An assessment study of quality model for medical schools in mexico

The authors in this paper assess the development of medical schools in Mexico considering a proposed Quality Model for Medical Schools QMMS having five levels of the Incremental Quality

Chapter 16

DOI: 10.4018/978-1-5225-0672-0.ch016

Jorge Eugenio Valdez García

Tecnologico de Monterrey, Mexico

ABSTRACT

Excellence in healthcare delivery is only possible by addressing the quality issues in medical education The authors in this paper assess the development of medical schools in Mexico considering a proposed Quality Model for Medical Schools (QMMS) having five levels of the Incremental Quality Model (IQM)

An exploratory descriptive approach was applied in this study wherein 46 authorities from medical schools self-assessed their processes (strategic, core, support and evaluation) included on the QMMS

to determine their development in the five levels of the IQM i.e Start, Development, Standardization, Innovation and Sustainability The results of the study show the average were: 3.09 strategic processes, 2.96 core processes, 3.19 support processes and 3.00 in evaluation process The overall mean obtained was 3.07 which correspond to Standardization level The authors consider that the proposed quality model may serve as a guide to improve their performance to advance to innovation and sustainability.

INTRODUCTION

Clinical practice is dynamic It is constantly being improved by scientific and technological innovations

on procedures, resources and techniques Medical education needs to be adapted to prepare professionals not only for currently society demands, but also for future requirements in healthcare (Flores Echavarría, Sánchez Flores, Coronado Herrera, & Amador Campos, 2001)

An Assessment Study of

Quality Model for Medical

Schools in Mexico

Silvia Lizett Olivares Olivares

Tecnologico de Monterrey, Mexico

Alejandra Garza Cruz

Tecnológico de Monterrey, Mexico

Mildred Vanessa López Cabrera

Tecnologico de Monterrey, Mexico

Alex Iván Suárez Regalado

Tecnologico de Monterrey, Mexico

Excellence in healthcare delivery is only possible by addressing the quality issues in medical tion There have been several studies to assure and improve quality in medical education, with three basic purposes: public accountability for future doctors’ skills, teaching and learning strategies improvement, and quality culture determined by institutional principles and values (Joshi, 2012) These initiatives have impulsed procedures of assessment, competency certification, and accreditation standards for undergraduate and graduate programs (Flores Echavarría et al., 2001).

educa-Quality models for medical programs and healthcare institutions are optional and recent in Mexico Medical education standards are not covering efficiently the present needs for all stakeholders’ expecta-tions Healthcare institutions nowadays require better professionals whose clinical competences impact medical care on the current and future epidemiology diseases

This chapter intends to suggest a Quality Model for Medical Schools based on quality management theory and other accreditations and regulations for medical schools It includes three components: prin-ciples, criteria and evaluation

The objectives of the chapter are:

• To describe the evolution of quality management and quality in medical education;

• To present the construction of the Quality Model for Medical Schools;

• To define the criteria stratified by processes type (strategic, core, support and evaluation):

◦ Strategic: Leadership and Planning, Program Design, and Research.

◦ Core processes: Students, Integral Education, and Faculty.

◦ Support processes: Facilities, Networks with other institutions, and Administration.

◦ Evaluation processes: Assessment and continuous improvement, and Results;

• To refer to the Incremental Quality Model to evaluate medical schools considering five stages: 1) Start, 2) Development, 3) Standardization, 4) Innovation and 5) Sustainability;

• To outline an exploratory study of a self- assessment instrument applied to medical schools in Mexico; and

• To suggest further research approaches and initiatives related to the Quality Model for Medical Schools

BACKGROUND

Importance of Quality Management

The concept of quality has not a unique or a permanent definition A general definition could be “to satisfy or comply design or expectations” Nevertheless, the concept is broad and dynamic and it should

be understood considering the historical moment in which it was conceived Its scope and focus have been variable over time The deployment has gone from products, processes, value chain, systems and even beyond organizational boundaries Regardless that manufacturing industry started to apply quality practices, the experience has been transferred to several organizational types, as healthcare institutions and medical education

Quality History

The concept of quality management has evolved through time According to Cantú Delgado (2006), there are five historical phases regarding this concept: a) Inspection, b) Statistical Process Control, c) Quality assurance, d) Total Quality Management and e) Strategic Reflection

Phase One: Inspection On the beginning of the XX century, quality was focused only on final products

Quality inspectors were used to segregate defective products from the valid ones in order to stop them from being delivered to customers Regretfully, the cost has already been spent on the defec-tive product and this final inspection was only useful as a barrier

Phase Two: Statistical Process Control At the thirties decade, a preventive approach was implemented

by applying sampling methods to prevent errors on processes Statistical methods helped to control variables and production parameters

