Applying a quality assurance system model to curriculum transformation: Transferable lessons learned

Abstract

As curricula are transformed throughout the world in response to the need for modern medical education, much attention is given to curriculum content and associated teaching, learning and assessment methodologies. However, an important component of any curriculum is its organisational management, how it is all held together, the way the process is conducted and what mechanisms are applied to ensure quality.

In 2008, the Faculty of Medicine at Damascus University embarked on a journey of curriculum transformation. The transformation process was specifically and initially based on a quality assurance model. This entailed a concept for realising curriculum transformation; a framework for organisational management, which ensures that the necessary enabling conditions are met and issues of conflicts in roles and responsibilities are resolved; a plan for securing resources and creating the necessary governance structures needed to carry the transformation process forward; and a systematic analysis of risks facing the effective realisation of the transformation process and the corresponding mitigation measures to alleviate their impacts.

Although a full evaluation of such an activity produces reliable results only after a period of time, this article demonstrates the principles and structures applied to the initial process based on some of the early lessons learned. We perceive that the lessons learned from this activity are capable of being translated to other Universities, in other similar developing countries; our hope is that others can learn from our experiences.

Introduction

Syria is one of the many countries that is looking to transform its medical curricula; concentrating on its undergraduate programmes initially but eventually including its postgraduate programmes and its continuing professional development activities. The Faculty of Medicine at Damascus University, which is one such faculty looking at the process of curriculum transformation, is one of the oldest medical institutes in the Middle East dating back to 1903. The Faculty's intervention for curriculum transformation came in response to the 10th five-year social and economic development plan (2006–2010) in which the Syrian Government identified challenges facing the higher education sector, including those under the umbrella of healthcare education (State Planning Commission 2006). The need to raise the importance of modern methods of teaching and learning, purposive assessment and issues pertaining to the globalisation and standardisation of generic teaching and learning methods were of specific relevance to education; differing very little from other emerging countries throughout the world. An empowered and informative society, a competitive philosophy towards advantage, a need for international skills standards, an invigorated programme of lifelong learning and a need to meet the requirements of the labour market were highlighted as specifically relevant to healthcare education for Syria (State Planning Commission 2006), but again probably differing very little from other developing countries. The recent and welcomed upsurge in interest in the importance of social accountability (Boelen & Woollard 2011; Gibbs 2011) and the standardisation of medical curricula (WFME 2003) have recently added to the argument for change.

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Practice points

Curriculum renewal, curriculum transformation and curriculum development are common activities throughout the modern world of tertiary education. As new Medical Schools develop their curricula and others undertake modernisation, the processes of curriculum development and transformation take on individual importance. The complexity of modern medical education is mirrored by the complexity of building the curriculum. The processes of curriculum transformation and development are best supported by a parallel process of total quality management. Quality management ensures an efficient product from an effective process.

To ensure the effectiveness of the outcomes of the curriculum transformation process in meeting governmental needs and expectations, a stepwise approach was introduced by the Centre for Quality Assurance (CQA) at Damascus University for adapting the proposed measures by the Faculty of Medicine to quality requirements. Quality is defined as ‘the totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs’ (BSI 1991). Mishra (2007) reports that quality in higher education revolves around four distinct concepts:

1. absolute, translating into the highest possible standard;

2. relative, whereby the quality of a product or service can be described in relative terms;

3. process, which suggests that in order to achieve quality of a product or service, it must undergo certain processes and conform to the procedural requirements; and

4. culture that recognises the importance of the organisational aspect of quality as a process of transformation where each entity is concerned and acknowledges the importance of quality.

In this article, we incorporate the concepts of ‘process’ and ‘culture’ in the development of a quality assurance framework for curriculum transformation. The quality assurance requirements stipulated in the international standard ISO 9001:2008 are applied for that purpose (International Standards Organisation 2008). The six requirements of clause 4.1 of the standard offer a roadmap that an organisation is expected to meet in order to ensure that planned outcomes can be achieved effectively. According to clause 4.1, an organisation is expected to:

1. Determine the processes needed and their application.

2. Determine the sequence and interaction of these processes.

3. Determine criteria and methods needed to ensure that both the operation and control of these processes are effective.

4. Ensure the availability of resources and information necessary to support the operation and monitoring of these processes.

5. Monitor, measure, where applicable, and analyse these processes.

6. Implement actions necessary to achieve planned results and continual improvement of these processes.

On the basis of these requirements, it can be inferred that the Faculty of Medicine response should incorporate at the planning phase the following points:

1. Specifying the outcomes or specific contributions by the faculty for achieving stated Government objectives.

2. Providing details on how the proposed measures will be regulated in an organisational management framework in order to create the necessary enabling conditions and preventing conflicting roles and responsibilities of key actors involved in the faculty response.

