmost significance for the sustainability of the program. The primary responsibility of health care education is to produce practitioners who possess relevant knowledge and skills for the delivery of high-quality health care to populations. Accreditation is intended to ensure that these schools achieve this outcome. For any valid validation to take place, several guidelines must be met.
First, the school head must determine the validity of the accreditation agencies. This must be a body recognized by the Ministry of Education or any government institution that oversees the implementation of educational activities. However, it must be noted that some countries mandate the Ministry of Health to carry out the responsibility. In other countries, this responsibility is delegated by the government to other independent statutory bodies (Paul, et al., 2017). An example is the Liaison Committee for Medical Education in the US or the General Medical Council (GMC) in the United Kingdom. In an ideal situation, the authority of an accreditation body should be established by suitable legislation. Similarly, from the perspective of a healthcare school head, the participation of healthcare institutions in the accreditation process should not be voluntary but rather mandatory.
Second, the school head should determine which specific accreditation standards are relevant to his or her school. Although the World Federation for Medical Education (WFME) promulgated basic standards that are supposed to be acceptable to all healthcare schools, the same is not used by accreditation agencies. The agencies have always argued that they operate in different educational settings that cannot allow them to use a standardized template for accreditation. This indeed brings legal challenges since there is no common legal backing upon which these multiple standards are based. Therefore, jurisdictions that are interested in developing standards that are unique to their settings should laisse with the WFME to ensure that they are congruent with the global body.
The school head is tasked with the responsibility of putting up an effective accreditation system in place to allow for its execution by first allowing for self-review mechanism. This self-review should be externally evaluated by a competent agency as well. The external group must conduct a site visit to the school to validate the results of its self-review before writing a formal report to the accreditation agency. The accrediting body will then produce a formal decision, which many suggest improvement areas (Pavlakis & Kelley, 2016). The report and the decision are then published and shared with the relevant authorities. While accreditation primarily serves to improve the quality of healthcare education, its nature and delivery can have significant effects on healthcare education.
As the CEO of the institution, the school head plays a major role in determining admission requirements subject to the nature of the healthcare college. The three major medical schools that have always attracted more accreditation include the faculties of dentistry, psychology, and nursing. In each of these faculties, the school head must balance various legal aspects, especially when it comes to admission.
Dentistry
In the United States, the Education Department has recognized the Commission on Dental Accreditation Programs by the American Dental Association as its specialized accrediting organization. This agency is charged with the responsibility of accrediting programs that prepare students in their pursuit to acquire certification or licensure in the field of dentistry. This agency maintains that the social, emotional, and economic circumstances of patients should occupy its top priority. To keep with this commitment, however, the accreditation agency established dental education program standards that are geared towards ensuring diversity in the admission of students (Batool et al., 2018). In this regard, therefore, it states that the procedures and policies for admission must be designed in such a way that they include the admission and recruitment of students from diverse populations.
The standards go on to state that graduates channeled from these healthcare institutions must be competent enough to handle and manage a diverse population of patients in addition to possessing communication and interpersonal skills to function successfully in a multicultural environment. From these two provisions by the Commission on Dental Accreditation Programs, it is evident that the word MUST has been used in the standards of dental accreditation (Howell et al., 2019). This means that circumstantial noncompliance means has been disallowed.
Despite the mandatory insistence of the standards by the Commission on Dental Accreditation Programs, there is no evidence to demonstrate the effectiveness of the dental profession in offering programmatic support that meets the ideals. In addition, there are no assessment tools that allow for effective measurement of the outcomes that the standards seek to achieve. This, thus, brings to question the legality of the use of MUST and its effectiveness in the recruitment and retention of students from diverse population backgrounds. Based on this observation, it might be helpful to consider if the accrediting agencies possess the right legal requirements to impose standards on institutions.