Phase Three: Quality Assurance By the end of the Second World War, Deming introduced continuous

improvement methods to attend customer requirements in Japan The verification process began with raw material from suppliers, to key processes and delivery to customers, considering the entire value chain Mercado (2008) mentioned that this model led to formalize quality systems ac-creditation ISO9000 standard originated with the purpose to homogenize requisites and language for organizations to satisfy customer requirements

Phase Four: Total Quality Management This phase included innovation in both key and support

pro-cesses across departments considering several organizational levels Instead of linear propro-cesses, a system orientation was encouraged During the 90’s, the importance of quality awards to recognize organizational excellence on productivity, performance and stakeholders’ satisfaction started to increase These total quality models have helped companies to improve formalization, productiv-ity, orientation to internal and external stakeholders; continuous improvement and innovation (Evans, 2014) In United States, the Malcolm Baldrige National Quality Awards (MBNQA) was established in1987 to raise awareness of quality management and to recognize U.S companies that have implemented successful quality management systems In Mexico, a couple of years later, the National Quality Award (PNC by its acronym in Spanish) and other local awards like the Nuevo Leon Quality Award for Competitiveness (PNLC for its acronym in Spanish) were founded to develop organizations to compete through benchmark, innovation and improvement After 1994, the Free Trade Agreement brought the urgent need for Mexican companies to compete on a global market and therefore, they started to use quality models to change traditional practices that used

to serve captive markets (Mata, 1994)

Phase Five: Strategic Reflection The importance of social responsibility and sustainability has recently

encouraged organizations to reflect on the future needs and demands for society, raising the portance of long term strategic approaches Lieber (2011) argues that today is required to balance stakeholders’ requirements supported on strategic plans established by excellent leadership and outstanding practices In Mexico, the National Quality Award (PNC by its acronym in Spanish) evolved in 2006 into a strategical resource base view oriented to capacities In 2016, this model proposed reflection through strategic maps to adjust future direction and sustainable growth

im-Evolution of Quality in Healthcare and Medical Education

Chandia (2006) describes the historical evolution of quality in health considering a similar structure as Cantú Delgado (2006) in manufacturing

• Early Approaches: Medical education has gone through different moments in the United States

during the twelfth century In 1910, Abraham Flexner severely questioned the quality of the cation provided in schools of medicine (Fernández González, 2007) This report encouraged med-ical schools to improve their integration with hospitals and healthcare centers to collaborate on a structured educational model This concern awakened when Flexner evaluated medical education faculties in Canada and the United States, discovering the general lack of standards for medical education

edu-• Measurement: According to Chandia (2006) in 1912, Codman developed a method to classify

and measure caregivers’ results

• Accreditation for Healthcare Institutions: In 1950, the Canadian Council for Accreditation

of Hospitals was created A year later in the United States, the Joint Commission was founded

to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value These organizations developed the first accreditation stan-dards and parameters for healthcare institutions In 1961, Avedis Donabedian made great contri-butions when he defined concepts related to quality in healthcare His language oriented quality structure, processes and results to be transferred to clinical environments In Mexico, it was until

1999 when the Certification Commission for Hospitals was established under the auspices of the General Health Council (Ruelas, 2010) However, the standards remained unchanged for 10 years

In 2009, the importance for accreditation was recovered and requisites were updated considering the Joint Commission standards

• Accreditation for Medical Schools: Regarding accreditation of medical schools, it was until

1989 that the World Federation of Medical Education (WFME) designed an accreditation ity model with standards for medical schools in the United States In Mexico, the first efforts date back to 1991 with the foundation of the Mexican Association of Faculties and Schools of Medicine (AMFEM by its acronym in Spanish), but it was until 2006 that the Mexican Council for Accreditation of Medical Education (COMAEM by its acronym in Spanish) was formalized, which started to assess medical schools considering standards

qual-INTEGRATION OF A QUALITY MODEL

Based on the Baldrige Excellence Framework System (2016), a graphical representation of the construction

of the Quality Model for Medical Schools is presented on Figure 1 On the center, the quality principles are included, these represent the philosophical foundation of the proposed 11 criteria to create a system presented on the middle layer On the present chapter, each criteria is broken down into a list of argu-ments, whose responses may be ranked in five levels of maturity (start, development, standardization, innovation and sustainability), which are represented on the outer layer

A synthetic self-assessment instrument was designed to know the quality level of the Medical Schools

in Mexico according to the proposed quality model

Quality Principles for Medical Education

According to the previous quality evolution phases, several quality principles have arisen It is important

to consider them for the design and management of the quality model Even though they may be applied directly to medical education, yet there are some issues to be considered for its practical application

