Demystifying Accreditation: An Inside Look at the Accreditation Commission for Acupuncture and Oriental Medicine
By Dort Bigg
It is no accident that politicians all over the country are offering many differing opinions on education. Everyone realizes on some level that how well you educate, motivate and inspire the current generation of students makes a big difference in the ongoing development of our society.
What is true for education in general is true for Oriental medicine: the effectiveness and spirit with which we educate the next generation of practitioners will profoundly influence the ongoing development, acceptance and integration of Oriental medicine into the health care system within the United States.
Oriental medicine and the modalities that comprise it have developed many traditions and philosophies stemming from its origins in China thousands of years ago. As acupuncture and Oriental medicine emerged in the United States, they have transformed from being viewed as quackery to "alternative medicine" to "complementary medicine" that has entered the mainstream and is now more fully integrated into the health care system in the United States. With this recognition of our medicine have come discussions as to the appropriate "scope of practice" for the field which, in turn, shapes the required standards of training for the next generation of practitioners. There are two arenas in which this discussion takes place. One is at the state level, since it is each state's prerogative to legislate, license and regulate its health care practitioners. The other is by the profession as a whole in the United States as it grapples with the core constituents that it wants identified as part of its medicine, as well as with the level of practice at which it wants to provide its medicine.
The integrity of the Accreditation Commission for Acupuncture and Oriental Medicine's ("ACAOM") accreditation process goes hand-in-hand with the efforts of our profession to ensure that consumers have the confidence that Oriental medicine and acupuncture practitioners have received the training necessary for safe and effective practice. As the only accrediting agency recognized by the U.S. Department of Education (DoE) as a reliable authority for quality of education and training in the field, ACAOM must ensure that its structures, policies, procedures, practices and standards are implemented with integrity so that they are responsive to the many constituencies ACAOM must serve, including students, patients, educators, practitioners and others. ACAOM constantly strives to meet these objectives in countless ways. We are sometimes asked, "How is the Commission structured, and what are the criteria for appointing ACAOM commissioners?" "How does the Commission meet its resource needs?" "What processes are implemented by the Commission to ensure that its standards are responsive to educators and the profession?" "What are the Commission's methods for reviewing programs, and how does the Commission ensure the integrity of the program review process?" and "What is ACAOM doing to ensure that it will continue to have the resources to accommodate its growth?" This article is designed to answer these questions and to provide general information about the Commission and its work.
What is Accreditation?
Accreditation is a process of external peer review in which a private, nongovernmental agency grants public recognition to an institution or program that meets certain established and nationally accepted standards for quality education and training.
Accreditation is used throughout higher education in the United States, from large multipurpose public and private universities such as the University of California system and Stanford University, to specialized professional education, such as medicine and chiropractic. Accreditation assures that educational institutions and programs meet basic standards of education and that such programs and institutions possess the administrative, academic, physical and financial resources to support their educational objectives and curriculums. Accreditation also provides assurances to the public and to regulatory boards that programs are providing the training necessary and appropriate for safe and effective practice. Accreditation commissions in all fields are national in scope and composition and establish the standards by which they review institutions and/or programs. These standards are developed with the input of the agency's relevant communities of interest.
Accreditation is utilized by the U.S. Department of Education as the basis on which access to student financial aid is administered and by which government grants are awarded. Specialized accreditation commissions such as ACAOM become "recognized" by the Department of Education as authorities for quality education and training in a particular field after undergoing their own rigorous review and approval process by the Department relative to stringent federal requirements. ACAOM has been recognized by the Department of Education as the accreditor for the field of acupuncture and Oriental medicine since 1989, and in 2000 its recognition was renewed for the DoE's maximum five year period.
Each of the health professions in the United States has an accreditation process, which is generally utilized as the basis for eligibility for certification and state licensure in that profession. A majority of the 40+ states plus the District of Columbia that currently regulate the practice of acupuncture and Oriental medicine require graduation from a candidate or accredited program as part of their eligibility process for licensure. The national certification process of the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) now also requires graduation from an accredited or candidate program to be eligible for NCCAOM certification.
ACAOM's Scope of Review
The Accreditation Commission was established in 1982 by the profession's educational and practitioner community and now reviews programs in the U.S. and Canada. The scope of ACAOM's activities that are recognized by the Department of Education at this time is to accredit first professional master's degree and professional master's level certificate and diploma programs in acupuncture and/or Oriental medicine. Acupuncture programs must be at least three academic years in length; Oriental medicine programs must be at least four academic years in length, following at least two years of accredited postsecondary education. This is considered the national educational standard for "entry level" professional practice in our field.
In May 2000, after many years of developmental work and public input, the Commission adopted accreditation standards for clinical doctoral programs in Oriental medicine. Once ACAOM has begun to accredit doctoral programs, the Commission will apply to the DoE to expand its recognized scope to include the accreditation of doctoral programs in our field. The Department of Education requires that commissions establish an adequate track record of accrediting new programs before it will recognize the review of such programs.