Psychology
Medicine students are required to understand the intricacies of human and health development. To be competent in this sector, the students are required to take up advanced-level psychology programs in their respective fields. In the United States, the Committee on Accreditation for Professional Programs in Psychology is the body legally mandated to oversee this. Under the auspices of this agency, the doctoral graduate training program, the postdoctoral residencies in professional psychology, and the doctoral training internship fall (Allen et al., 2017). The organization is also committed to ensuring that students joining its faculties are culturally competent and drawn from diverse backgrounds.
The fifth standard under this domain gives directions on the engagement of the program in understanding individual and cultural diversity based on demographic and personal characteristics. There should be no limitations based on age, ethnicity, language, religion, race, socioeconomic status, disabilities, sexual orientation, and national origin. The program’s policies regarding the recruitment, retention and development of students and faculty reflect its intention to understand and respect individual and cultural diversity in field placements and curricula (Gotian et al., 2020). To achieve this objective, standard three states that the program must possess and implement a coherent and clear curriculum plan that offers means that allow all learners to obtain and demonstrate substantial competencies and understanding. The areas accorded much focus are those touching on individual and cultural diversity issues.
The standards stress further that the programs offered in these healthcare institutions must be “systematic, coherent, and long-term efforts” in attracting and retaining faculty from diverse racial, personal, and ethnic backgrounds. This is stipulated in standard one that falls under the Cultural and Individual Differences and Diversity domain. Standard two of the same domain further states that the program must possess and implement a coherent and thoughtful plan to provide students with relevant psychological phenomena experience and knowledge. This should be pegged on the role that individual and cultural diversity plays in the practice and science of professional psychology.
Nursing
There are two accreditation bodies recognized by the U.S. Education Department for nursing education. These include National League for Nursing Accrediting Commission (NLNAC) and the Commission on Collegiate Nursing Education (CCNE). The NLNAC is the older of the two, and it is mandated with accrediting all nursing program types, whether higher degree or postsecondary, as long as they offer certificates, diplomas, or professional degrees. One of the key goals of the NLNAC is to promulgate a universal core of criteria and standards for nursing program accreditation (Thomas et al., 2016). However, unlike the accreditation agencies for dentistry and psychology discussed above, the NLNAC does not currently have standards that are directed toward the achievement of diversity. It has, nonetheless, voiced its support of a report done by the Pew Health Commission Competencies that called for a change in strategies in the role of state and federal government in education and health care (Taber et al., 2020). According to the report, the federal government should encourage a close working partnership between the accreditation bodies and healthcare provision schools in developing responses to a changing world.
The report, however, has one of its core competencies related to diversity. Competency 12 of the report calls for the need to offer care that is culturally sensitive to a diverse society. This should be through the creation of a diverse learning environment, which a student body and faculty can achieve from a racially and culturally diversified pool. According to the NLNAC, all these competencies are excellent and should be adopted (Cuff & Perez, 2017). It, however, asks nursing programs to interpret these competencies and skills in their respective programs’ context, structure, content, and function.
The Commission on Collegiate Nursing Education (CCNE is another accrediting agency recognized by the U.S. Department of Education. This professional and specialized accrediting organization was created with the aim of making judgments on the quality of U.S. graduate and baccalaureate nursing programs. It was conceived in the year 1996 by the American Association of Colleges of Nursing but began its accrediting activities two years later. The body is governed by a board of commissioners, which also serves as its final authority on matters to do with accreditation and policy.
The Commission on Collegiate Nursing Education (CCNE) holds that all nursing programs should be accountable to the common interests of the community. CCNE must, thus, ensure that its programs have appropriate goals, outcomes, and mission statements to prepare individuals who wish to enter the nursing field. The CCNE also evaluates the nursing programs’ success towards the achievement of goals, outcomes, and mission and assesses to what extent the programs are meeting the accreditation standards. It also informs the public of the values and purposes of accreditation in addition to fostering continuous improvement in programs of nursing education.
