Guidelines for Accreditation of Basic Medical Education (2019)

In order to further promote the scientific and standardized accreditation of basic medical education, the Working Committee for the Accreditation of Medical Education, Ministry of Education (WCAME) has formulated the Guidelines for Accreditation of Basic Medical Education (GABME) and has continuously revised these guidelines to provide guidance on the accreditation of basic medical education. This revision was implemented after the approval of the WCAME in March 2019.

I. Accreditation principles

1. To ensure the independence, objectivity, and impartiality of the accreditation process;

2. To respect the autonomy of educational institutions and diversified educational models;

3. To focus on investigating the medical school’s orientation, educational objectives, running process, educational outcomes, and quality assurance system in the aspect of basic medical education, based on accreditation materials submitted by the school;

4. To emphasize the authority and reliability of accreditation standards and procedures , and make evidence-based accreditation decisions.

II. Accreditation organizations

The WCAME is responsible for the accreditation of basic medical education in mainland China. A secretariat is established for the daily operations of the WCAME. The WCAME’s main responsibilities are:

1. To formulate and revise Standards and GABME;

2. To formulate annual, medium-term and long-term plans for accreditation;

3. To form and assign assessment teams to carry out accreditation-related work;

4. To deliberate accreditation reports and recommendations for accreditation decisions;

5. To handle feedback and appeals in the accreditation process;

6. To promote relevant international exchanges and cooperation, and strengthen medical education research;

7. To provide relevant training and consultation for assessment team members and educational institutions to be accredited;

8. To establish the accreditation database, website, and pool of assessors;

9. Other matters that are involved.

III. Assessment teams

Assessment teams are appointed by the WCAME to conduct preliminary visits, site visits, and review visits to the designated educational institutions.

Composition of an assessment team

1. The assessment team for the site visit is composed of seven to nine members, including one chair, one vice chair (if necessary), one or two secretaries, and one program manager. The assessment team for the preliminary visit or the review visit is composed of three to five members, including one chair and one secretary or program manager.

2. Backgrounds of team members should be diverse (such as medicine, education, management, and others).

3. The secretariat of the WCAME will decide whether to invite international assessors as the case may be.

Eligibility of the team members

1. Engaged and experienced in medical teaching, research, and/or management and well-informed of the laws and development trends of medical education;

2. Be familiar with the Standards and accreditation procedures and are physically fit enough to be committed to the full participation in the accreditation;

3. Having no conflict of interest with the educational institution under accreditation;

4. Following the principle of being fair and honest, and acting with team spirit and leadership.

Responsibilities of the assessment teams

1. Responsibilities of the team chair

(a) To be fully responsible for the site visit, and to provide relevant guidance to the team members;

(b) To assign tasks to team members with consideration of individual preferences;

(c) To finalize the site visit schedule;

(d) To chair the online preparatory meeting to be held at least one week before the site visit ; to chair team meetings and discussions during the site visit and make sure that all team members fulfill their tasks in time; to lead the team in a discussion of the accreditation decision recommendations and vote by open ballot for the recommended accreditation decisions.

(e) To inform the school of the inspection findings and ask for feedback, and to finalize the preliminary report and the accreditation report;

(f) To submit the accreditation report to the WCAME;

(g) To organize the team to review the progress reports and the comprehensive reports submitted by the educational institution as required during the valid period of accreditation, and to provide the WCAME with written comments;

(h) To be fully responsible for the whole process of the preliminary visit or review visit, and to submit the report on the preliminary visit or the review visit to the WCAME;

(i) To provide the WCAME with suggestions to improve accreditation procedures.

2. Responsibilities of team members

(a) To give written comments on the self-evaluation report submitted by the educational institution before the site visit and point out issues to be noted during the site visit according to the Standards. The team secretary may request supplementary materials from the educational institution if necessary;

(b) To attend the online preparatory meetings to be held at least one week before the site visit;

(c) To fulfill assigned tasks during the site visit, acquire necessary information, and validate it through symposiums, interviews, documents, and observations, etc.; to present personal opinions, participate in the discussion of the accreditation decision recommendations, and partake in a open ballot for the recommended accreditation decisions;

(d) To submit individual report by the due date after the site visit and give comments and suggestions on the accreditation report;

(e) To review the progress reports and comprehensive report submitted by the educational institution during the valid period of accreditation, and submit written comments to the WCAME;

(f) To fulfill assigned tasks during the preliminary visit and the review visit, and put forward suggestions on the visit reports;

(g) To provide the WCAME with suggestions to improve accreditation procedures.