Regulations Compliance

The most basic quality principle is the compliance of governmental regulations and legal requirements Before implementing a complex and multidimensional quality model, it is important to attend norms established for facility safety, personnel benefits or any other legal requirement On the educational field, the ministry of education specifies certain rules to approve a higher education program in order to guarantee fundamental teaching requirements Specifically, on medical education, the ministry of health and healthcare institutions request additional specifications for the programs

Figure 1 Components of the Quality Model for Medical Schools

Management by Facts

Decision making is always based on facts Managers should determine which variables require indicators

or qualitative information to be registered and tracked The measurement system should be defined cording to the timing for decision making Daily measurements are internal and operative for corrective decisions Monthly evaluations are focused on continual improvement projects Annual records should be related to organizational objectives and long term information should definitely include external context

ac-Personnel Focus

Every organization should focus on its personnel The basic focus should be on job training A high level

of relation could be achieved by personnel involvement through problems solving or projects teams The next engagement with personnel refers to motivation programs, recognition and rewards Finally, excel-lent organizations have long term development and career programs aligned and influenced by strategic plans On educational institutions, faculty members are the fundamental talent to develop learning on students On medical education, there are other healthcare professionals and staff that facilitate learning for the students, who should also be considered as part of the training strategy of the school

Process Orientation

A process is a sequence of activities to achieve an intended result Davenport and Short (1998) state that a process is a structured and measured activities that maintains a specific order along the time and space, with a beginning, end, inputs and outputs identified as a framework for action A process oriented organization has clearly defined its processes by type (strategic, core, support and evaluation) and their relation among them A complete process includes: a) an input requirement, b) a transformational objec-tive, c) a desired output, d) a feedback measurement and e) a responsible position to assist the process results and improvements Chang (2005) adds that a process is any activity or group of activities that add value to an internal or external customer

Also, functional processes are internal and exist in one specific department, but inter-functional processes are transactional to several departments In education, the most important process is the teaching and learning Recently, educational outputs have been associated with competences Medical competences have been well established by academic groups who consider as relevant outcomes: clini-cal skills, biomedical and scientific aspects of medicine, instrumental and methodological aspects of sciences and humanities, ethics and professionalism, quality of patient care and teamwork, social and community care, and participation into the health system (AMFEM, 2016)

Stakeholder Focus

A quality model should consider feedback from customers and other stakeholders A stakeholder is one, who is interested or affected by the organization, such as government, employees, customers, suppliers, shareholders and society In medical education stakeholders include patients and their families, students and their parents, faculty, healthcare institutions, ministry of education, ministry of health, accreditation boards, certification councils, medical boards, etc A patient centered approach is fundamental in the medical field

Leaders’ commitment is a fundamental condition for implementing any quality program The leadership level correlates directly to the task complexity to transform processes, systems or contexts The timing and scope for decision making is also another variable which increases solidity to the leader profile, as he/she envisions a further distant future In medical education, a visionary leader requires an important networking to attend demands from different stakeholders

Innovation and Continuous Improvement

The first step to improve results is to control and standardize internal processes Imai (1986) states that continuous improvement should focus on the recognition of a specific problem The improvement is achieved when the root cause of the problem is detected and eradicated reaching a new level of devel-opment Innovation implies additional effort since it requires an extraordinary gap on an output or to develop a novel and original proposal In medical education innovations may be established in several aspects as: programs design, infrastructure, pedagogical methods, etc

Social Responsibility

The final goal of every organization should be to transform society This focus may be related with practices and programs oriented to benefit vulnerable communities, to improve social or nonprofit organizations and to protect the environment Some examples may be related to funding, innovation, regulation policies, educational programs or business models to contribute to the society quality of life;

or to benefit individuals and groups from local, regional or international contexts

Criteria Stratified by Process Type

Since long time, the term processes have been considered part of the business language as an important element to achieve operational efficiency Hammer and Champy (2009) point out that a process is a set

of activities that receive one or more input elements, to supply a product to give value to the customer (Hammer & Champy, 2009) However, the definition provided by the International Organization for Stan-dardization in its ISO 9000: 2005 specifies that a process is a set of interrelated activities or interacting elements of transforming inputs into outputs (ISO, 2005) The efficient management of business processes

is a key element for organizations operating in a competitive business environment (Bae, Lee, & Moon, 2014) On the other hand, Smith and Fingar (2006) discuss the concept of business process as a set of collaborative and transactional activities that are coordinated and deliver added value to customers as recipients of the output of a process The processes facilitate the synergy of three critical dimensions in companies formed by people, processes and methods, and tools and equipment (Smith & Fingar, 2006) The processes are classified into: strategic, core, support and evaluation The proposed Quality Model for Medical Schools has eleven criteria classified by process type represented on a process map (Figure 2) A process map is a graphical representation to present the four types of organizational processes.The purpose of the model is to invite Medical Schools to reflect on their quality systems and assess them from an excellence approach The definition of each of the criteria is established considering

general quality awards, such as MBNQA, PNC and PNLC Each standard was broken down into several arguments based on international and Mexican accreditations for medical schools as the proposed by the WFME and COMAEM The arguments were phrased and supported on quality management and medical education theory explained after each criterion.