Positive Effects of Accreditation of Health Care Education
The United Kingdom’s General Medical Council (GMC) is an exemplification of how accreditation can produce positive results. Since 1858, the GMC has continued to play a significant role in ensuring that medical schools in the UK operate within the required standards. GMC is presently governed by the Medical Act of 1983 and established by statute law. From its inception, GMC expressed concerns that the then-medical curriculum was burdening to learners (Kuwaiti & Muhanna, 2019). As a result, it recommended and produced reports on areas of change to healthcare education. These reports and recommendations retained the basic education’s overall structure but expanded the contents in line with emerging medical knowledge.
This method necessitated students to put much focus on passing their next examinations instead of having a deep understanding of the materials. Further, the learning was purely memorization and superficial in nature. As a consequence, this educational approach did not produce competent students who could apply their knowledge and skills effectively in clinical settings. However, through a document known as Tomorrow’s Doctor, GMC published new regulations for basic training on health care. This document laid down the expected outcomes that the students were supposed to have achieved by the time they graduated. In the past, the focus was given to the subjects that had to be studied (Bogossian & Craven, 2021). This way, there was greater integration of healthcare subjects into clinical settings as well as contact with patients.
It also formally recognized that it was not possible for students to cover all medicine and health care stuff through their basic education. The course was, therefore, divided into two; the core and electives (options). The elective segment gave the students the option of exploring topics and subjects that they are interested in and developing generic cognitive skills like critical analysis and literature searching. Major transformations were indeed carried out by Tomorrow’s Doctors within the UK medical schools. From Manchester to Glasgow to Liverpool, healthcare schools undertook curriculum reforms that were characterized by problem-based learning rather than subject-based curricula. As a result, universities in the United Kingdom have witnessed increased diversity of teaching methods and curricula (Frank et al., 2020). A huge percentage of UK medical schools have established healthcare education departments and units, which enhance discipline. GMC is an example of jurisprudence that has significantly influenced the legal and ethical decision-making of school officials regarding the issue of accreditation.
Negative Effects of Accreditation on Health Care Education
In addition to all the listed benefits of accreditation, particularly in healthcare education institutions, the bodies charged with the responsibility can instead be a deterrence to innovation. This is commonly true in a jurisdiction with rigid national curricula. This discourages healthcare schools from introducing any changes that will affect the status of accreditation. Healthcare education, hence, stagnates since teachers do not adopt new approaches to learning, such as modern communication and digital technology. In addition, new scientific and medical advances are incorporated into the course’s content without removing some existing materials. This increases an overload to learners, a factor that discourages them further.
In some other jurisdictions, the accreditation agencies even determine the type and number of faculties as well as the staff to be employed. This implies that the accreditation body dictates to the schools the faculty that they should have. The problem with this model is that it is not sustainable and is prone to be overtaken by events. An accreditation body may demand that a healthcare education institution should have five full professors and fifteen associate professors in anatomy, for instance. The specifications might not have requirements for a molecular genetics’ professor. This means that out of the full and associate professors specified by the body, none could have a background in molecular genetics, a key requirement in the study of anatomy.
Similarly, the traditional learning approach for anatomy requires students to dissect a cadaver. Accreditation agencies have always demanded that each medical student must have access to a well-equipped room that has adequate dissection equipment in addition to a dead human body. However, as computer learning becomes more advanced, virtual reality is slowly replacing cadaveric dissection (Hoffman et al., 2017). Some medical schools are indeed abandoning dissection and, in their place, opt for models, thanks to high-fidelity programs. One of the most significant legal aspects of accreditation of health care education institutions is regulations by respective governments.
Based on the above effects, it is evident that accreditation has both positive and negative effects. However, healthcare education institutions do not have a legal mandate to be accredited. The school head chooses to do it voluntarily, perhaps because of market forces. In many countries, the national strategies for education in quality health care are based on both voluntary and statutory activities. However, the ability of these strategies to work effectively hugely depends on the willingness that healthcare school administrators have. In addition, in those countries having legislation for accreditation, compliance is subject to inspection by relevant authorities.