3. Addressing the issue of securing competent human resources to undertake the work and providing any required support and information.

4. Providing details on how the faculty response measures will be realised.

5. Anticipating risks facing the effective realisation of the outcomes of the faculty response prior to implementation.

6. Planning necessary mitigation measures to alleviate the impacts of identified risks.

In this article, we illustrate how the above-noted requirements were incorporated into the curriculum transformation process at Damascus Medical School's and the Schools response.

Most importantly, however, we envisage that the reader recognises these actions and responses as not just pertaining to Damascus, but to many other schools undergoing curriculum transformation, particularly those from emerging/developing countries and any lessons learned are transferable to perhaps their particular situation.

Formulating a faculty response

In order to formulate appropriate measures for curriculum transformation, a model referred to as the driving-forces–pressure–state–impact–response (DPSIR) framework was applied. This framework is based on the pressure–state–response model, which was originally developed by the Organisation for Economic Cooperation and Development (Walmsley & Pretorius 1996). The DPSIR framework is a systematic and useful tool for organising and presenting physical data from various subject areas and sources affecting a public sector. It can serve to identify key areas that a Faculty of Medicine should or could address as part of the curriculum transformation process. The framework links the external forces or drivers (D) and the exerted pressures (P) on the education system to the resulting state (S) of the University, which in turn impacts on (I) students and society, for whom a certain response (R) has to be made. The DPSIR framework for Damascus University is shown in Figure 1. Although drawn specifically for Damascus, the authors believe that many of the factors found in each of the DSPIR ‘boxes’ are equally relevant to other medical schools. Information required for this framework was obtained from research studies and surveys conducted on the university and faculty level. These included a university-wide survey conducted in 2006 in which feedback was obtained from 8300 undergraduate students (over 400 medical students), 700 teaching staff, 160 administrative staff and 150 external stakeholder groups represented by alumni, parents of students and employers of graduates (Centre for Quality Assurance 2007).

Figure 1. DPSIR framework for analysing necessary response by Damascus University.

An important set of data that should shape any medical curriculum is based upon employers’ needs for the future and their present perceptions of the most recent graduates’ abilities. Employers’ feedback concerning the ability of the university to develop its graduate's intellectual, personal, social and professional skills is presented on Table 1.

Table 1.  Opinions* of representatives of employers on the extent to which Damascus University has succeeded on meeting their needs in terms of graduates’ skills and competencies (Centre for Quality Assurance 2007)

Research conducted by the Medical Faculty was also used for completing the DPSIR framework. Research topics on the attitudes of students to various disciplines (Dashash & Bashour 1997), appropriateness of multiple choice questions in assessment (Latifeh 2008), community-based medical education (Al-Faisal 2006), opinions of students on clinical instruction (Bashour et al. 2010) and opinion of students on required versus acquired clinical skills (Al-Ourfi et al. in press) provided evidence. The findings illustrated that, apart from the University's history and cultural heritage, all drivers were of an external nature. Pressures are mainly attributed to elements of resource management concerning teaching staff, infrastructure and instructional facilities; again a feature common to many medical schools in the present times of financial restraint and austerity measures. These in turn affect teaching, learning and assessment processes in relation to methodologies to be used, available resources and governance structures. The resulting impacts are seen in students’ performance, expectations of employers, status of educational methods, quality aspects of core educational processes and willingness of staff and personnel to pursue professional development.

On the basis of this analysis, the Faculty of Medicine response for alleviating the identified impacts was to embark upon a process for curriculum transformation, which not only covers the simple upgrading of the course syllabus and programme but also addresses related issues such as modernising teaching, learning and assessment methods, human resources development, good management practices of teaching facilities in addition to revising rules and regulations governed by the current institutional and legal frameworks of the higher education system.

Accordingly, the following measures were proposed for realising curriculum transformation:

1. Defining the scope of the curriculum transformation process, which includes identification of the existing contextual framework governing the current educational system and proposing principal aspects of the new curriculum, which are based upon the intended outcomes to be fulfilled in newly graduating students.

2. Designing the new curriculum, which includes important aspects such as student selection, information regarding the curriculum, organisational management and governance, regulations regarding the curriculum, student support, student representation, the curricula teaching, learning and assessment methodologies, learning resources including library and information technology support, staff support and development and evaluation of the curriculum and its potential improvement.

3. Proposing modifications to existing legal and institutional frameworks in order to meet the requirements of the new curriculum including evaluation of current rules and regulations governing the implementation of the curriculum and recommendations for necessary changes and follow-up for adoption.