Strategic Process

Strategic processes are those that provide guidelines and policies to achieve innovative long term goals These types of processes establish limits for other initiatives and set the direction according to a clear vision Strategic processes correspond to the top level leadership decisions, which include management review and innovation In medical education, these processes are also related to programs design and research and these are:

1 Leadership and Planning: Refers to the credentials and capacities of the top management team

(dean, program director, academic dean and chief departments) to manage the quality systems and define the strategic planning for the medical school in order to prepare the best physicians to attend current and future challenges in healthcare

Figure 2 Quality Model for Medical Schools

a Leadership

i Describe the foundational philosophy of the School of Medicine to impact on graduate’s competencies to transform the healthcare system It can be described by: vision, mission statement, values, code of ethics, policies, regulations, etc

ii Define the networking strategies with government health sector, healthcare institutions, research centers, other academic institutions, technology partners, and to balance benefits among partners and allies

iii Describe how the government structure is organized for operation and improvement Include the process for leader’s development, promotion and replacement considering credentials and performance

iv Describe how leaders develop individual talent and team groups to engage them to contribute to foundational philosophy

b Planning

i Describe the strategic planning process to face medical education considering actual society healthcare demands, challenging epidemiology transitions for vulnerable groups and emerging medical knowledge and technology

ii Define the mechanisms and strategies to generate and expand original knowledge to transform education, science or medical assistance

iii Describe the operative planning process to define measurements, objectives, goals and projects for a monthly or annual basis

iv Describe the method to develop a systematic self-assessment of the School of Medicine quality system

Theoretical explanation: Leadership concept in quality models is conceived in two perspectives: organizational and individual At the organizational perspective, according to Abell (2006), leader-ship integrates vision, mission, strategy, actions and results At the individual perspective, leaders should engage people to collaborate and develop their potential to achieve innovation Maxwell (2011), Wooldridge (2011) and Deming (Evans & Lindsay, 2014) emphasize the importance to guide talented people to become leaders, developing their competences and skills to lead their groups and attain better opportunities The four arguments included on the leadership criteria are also related to the four frames

of reference proposed by Bolman and Deal (2013) in the following order: symbolic, politic, structural and human The symbolic frame of reference is related to cultural organizational characteristics; politic frame of reference states the power to influence contexts and networks; structural frame of reference is defined by order and processes; and human frame of reference represents the people oriented actions

In addition to mission, vision, values and objectives, the planning to translate the objectives into key performance indicators for the short and long term planning is necessary Evans & Lindsay (2014), Trainer (2004) and Dooris, Kelley and Trainer (2004) point out the importance of having a set of indica-tors aligned with organizational objectives to measure, follow trends and compare results with leading institutions

2 Program Design: It refers to the creation, assessment and improvement of the medical program

considering entry profile, graduate competences, courses map, curriculum, pedagogical methods and other resources to prepare the best physicians to attend current and future challenges in healthcare

It consists of five steps including:

a Describe the information considered as an input for the medical program design including previous institutional results and demands from context and environment.

b Describe the program design method including participants’ roles invited from multiple contexts: faculty, authorities, personnel from healthcare institutions, partners, alumni, active students, etc

c Define the students’ entry profile and graduate outcomes by competence and other tions for medical school

qualifica-d Determine educational strategies to develop both disciplinary and generic competences to perform with professionalism, quality and patient safety, and social responsibility For ex-ample: pathways, pedagogical methods, educational environments and any other teaching and learning characteristics

e Determine the elements of the program to be distinguished as original, innovative and transformative

Theoretical explanation: Bordage and Harris (2011) state that the curriculum is aimed for students

to acquire the necessary skills to fulfill their professional and social role as doctors Program design should be based on internal and external approaches From an internal approach, Vicedo Tomey (2014) arguments that the curriculum design should start from a diagnosis to detect deficiencies and limitations

of the actual programs As an external approach, Piña-Garza et al (2008) determine that the curriculum should be based on social and health problems