3. Responsibilities of the team secretary

(a) To assist the team chair in collecting comments on the self-evaluation report from team members and liaise with the educational institution in collecting supplementary documents as needed by team members;

(b) To assist the team chair in organizing the online preparatory meeting at least one week before the site visit;

(c) To assist the team chair in planning the visit schedule and liaising with the educational institution to be accredited;

(d) To distribute and collect relevant documentations and to communicate with team members in time;

(e) To keep minutes of the meetings, summarize the documents, and assist the team chair in finalizing and submitting the accreditation report;

(f) If international assessors are involved, to keep them informed of the domestic assessors in order to better fulfill their responsibilities and to ensure accurate interpretation and translation for all meetings and documents;

(g) To submit materials requested by the Secretariat of the WCAME.

1. Responsibilities of the program manager

(a) To familiarize with and follow up on accreditation procedures and the work of accreditation teams, to timely determine and solve problems, if any, and report them in time to the WCAME ;

(b) To coordinate with the educational institution liaison staff on the itinerary of the assessment team before and during the site visit and assist in receiving the team;

(c) To assist the educational institution in the use of site-visit funds and the collection of relevant materials in accordance with corresponding rules and regulations;

(d) To assist the secretary in completing other relevant work;

(e) To submit materials requested by the Secretariat of the WCAME.

IV. Accreditation standards

The accreditation standards, which is formulated and published by the WCAME and reported to the Ministry of Education for the record, is used to judge whether the educational institutions has reached the accreditation requirements. It is also the basis for the educational institution to conduct and finish the self-evaluation report. The WCAME is responsible for the continuous update and improvement of the Standards so that it can keep up with the international trend, domestic status, and social expectations of medical education.

V. Educational institutions to be accredited

All educational institutions delivering basic medical education programs under the approval of the Ministry of Education may submit their application for accreditation to the Secretariat of the WCAME. Their responsibilities are:

1. To submit to the Secretariat the application for accreditation one year in advance by applying online, completing the Application Form for the Accreditation of Medical Educational Programs in China, uploading the quality monitoring data of the medical education program, and providing the curriculum and other supporting documents. A contact person is needed to fulfill the responsibility of communicating with the Secretariat of the WCAME.

2. To assist the Secretariat in deciding on the dates of the site visit or preliminary visit after the accreditation application is approved;

3. To submit a self-evaluation report to the Secretariat and assessment team members at least one month before the site visit;

4. To provide supporting documents as requested in a timely manner, respond to relevant questions, make necessary arrangements, and provide convenience regarding transportation, accommodation and operations for the assessment team in order to ensure a smooth progress in accreditation, complying with the Details for the Use of Funds for the site visit of the Accreditation of Basic Medical Education ;

5. To organize interviews participated by representatives from staff and faculty, students, healthcare sectors or authorities, and other stakeholders, and to coordinate the itinerary for the inspection of teaching facilities, such as classrooms, laboratories, and libraries, without affecting normal teaching, research, and healthcare services ;

6. To present the assessment team with empirical materials for discussion if any objectionable portion is found in the accreditation report, even to appeal to the Secretariat when an agreement cannot be reached with the assessment team through negotiations. If there should be any objection to the accreditation decision, the university may file a written appeal to the Secretariat during the publicity period;

7. To correspondingly improve its medical education programs by referring to the recommendations on the accreditation report; to update the quality control data annually and submit progress reports and a comprehensive report in time; to prepare for necessary review visits to be arranged by the WCAME through communication with the Secretariat;

8. To submit an application for re-accreditation 6 months prior to the end of the accreditation period (not extended) or by the end of the extended accreditation period.

VI. Accreditation procedures

1. The educational institutions submits its application for accreditation together with education quality control data to the Secretariat of the WCAME in April or October. The Secretariat organizes the data review of the application and notifies the educational institution when the application is approved.

2. The Secretariat determines whether to approve the educational institution's application based on the quality control data and the documents provided. A one-day or two-day preliminary visit may be organized when needed. The educational institution should provide documentation as requested and respond to relevant questions without delay. The Secretariat determines whether to approve the educational institution's application based on the recommendations of the assessment team for the preliminary visit.

3. The Secretariat informs the educational institution of the site visit date six months in advance and proposes the recommended assessment team members one month ahead of the site visit.

4. The educational institution submits the self-evaluation report to the Secretariat one month ahead of the site visit. If any international assessors are included in the team, an English version of the self-evaluation report should be submitted at the same time. An English version of the relevant materials offered during the site visit should be prepared as well.

5. The assessment team conducts a site visit to the educational institution, which lasts four to six days and may be extended according to the distribution of campuses and hospitals.