The progress and success of any accreditation exercise can only be guaranteed if there is good leadership in place. Therefore, the healthcare school head must rise to the occasion and show visionary and effective leadership. Similarly, the accreditation authorities must desist from any attempt to make the process complex and bureaucratic that enforces acceptable practices that have been statically formulated (Sperling & Pikkel, 2020). The school principal must, thus, work together with the accreditation bodies to regularly review the standards for accreditation. In so doing, he must also take into account new developments in the relevant fields.
The significance of the legal and ethical decisions making of school officials has been established by several jurisprudence across the world. One such jurisprudence was Hampton University v. Accreditation for Pharmacy Education. The university filed a civil lawsuit in a federal court against the accreditation agency on July 23, 2020. This is after the Accreditation Council for Pharmacy Education decided to remove the university’s accreditation early in the year (Hampton University files lawsuit over the withdrawal of accreditation, 2020). Incidentally, the doctor of pharmacy education (Pharm.D.) program offered by the university has been put on probation since 2017.
Pharmacists are required by state law to graduate from an institution that the ACPE accredits. Therefore, by losing its accreditation, the university also risks losing its eligibility to receive federal funding and student aid. Hampton University was found by the ACPE not to have met some of its key standards. Specifically, standard no. 17 was cited as having been unmet by the institution. This is a standard on progression and expects a medical learning institution to develop, assess, and implement its student progression-related procedures and policies through the program of PharmD. The university was also guilty of not complying with standard 24 on educational outcomes.
Standard 17 contains two prongs: policies of progression and early intervention. Concerning the progression policies, the university must develop and stick by the policies, procedures, and criteria relevant to remediation, academic probation, academic progression, appeal mechanism, and leaves of absence. These policies must be availed to be assessed by both current and future students. On the issue of the intervention prong, the university is expected to have a system designed to monitor students’ performance to detect behavioral and academic issues early enough (Jones, 2020). Moreover, it is the responsibility of the school to develop and execute appropriate interventions that will bring success when it comes to resolving the issues.
There were four significant elements that involved the plan of the school to assess the achievement of educational outcomes of the students in standard 24. All these elements are meant to ensure that students are adequately prepared to enter into practice when they graduate. The first element, the formative and summative assessment, implies that valid, reliable, knowledge-based and systematic assessments are incorporated into the assessment plan. The second element comprises the standardized and comparative assessments, which means that the assessment plans contain ACPE required standardized assessments. This will allow for both school-determined peer comparisons and national comparisons.
The third element is all about the achievement and readiness of the student. It measures the achievement of students at various professional competency levels that the ACPE has defined. The school desired assessments are supplemented by the assessment of the readiness of the student to proceed to advanced practice experience in pharmacy and offer direct care to patients in different healthcare settings. Meanwhile, the fourth element speaks of continuous improvement and calls upon medical schools to use the assessment measures’ analysis towards the improvement of student learning and the educational outcomes’ achievement level.
It is the failure of Hampton University to abide by these standards that prompted the ACPE to remove its accreditation status. However, the university filed a civil suit against this decision by the ACPE and alleged that the accrediting agency acted out of revenge, among other allegations. It claimed that it has attempted to resolve the issues raised by ACPE but the latter has not been cooperative. It specifically raised the reluctance of the agency to change accreditation status in areas that it has shown improvements.
The Dean of Hampton University’s School of Pharmacy, Anand Iyer, in a statement delivered in 2018, stated that a comprehensive plan designed to meet the student’s educational needs had been created by the university. Professor Iyer went on to state that the plan was also meant to ensure that the students’ successes were assured when it came to NAPLEX licensure examination. The university is seeking nullification of what it terms as an arbitrary action by the ACPE.
An ethical dimension to this case emerges when the school puts forward a case against the nullification decision. This is an institution that has historically given students from African American backgrounds an opportunity to study pharmacy and enter into practice in a field that had for many years been dominated by whites. According to the school’s head, more than 96% of its students have proceeded to work with communities that have historically been medically deprived (Hampton University lawsuit over the withdrawal of accreditation, 2020). While the accreditation agency is mandated to ensure that all education institutions operate within the set standards, here is an institution that puts forth a strong case of its moral responsibility.