The method to define the program is collaborative according to several authors Bordage and Harris (2011) suggest that the curriculum should be developed and renewed through a deliberative process.According to Karpa and Abendroth (2012), universities should encourage the incorporation of a group

of trusted colleagues as internal reviewers for the proposed curriculum Duvivier and Rodriguez Muñoz (2010) recommend the opinion from different perspectives, such as managers, teachers and students Bleakley (2012) add that even patients may participate

As a result, Prat-Corominas and Oriol-Bosch (2011) affirm that a curriculum should include sequencing learning activities and a course catalog with appropriate content and educational objectives to develop competencies This competency-based approach should ensure that students complete the professional skills and social values (Piña-Garza et al., 2008, Dharmasaroja 2013) The AMFEM in Mexico has a competency-profile for medical students, which may be taken into consideration to define curriculum contents and pedagogical methods

3 Research: It refers to knowledge generation and its deployment to impact healthcare social needs

through intellectual contributions of consolidated research groups in topics related to biosciences, clinical care and medical education and consists of following steps

a Describe the research areas in which the school of medicine is developing knowledge to attend fundamental healthcare issues in biosciences, clinical care and medical education

b Explain how research groups are conformed and how they collaborate as a community ing group of faculty, students and other scientific members

learn-Theoretical explanation: Research in universities is essential to fulfill the commitment to contribute

to knowledge generation, and to develop professionals capable to generate intellectual and scientific developments in their discipline for the benefit of the community (Salmi, 2009) While the guidelines

of advanced research is required, the development of passion for research in both faculty and students

is more important

Hu, Kuh and Gayles (2007), and Osborn and Karukstis (2009), state that involvement of students in research is an innovative strategy which benefits students, teachers and the entire academic community Furthermore, Osborn and Karukstis, Laidlaw, Aiton, Struthers and Guild (2012), and Dienstag (2011) agree in the need to offer a curricula focused on research, in order to nurture students’ curiosity and desire to discover solutions to problems that will surely have an impact in the quality of life

Core Process

Core processes affect directly the provision of products or services to the customer Core processes are sequential and located on the value chain Key processes are considered the main part of the mission statement of an organization and therefore linked with the economic performance of the company In medical education the core processes are those that directly affect the provision of educational services

to students to develop competences on a daily basis The proposed criteria for core processes are:

4 Students: It refers to admission, education and graduation processes to guarantee graduate

com-petences to influence on institutional and external contexts These services must provide tory experiences and opportunities for involvement of the students during their program and after graduation as following:

satisfac-a Describe the admission processes to guarantee high qualifications and competence standards for freshmen students Include how to address minorities’ inclusiveness

b Describe how competency based education is implemented to guarantee desired outcomes established on the program design

c Define the concept of student satisfaction and the associated methods to continuously improve

it considering measurements for active students and alumni

d Describe students and alumni participation and involvement to positively influence both institutionally and external contexts (local, regional, national or international)

Theoretical explanation: Lumsden, Bore, Millar, Jack and Powis (2005), Reibnegger, Caluba, Ithaler, Manhal, Neges and Smolle (2010), Urlings-Strop, Themmen, Stijnen and Splinter (2011), Bore, Munro and Powis (2009), Mehmood and Borleffs (2011), and Courneya, Wright, Frinton, Mak, Schulzer and Pachev (2005), quote the importance to have mechanisms for the selection of students into an academic institution, in order to guarantee the admittance of the best candidates for a future physician role Besides, the selective entry profile for students, schools of medicine should ensure the academic performance throughout the program to guarantee outcomes according to the graduate competency profile (Stegers-Jager, 2012; Stegers-Jager, Cohen-Schotanus, Splinter, & Themmen, 2011)

From a customer perspective, authors like Mark (2013a), Mark (2013b) and Taylor, Brites, et al (2008) consider that students should have a satisfactory educational experience and the institution should constantly seek to measure and improve this result In order to achieve this goal, Duvivier and Rodríguez-Muñoz (2010), Divaris et al (2008) and Kezar (2005), recommend that students and alumni should contribute to improve their education, through feedback, participation on committees and other leading roles for institutional decision making

5 Integral Education: It refers to professional and personal development of students beyond academic

services, in order to impulse their self-realization with humanism, interpersonal skills, rial competences and entrepreneurship profile for social responsibility From Medical education perspective, it includes:

manage-a Describe opportunities for students to develop extracurricular activities related to sports, cultural activities, student councils, volunteering for community assistance, etc

b Explain mechanisms for academic or emotional counseling for students through individual tutoring and learning communities

c Declare formal opportunities to train students on humanism, managerial competences and entrepreneurship for transformation and social responsibility It may include activities or projects related to professionalism, quality and patient safety, community care, etc