4. Allocating necessary resources required to implement the new curriculum.

5. Overseeing implementation of the new curriculum, monitoring and evaluating areas of weaknesses and following-up for continual improvement.

Although these features are probably second nature to advanced curriculum developers in some parts of the world, the authors are again of the opinion that this ‘total curriculum approach’ – as defined by Harden et al. (Harden 1986; Harden et al 1997; Harden 2001) is not universally found throughout many parts of the world and may be a unique feature in some.

Introducing organisational management

The process for elaborating a curriculum transformation plan by the faculty offers a unique opportunity to explore issues of organisational management of critical nature for success in the curriculum transformation process. The preparatory phase for the plan in this situation entailed a number of activities, such as the formation of interest groups and institutionalisation1 of their roles and responsibilities within the faculty hierarchy, assignment of quality coordinators to lead various working groups and the convening of a medical education conference (the first one in Syria that brought in International experts to present and discuss specific issues of curriculum transformation), in order to enhance knowledge transfer, networking and capacity building. These activities demonstrated the complexity of the curriculum transformation process within the existing governance structure and provided evidence suggesting that curriculum transformation can be only achieved when the following enabling conditions are met:

• A universal willingness and commitment from informed decision makers; these could be at the levels of Ministry of Higher Education, University and Faculty of Medicine.

• An ownership of the process and its outcomes, together with full participation in the transformation process, by faculty members, of whatever rank or grade.

• A supportive institutional framework, designed to create the necessary organisational structures needed to undertake the task of curriculum transformation.

• An innovative and possibly new legal framework that is able to adopt the necessary recommendations for the new curricula.

• A group of competent human resources (drawn from present and new faculty members) to undertake the development work.

• A logical and transparent set of financial commitments to fund the work, in terms of the long-term financing of faculty members and international experts to undertake the task of curriculum transformation; the financing of the necessary and expected new infrastructure needed for the implementation of the new curriculum; and the financing of faculty development in research and individual scholarship.

Successful achievement of curriculum transformation also requires that key actors involved in this process undertake specific tasks and fulfil their responsibilities as depicted in the schematic chart shown in Figure 2. This organisational management framework ensures that the necessary enabling conditions are met and issues of conflicts in roles and responsibilities are resolved. In Damascus, this was based on division of roles between the CQA, the University Council, the Medical Faculty Council and the Educational Development Unit (EDU), which consisted of a group of recognised and competent faculty members mandated with the task of preparing a new curriculum. The Faculty and University Councils play the executive role by adopting the recommendations raised by the EDU. The CQA plays a regulatory role on behalf of University Administration for the curriculum transformation process. It ensures that through well-designed organisational measures, the final product of the transformation process, i.e., the new curriculum, meets Government needs and expectations. The CQA also provides the EDU with the necessary resources in terms of expertise and networking for capacity building purposes. It also assists the EDU in tackling issues of legal, institutional and financial nature with the University Council. The integral nature of these relationships is recognised by the arrows, which flow mainly both ways from the differing units. In many countries, the University exerts strict control over each Faculty; Damascus is no exception. The organisational management described in Figure 2 attempts to overcome some of these top-down management issues.

Figure 2. Organisational management of the curriculum transformation process.

Developing human resources

Curriculum transformation requires that a critical mass of well-informed faculty members be created. They should be knowledgeable about medical education, the need for change and the requirements of the transformation process. The aim is to prepare a qualified and competent group of people capable of carrying forward the curriculum transformation process. This concept is illustrated in Figure 3. In Damascus, this process was achieved over a period of 18 months. However, each medical school/faculty is different and each will work in its own time frame. The objective is to build ownership in the transformation process in a gradual manner from few faculty members to a critical mass of interested and committed members. The principles of good governance are advocated in this process in order to enlist enthusiastic academic specialists willing to take the curriculum transformation process forward. The aim is that all faculty members and staff associated with the academic programme have the basic knowledge about modern methods for teaching, learning and assessment; thus enabling them to interact in the future with members of the EDU in curriculum development issues.

Figure 3. Capacity building concept for curriculum transformation.

Realisation of capacity building is undertaken on two levels. On the first level, all faculty members and staff (including peripheral teaching staff) associated with the academic programme are required to attend a basic course on ‘The Principles of Modern Medical Education’, during which the faculty are introduced to new concepts, theories and practices pertaining to teaching, learning and assessment. Once a critical mass of trained people is achieved (interested and active members), the second level of targeted capacity building for members of the EDU is initiated. Envisaged training includes advanced certificate courses in modern teaching, learning and assessment methods; participation and attendance of international conferences; and visits and sabbaticals in other academic medical institutions. Once this programme is near completion, arrangements are made for institutionalisation of the EDU in the faculty. These arrangements include the appointment of its members, recognition of their responsibilities and authorities, appointment of academic leads from the various departments and allocation of necessary resources needed for the EDU to undertake its tasks. The EDU is staffed by coordinators specialised in teaching and learning strategies, assessment methods, community outreach, information technology and learning resources, students’ support, students’ selected components and electives, in addition to representatives of key technical areas in the academic programme and a student representative.