6. By the end of the site visit, the team presents the educational institution faculty and students with a fully-discussed the preliminary report. Every team member votes by open ballot on the recommendations for the accreditation decision. Based on the results of the discussion, the team chair determines the frequency for submitting the progress report during the validity period of the accreditation.

7. After the site visit, the team members prepare their due part of the accreditation report based on the Standards and the evidence obtained during the site visit. The secretary collects the information and submits the first draft to the team chair. The team chair finalizes the accreditation report within two months after the site visit and submits it to the WCAME for review after consulting the educational institution.

8. The WCAME informs the accredited educational institutions of the accreditation decision in writing.

9. Once accreditation is granted, the educational institution should update the quality control data annually and submit timely progress reports to the WCAME as required. An English version should also be submitted if international assessors are included. The WCAME organizes the review of the progress report and a review visit may be organized if necessary. The WCAME can revoke the accreditation decision in the valid period based on the progress report and review visit, and then report it to the Ministry of Education for record.

10. The Secretariat organizes the review of the comprehensive report, which is submitted by the educational institution six months before the expire of the accreditation period (not extended), and the WCAME then decides whether to extend the accreditation period or to conduct a re-accreditation. A review visit may be organized when necessary. The accreditation period can only be extended once and all by 4 years, not exceeding 10 years in total.

11. The WCAME informs the educational institution in writing of reasons for “Rejection” or “Revocation”. The assessment team proposes rectification suggestions for the defects or major problems existing in certain aspects and notifies the rectification deadlines (usually 2 years). These educational institutions cannot apply again for accreditation until after these two years, before which they should make improvements as required in the accreditation report.

VII. Accreditation Decisions

The assessment team members propose the recommended accreditation decision based on the extent to which the educational institution’s educational quality conforms to the Standards. Their judgment is made according to the information they have collected from the educational institution’s self-evaluation report and the site visit. The WCAME reviews the suggestion and makes the final decision.

The final decision on accreditation includes “pass the accreditation” or “no accreditation”.

Pass the accreditation

For educational institutions that have been accredited for the first time by December 31, 2020, the validity period of accreditation begins from the end of the site visit and lasts 3 to 8 years. For educational institutions that are not accredited for the first time or are accredited after December 31, 2020, the validity period of accreditation begins from the end of the site visit and lasts 6 or 10 years.

No accreditation

VIII. Accreditation Management

The Secretariat of the WCAME is fully responsible for daily routines of accreditation for basic medical education in China.

1. Assessment team members should have no conflicts of interest with the educational institution to be accredited.

2. The accreditation process should be fair and just. The site visits should not affect the normal teaching, research, and healthcare services in the educational institution involved.

3. Assessment team members should comply with relevant rules and regulations, laws, and work specifications under the scrutiny of the educational institution, the WCAME, and society.

4. The educational institution may put forward their disagreements regarding the facts in the accreditation report made by the assessment team. When an agreement cannot be reached after discussion, the educational institution should appeal to the Secretariat. The Secretariat will organize a team for re-assessment and will submit the result to the WCAME, whose arbitration should be the final decision.

5. The WCAME holds at least one plenary meeting every year to deliberate important issues, including work reports, annual working plans, decisions on accreditation, and the handling of appeals. Two-thirds or more of the WCAME members shall be present at the plenary meeting. The result is valid only when more than one half of the WCAME members vote for it. Members who have an interest in the matter under consideration shall not participate in the discussion or vote on the matter.

6. On the basis of full discussion, the WCAME adopts a secret ballot to confirm the accreditation decisions. The result is valid only when more than one-half of the WCAME members vote for it.

7. The accreditation decision, after reviewed by the WCAME, is posted on the website for 10 working days. Any disagreement should be submitted to the Secretariat within this period by a written appeal, following which the Secretariat will submit the arbitration to the Expert Committee for Medical Education of the Ministry of Education, who makes the final decision.

8. The educational institution should inform the Secretariat of any significant changes which have occurred during the valid period of accreditation, including changes in school name, school sites, administration and management systems, enrollment, resources, educational programs, and other areas.

9. Assessment team members should return or delete confidential documents, data, and information (including relevant e-mail messages) by the end of the site visit.

10. The Secretariat should keep and use properly or destroy the relevant data and information of each educational institution.

IX. Annex

1. The Guidelines shall be interpreted by the WCAME.

2. The Guidelines shall come into effect as of the date of publication and the former edition Guideline for the Accreditation of Basic Medical Education (2016) shall be abolished at the same time.