Theoretical explanation: Education should not only develop dispersed skills but also demonstrable competences that foster a commitment to peace, values and rights, in order to educate integral citizens (UNESCO, 2009) Olivares (2015) classifies competences as individual, interpersonal, managerial and contextual The medical school should promote a balanced training on each one to educate integrally the students

Blakey, Blanshard, Cole, Leslie and Sen (2008), Drake (2014), Kiker (2008), Taherian and archian (2008), and Molina Aviles (2004), emphasize the importance to provide support and direction

Shek-to students through tuShek-toring and academic counselling for their individual academic development and wellness It is important to continuously identify and monitor the students with lowest performance and academic difficulties to timely help them

Morales-Ruiz (2009), Angulo, González, Santamaría and Sarmiento (2007), Tchibozo (2007), art et al (2011), and Rodenhauser, Strickland and Gambala (2004) agree on the importance of integral education of students through extracurricular activities and other opportunities to develop interpersonal skills (Roulin & Bangerter, 2013)

Stu-Espíritu Olmos & Sastre Castillo (2007), Taatila (2010) and El-Khasawneh (2008) understand rial education as part of the formal training to motivate financial benefits for students and the healthcare where they participate Process efficiency and procedures compliance favor patient safety and should be also part of the training programs

manage-Another element for integral medical education is to develop contextual awareness of the privileged communities and other similar groups Vázquez Martínez (2010) and Mungaray Lagarda et

under-al (2002), declare that social service promotes community quality of life and develops service skills in the students

6 Faculty: It refers to institutional efforts for the search, recruitment, development, assessment and

recognition of faculty members, attending doctors and other professionals, who participate on medical education to contribute to their individual growth and satisfaction In the quality assess-ment model, it includes the following steps:

a Describe the process to invite, select and recruit faculty and staff members to formally ticipate on the medical school

par-b Declare the training and development programs for faculty members including induction, pedagogical education, disciplinary actualization and advanced instruction

c Explain the opportunities for career path development and promotion for faculty members and how it is aligned with institutional strategic plans.

d Describe the processes to assess faculty performance, provide feedback and recognize special achievements to continuously improve their teaching and professional outcomes

Theoretical explanation: It can be said that medical schools are responsible for selecting, training and developing human resources for the medical healthcare, having capable and suitable human resources for their teaching responsibilities (Alles, 2006; Evans & Lindsay, 2014) According to Perez Santana

et al (2009), faculty focused practices are developed to align institutional ideals with their individual professional aspirations Among these practices are included: training and development, career promo-tion and motivation

Beltrán (2004) emphasizes the importance of teaching evaluation as mechanism for quality ment Preciado Cortés, Gómez Nashiki and Kral (2008) emphasize the need to evaluate and debrief faculty members with different parameters; and also to place recognition and rewards to inspire them

improve-to high performance

Support Process

Support processes are those that provide assistance to key and strategic processes Similarly to a backstage

on a theatrical performance, efficiency on support processes are mainly perceived by internal ers In medical education, additional services, administrative support, facilities management, and other technical assistance may be considered on this category

custom-7 Learning Facilities: It refers to tangible spaces, equipment, information technology and other

bibliographical resources to provide an innovative environment for teaching, learning and research

on a collaborative athmosphere among faculty members, students and staff The learning facilities for quality assurance perspective includes:

a Describe the learning spaces available to foster a vanguard teaching and learning environment including classrooms, simulation labs, library, assessment centers, etc., congruently with the medical program design and enrollment capacities

b Describe equipment, information technology and bibliographical available resources for learning and research to impact on students’ education

c Explain how the spaces provide an environment for both self-directed learning and tion with faculty and staff members

collabora-Theoretical Explanation:

Lavy (2008), and Hill and Epps (2010), affirm that the infrastructure affects how the students learn and how they interact with each other and with faculty Therefore, the infrastructure should be considered during planning stages as a contributor to the student satisfaction

Torres Landa López (2010) concluded that the spaces in which the teaching-learning occurs, affect the performance of both students and teachers, it requires the infrastructure that fosters learning and interaction

Drew (2001) affirms that the infrastructure and resources have influence in the time management

of students; therefore they should promote research and provide space, equipment and informational resources to enable student to carry out their activities independently and effective Spaces and resources should promote participation between students and teachers from other educational and healthcare insti-tutions for the generation of knowledge Salmi (2009) highlights that the best universities are investing

in having cutting edge facilities that foster inquiry based learning, and consequently propose appealing ideas to: (1) potential students, facilitating the recruitment and improving the image and reputation of the institution, and (2) researchers to promote inter-institutional collaboration