One may argue that in the process of defining faculty roles that role descriptors are first drawn and then faculty allocated to each. The authors believe that this is ideal in a resource (person) – rich situation. However, in many countries were faculty are scarce, then a reverse of this situation is frequently necessary, often depending on the minimum skills faculty have.

Risks and mitigation

The major risks that the curriculum transformation process faces during implementation and required mitigating measures are presented in Table 2. The table draws on examples found at Damascus University Medical School; however, the authors believe that these risks and mitigating factors are frequently found within other medical schools throughout the world.

Table 2.  Risks facing successful realisation of curriculum transformation and mitigating measures

Risks	Mitigation
The CQA fails in convincing the University Council to adopt the recommended changes in the legal and institutional frameworks needed to institutionalise curriculum transformation	Ensure University Council ownership when proposing such recommendations
The CQA is viewed to interfere with responsibilities of the Deans and Faculty Councils when playing the role of organisational management for curriculum transformation	Ensure Faculty Deans and Councils are updated regularly about work progress, and are given opportunities to become involved and recommend organisational measures in curriculum transformation
The Faculty Council does not provide members of the EDU with the necessary means and resources to develop their capacities and undertake the necessary work	Ensure Faculty Council has ownership in the transformation process Ensure the EDU presents a work plan with necessary financial allocations to the Faculty Council for their approval
The EDU fails in getting the Faculty Council to adopt recommended changes in curriculum design (e.g. teaching, learning and assessment methods) needed to implement curriculum transformation	Ensure Faculty Councils have ownership in the transformation process and have all attended basic courses on modern educational methods
Trained Faculty members and staff, particularly in the EDU, vacate their positions in the long-term, and no longer participate in curriculum management	Ensure that sufficient number of staff is trained to substitute for Faculty members who withdraw from the curriculum transformation process, and ensure succession planning is an intrinsic activity within each EDU.
The Faculty Council interferes in the assignment of members of the EDU hence impacting its ability to accomplish its tasks efficiently and effectively.	Ensure that strong governance structures are enforced and respected by all.

As can be seen, risks may arise if university and faculty councils are not responsive to proposals and recommendations made for curriculum development; in case of institutional and structural conflicts; if due to limited financing or loss of competent human resources, or due to weak governance structures. Mitigation is achieved in proper planning and preparation prior to making any proposals and recommendations, in addition to ensuring ownership for the curriculum transformation process by all involved in decision making within the University hierarchy, and ensuring that existing governance structures are respected.

Conclusions

Curriculum transformation should incorporate aspects of quality assurance in order to ensure that planned outcomes are achieved effectively and efficiently. This entails:

• A well defined and clear expectation of what the curriculum intends to produce, based upon realistic, achievable and worthy outcomes.

• A clear concept and an elaborate plan for realising curriculum transformation, in order to achieve these outcomes.

• A framework for organisational management, which ensures that the necessary enabling conditions are met and issues of conflicts in roles and responsibilities are resolved.

• A plan for securing competent human resources and creating the necessary academic and administrative structures needed to carry the transformation process forward.

• A systematic analysis of risks facing the effective realisation of the curriculum transformation process and the corresponding mitigation measures to alleviate their impacts.

This early work by the Faculty of Medicine at Damascus University demonstrates a way forward in incorporating the principles of quality assurance in the organisation of its curriculum transformation process. Total quality management involves the measurement of the effects of curriculum transformation upon the organisational structure, its component parts, its users (faculty, students and patients) and an overall effect upon society (future health statistics).

Although a true reflection of these various parameters can only be obtained through time, it is envisaged that the final product – the development of competent medical professionals capable of delivering a high quality healthcare to the populace of Syria – will happen. It is the responsibility the Faculty of Medicine at Damascus University to initiate and progressively evaluate this process.

We hope that this article will both help and inspire curriculum developers, in that although the path to curriculum change and development is far from smooth, with effective organisational management and quality control, it can be improved. We hope that the lessons we have learned from our experiences in Damascus can be utilised by others undergoing a similar change; we would wish everyone involved well!

‘It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change’.

Charles Darwin

English biologist (1809–1882)

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Notes

Notes

1. Institutionalisation: to make part of a structured and usually well-established system.