Discussions
The Hampton University case is an example of a jurisprudence that has significantly influenced the legal and ethical decision-making of school officials regarding the issue of accreditation. The institution has rescued educationally marginalized African American students and given them an opportunity to study. According to the university, the positive results of the university’s affirmative action are demonstrated by the high number of professionals it delivers into the practice. A huge percentage of these professionals end up serving in communities that have historically been underserved. Therefore, the decision to close the school, as suggested by the accrediting body, ACPE, will not only ruin the reputation of the institution but also put the future of a whole community in limbo. The Dean of the school, together with the University’s Vice-Chancellor, is, thus, in a state of an ethical dilemma.
This situation presents a problematic scenario to the head of the University’s Pharmacy School, who is the Dean in this case. There are two alternatives from which the Dean is supposed to choose. The first alternative is to close the school as directed by the ACPE and toss the medical students’ future, most of whom are drawn from the black community, into jeopardy. The second alternative is to ignore the directives issued by the accrediting agency and save the future of a deserving community (BörĂĽ, 2010). It will be important for the Dean to think deeply before reaching the final decision. His ethical perception will be required to be explicit since he will rely on his values during the decision-making process.
The Dean is in a situation of an ethical dilemma since he is expected to choose an ethically appropriate alternative from the two choices before him. Based on the nature of the choices, this is not about choosing right or wrong but taking a stand. The teaching profession is not short of situations calling for players to make reasonable judgments and decisions in uncertain and complex circumstances (Gotian et al., 2020). School heads always handle problems that are extremely complex with limited mental processes. In navigating this ethical dilemma, it will be essential for the dean to take into consideration the rules and policies governing the faculty, the stand of the administration, and the future of the school.
Conclusion
Throughout the globe, the health profession, education, and practice are constantly under scrutiny. Accreditation is considered to be one of the most effective tools available to achieve these goals. It is the process through which the ability of an organization to meet certain standards, requirements, and regulations is reviewed. In the healthcare industry, accreditation simply helps specific education institutions meet certain standards by setting accrediting agencies. Not all schools qualify to offer training on health care. For a school to be considered healthcare accredited, it must complete certain steps.
School heads are the focal point of all accreditation exercises in their institutions. Only colleges and universities that have been in operation for a particular amount of time are eligible for accreditation. The institutions must begin by doing a self-evaluation of themselves first and then submit the same to their accrediting agencies. These bodies will then review the policies and programs offered by the institutions to ascertain if they meet the recommended standards. However, it must be noted that accreditation is not a one-off event but rather a continuous and ongoing process in the entire lifecycle of an institution. This is meant to ensure that the institution has the requirements and standards set.
In every jurisdiction, many bodies are involved in the accreditation process. However, it must be noted that accreditation is not a mandatory requirement for institutions to perform. Nonetheless, although it is a voluntary exercise, many institutions do not have a choice but to conduct it, perhaps because of the numerous amounts of benefits associated with it. Accreditation leads to institutional improvement and processes in addition to offering continual assessment mechanisms by setting academic standards. Indeed, it is a significant tool that enhances the diversity of the health profession and promotes transformative institutional change. However, the commission of this exercise is laced with numerous legal and ethical perspectives.
Ethical aspects range from a lack of universality in the enforcement of the recommended standards to the existence of very many accrediting bodies offering the same thing. Some of the repercussions of not abiding by the standards set by the accrediting bodies can be very punitive and even threaten the continued existence of the school. Considering the significant roles played by schools in the socio-economic upliftment of communities, these repercussions can be so detrimental to society. This usually leaves the school heads in a state of ethical dilemmas. It is, therefore, incumbent upon the school to employ moral judgments in navigating through the problem.
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