8 Administration: It refers to the administrative planning to allocate financial and personnel resources

according to short, medium and long term planning It includes the following steps:

a Describe the process for planning and managing financial and personnel resources ently with short, medium and long term planning

congru-b Explain how additional resources are funded and managed to introduce innovative and formative elements to education and research of the school of medicine

trans-Theoretical explanation: Shattock (2010) particularizes the importance of conducting a holistic agement approach in higher education institutions according to a dynamic changing system Shattock, and Nkrumah-Young and Powell (2008) refer that financial funding and economic stability are crucial

man-to improve processes and fulfill the mission statement of the medical school Planning and management

of resources should be based on a systematic internal assessment that considers desired improvements and specific requests (Méndez Fregozo, 2005; Shattock, 2010), Salazar Mora, 2006; Trainer, 2004; Dew & Nearing, 2004) An adequate administration includes the budgeting of resources on a systematic scheduled plan based on assessment and desired projects for improvement

9 Contributions with Other Institutions: It refers to the search, creation and engagement of

partner-ships and agreements with public, private and social sector to collaborate on students’ competence development and healthcare improvement It includes the following:

a Describe the process to formalize partnerships and agreements with institutions from the public, private and social sector to contribute to medical education and research

b Define continuous education and extension services for health professional’s growth and development throughout long life learning

Theoretical explanation: Higher education benefits from networking with other institutions Alvarado Borrego (2009) emphasizes the need to link education to the labor market to benefit both universities and private and public sector Elmuti, Abebe and Nicolosi (2005), Brown, White and Leibbrandt (2006), and Boland, Kamikawa, Inouye, Latimer and Marshall (2010) refer to the importance of partnerships between institutions of higher education and formal organizations from public, private or social sector Each organization offers different resources and training environment to benefit both students and soci-ety In medical education, agreements between universities and healthcare centers are crucial to develop clinical competences on students

Besides local partnerships, international agreements provide a global perspective on students There

is a trend in exchange programs and international cooperation to improve the quality of higher education (Fresno Chavez., 2005; Morales Suárez, Borroto Cruz & Fernández Oliva, 2005)

Evaluation Process

Evaluation processes determine the objective facts for planning and decision making horizontally and vertically across organizations Assessment practices identify results to detect opportunities and weak-nesses on strategic, core or support processes In medical education, it includes student assessment and grading, faculty performance evaluation and program evaluation by third parties The evaluation process includes the following:

10 Assessment and Continuous Improvement: It refers to a formal and systematic verification

process to review outcomes performance on processes and stakeholders’ expectations and from quality assessment perspective, it includes:

a Define the assessment strategy for medical students to advance on their program considering both generic and disciplinary competencies to promote excellence instead of minimum require-ments Explain how to address validity of quantitative and qualitative evaluation instruments

b Describe mechanisms to assess, compare and improve strategic, core and support processes

of the institution, considering outcomes from students, alumni, faculty and staff

Theoretical explanation: Assessment on medical students is a process to confirm knowledge learning and generic competences acquisition Academic institutions need to develop assessment mechanisms to provide feedback to the students and to diagnose the teaching-learning process of the program (Fletcher

et al., 2012; Hernández, 2012; Moreno Olivos, 2009) A competency based education requires to assess not only disciplinary content, but also skills and behaviors on a patient-physician relation, a team work interaction or as project leader (Gil-Flores, 2012; Vanderbilt, Feldman, & Wood, 2013; Epstein 2007) Assessment based on excellence has no limits of learning evidences from students, in order to impulse their potential This orientation requires the use of several assessment methods like work based assess-ment, bed-side teaching, clinical simulations and portfolios among others

As an institution, other external evaluations should be included on the evaluation system Although students’ performance on internal assessments provide valuable information, only comparison parameters considering rankings, accreditations and standardized tests will provide a real organizational overview Tracking alumni positions and performance is also an effective method for assessing and improving organizational results (Díaz Barriga, 2005; Flores Echavarria et al, 2001)

11 Results: It includes indicators and measurements results for processes and stakeholders considering

goals, trends and benchmark analysis and for evaluation process It consists of the following steps:

a Describe medical school indicators for strategic, key and support processes including desired trends, goals and benchmark comparison

b Present historical satisfaction and goals from faculty, students, alumni, patients, residency programs which have enrolled graduates, community, and healthcare centers

c Indicate the ranking level of the medical school, accreditation by third parties and any other institutional recognition

Theoretical explanation: Evans & Lindsay (2014) and Lozano (2006, cited by Gutierrez Ruiz, García Céspedes, Cazorla & Lima, 2014) agree that results should include school processes and operations to verify the effectiveness of the strategic planning and the impact to society Friedman (2004) and Salmi

(2009) recommend that results should be compared with other benchmark institution with international prestige, to identify the best strategies to follow.

Salmi (2009) emphasized that in addition to the measured and comparable results, the best universities

of the world have evidence of admirable results, transforming them in a role model that sets the course

in their sector and to inspire others worldwide

Dew and Nearing (2004) promote the continuous improvement of the way learning is provided to students because this translates to the constant incorporation of value to the institutions Cleland, Arnold and Chesser (2005) inquire about the need for a culture of improvement in academic performance, of-fering students support and guidance mechanisms to excel in their performance

Incremental Quality Model (IQM)

The stages of the Incremental Quality Model (IQM) were determined from the evolution of tions by Cantú Delgado (2006), but the language was adapted for the medical education context Table

organiza-1 shows the equivalence between the reference model proposed by Cantú Delgado and the proposed model for assessment

Medical schools can be classified into different maturity stages, depending on the degree of compliance and commitment to quality systems: (1) Start, (2) Development, (3) Standardization, (4) Innovation and (5) Sustainability as shown in Figure 3 Each stage includes a number of characteristics that accumulate through an incremental process

Start

It is a beginning stage in which higher education institutions are designed to meet the minimum ernmental regulations to provide certain academic programs The focus at this stage is corrective since problems emerge from a daily basis and they are solved as they appear At this phase, the early steps to structure, organization and management of priority activities are designed

gov-Table 1 Equivalence between Cantú Delgado and

proposed model

Stages of Quality by Cantú

Delgado Levels of Incremental Quality Model (IQM)

Inspection (early twentieth

century) Start

Process control (thirties) Development

Quality assurance (fifties) Standardization

Total Quality Management

(nineties) Innovation

Strategic reflection (present) Sustainability

Figure 3 Incremental Quality Model (IQM)

The innovation stage refers to a maturity rank where all organizational levels and departments are involved through Total Quality Management model Institutional planning occurs considering a medium-term impact through a value added differentiation that excels other institutions Institutions have a founded strategic planning, which includes prospective context information, all stakeholders’ expectations, benchmark analysis and the creation of innovative medical education proposals based on research The linear process management to achieve desired outcomes has been upgraded into a systems approach for excellence Faculty members and staff interact not only among colleagues from institution, but collabo-rate with national and international medical education leaders The medical school, faculty members, students and graduates are frequently awarded, recognized and prized for standing out on their achieve-ments on regional or national forums

Sustainability

At this stage medical schools not only prove excellent educational results, but they are able to prove healthcare impacts on vulnerable groups, communities and society The planning relates to long term initiatives for transformation on healthcare systems adopting a holistic approach towards technological, epidemiological and social changes The medical school at this stage is actively involved on global health initiatives, vanguard research and international committees

At the level of sustainability, schools become international benchmarks of excellence and are able to evidence tangible influence on healthcare systems at local, national and international levels The medi-

cal school, faculty members, students and graduates are frequently awarded, recognized and prized for standing out on their achievements on international forums.

Research Method

The research method is non experimental, transactional, exploratory and descriptive by quantitative data A self-assessment instrument based on the 11 criteria of the Quality Model for Medical Schools (QMMS) was designed to be scored on the five levels on the Incremental Quality Model (IQM).The self-assessment was applied to 52 directors, managers and deans of medical schools in Mexico belonging to AMFEM Only 46 surveys were considered for the study, discarding 5 due to incomplete answers

Quality Self-Assessment for Medical Schools

The reliability of an instrument refers to the degree to which it produces consistent and coherent results (Hernández Sampieri, Fernández Collado, & Baptista Lucio, 2010) The most common analysis to cal-culate this reliability is Cronbach’s alpha This coefficient ranges from 0 to 1, where 0 indicate a lower level of reliability, and 1 stands for the maximum level of reliability Vogt, Vogt, Gardner and Haeffele (2014) recommend a value of 0.70 or superior The obtained Cronbach’s alpha of the self-assessment instrument for this study was an acceptable value of 0.896

Participants scored the quality of medical schools in Mexico for each of the eleven criteria for the Quality Model for Medical Schools (QMMS) applying a 5 level rubric from the Incremental Quality Model (IQM) as 1: Start, 2: Development, 3: Standardization, 4: Innovation and 5: Sustainability The Table 2 present the score ranges considered to assess each level

SOLUTIONS AND RECOMMENDATIONS

This section presents the results of the self-assessment application based on the proposed QMMS The objective of this study was the proposal of a quality model presented in previous sections of the chapter, answering the following research questions: Which is the quality level that medical schools in Mexico have reached? Are they ready to face the future requirements of a globalized healthcare? The specific objective was to perform a diagnostic of the quality level of medical schools in Mexico using

a self-assessment based on the Quality Model for Medical Schools The analysis is presented