The Commission is organized and incorporated as a tax-exempt 501(c)(3) organization with its own board of directors who comprise the "commissioners." There are nine commissioners who are collectively and solely responsible for establishing and approving ACAOM policies, procedures and accreditation standards, and for rendering accreditation decisions. Consistent with the recognition criteria promulgated by the Department of Education, the composition of the Commission is specifically designed to ensure that it is responsive to the critical constituencies it serves. Three commissioners are designated as public members; three are practitioner members; and three are institutional members. A public member is a person who is not: an employee, member of the governing board, owner or shareholder of, or consultant to, an institution that offers an acupuncture or Oriental medicine program; a practitioner; or in any other way associated with the field of acupuncture or Oriental medicine. Public members are required to have knowledge or expertise in higher education. Practitioner members of the Commission are individuals whose principal occupation is as a practitioner of acupuncture or Oriental medicine who are actively involved in the development of the profession, but who are not affiliated with an educational training program in the field. An institutional member of the Commission is an individual who is significantly involved with a program accredited or in candidate status with ACAOM. All ACAOM commissioners must be: qualified by academic training, professional experience and knowledge of the accrediting process; sensitive to the uniqueness of individual programs; impartial, objective and without conflicts of interest; responsible and ethical with a history of fulfilling commitments on time; and willing, capable of and committed to fulfilling commissioner responsibilities. Since commissioners serve in their individual capacities and not as representatives of any institutions or organizations, ACAOM does not appoint commissioners who serve in any official capacities (e.g., officers or board members) with outside professional or educational organizations or associations in the field of Oriental medicine.
Since the Commission is national in scope, its composition must adequately reflect appropriate geographical, programmatic and community diversity. The wide-ranging experience and expertise of the commissioners in education in general and acupuncture and Oriental medicine education in particular provide ongoing assurances that the accreditation review process in this field is fair, reliable and effective. The Commission has a current staff of four employees who administer all of ACAOM's operations.
Although many accrediting agencies receive financial, administrative and other types of subsidies and support from related professional and educational organizations and associations, ACAOM receives no such support. The Commission's operations are financed and supported solely through accreditation fees charged to programs in the accreditation process. ACAOM maintains two offices. The main office in Greenbelt, Maryland co-leases a suite of offices with the Council of Colleges of Acupuncture and Oriental Medicine which reduces overhead costs, but for which ACAOM pays its fair market share of costs for rent and for use of joint office equipment which is typical among accrediting agencies recognized by the U.S. Department of Education in other fields. The Commission also maintains a small west coast office in the Los Angeles area. The Commission's operations, finances and decision making are independent from any of the other national associations or organizations in the field.
Consistent with the DoE's requirements, commissioners and staff are governed by ACAOM's strict and consistently enforced conflict of interest policies to ensure that all Commission operations are conducted with integrity. These policies require full disclosure to the Commission of potential conflicts of interest on the part of individual commissioners and staff, and abstention from discussion and voting on matters where potential conflicts of interest exist.
The Accreditation Process
The accreditation review process is rigorous and multifaceted. Colleges seeking accreditation must first achieve ACAOM candidacy status. Both the accreditation and candidacy review process require college representatives to attend a workshop designed to educate colleges regarding ACAOM's standards and expectations for documenting compliance with ACAOM's accreditation standards (i.e., an eligibility workshop for colleges seeking candidacy and a self-study workshop for colleges seeking accreditation). Colleges are then required to submit a comprehensive report documenting how the college complies with each of the Commission's accreditation standards. Colleges seeking candidacy must submit an eligibility report; colleges seeking accreditation or reaccreditation must submit a self-study report. All school reports are assigned to a Commission review committee, consisting of two commissioners and a staff reviewer to assess whether the program is sufficiently developed to approve a site visit. Based on the rigor of this review process, the Commission has been rejecting approximately one half of the eligibility reports for candidacy it receives. Typically, the Commission review committees will require supplemental information from programs seeking clarification on aspects of their submitted documentation.
Following acceptance of a program's self-study or eligibility report, the Commission conducts an on-site inspection of the program by a team of experienced site visitors. The function of the site visit team is to verify the accuracy of the program's submitted reports and to evaluate the program's compliance with the Commission's accreditation standards. Site visit teams typically include a management specialist familiar with administration and the business aspects of school operations; a general educational specialist familiar with instructional methods and educational processes; one or more acupuncture and Oriental medicine practitioners familiar with curricula offered in acupuncture and Oriental medicine programs; and one or more acupuncture and Oriental medicine educators familiar with the curricula, methods of training, program evaluation and development. If the Commission determines that the particular circumstances of a program being visited require particular expertise in addition to those above, a person with that expertise may be added to the site visit team.
Integrity of the Process
The integrity of the site visit process is a critical element of the Commission's review of programs seeking candidacy or accreditation. To ensure that each program receives a balanced, fair and impartial site visit review, the Commission has published and consistently enforced conflict of interest policies governing the selection and conduct of site visitors. These policies ensure that site visit reviews are not influenced either directly or indirectly by any factors other than the program's compliance with the Commission's accreditation standards. The policies specifically require individuals to decline an invitation for a site visitor appointment if the visitor has a possible conflict of interest or will otherwise be unable to conduct an impartial evaluation of the program. Under the Commission's procedures, programs are also notified of the proposed visiting team members in advance of a site visit and are permitted to object to any proposed team members for reasonable cause. The Commission typically defers to the program and replaces site visit team members whom the program reasonably believes will be unable to render an impartial evaluation of the program.
As an additional "check" on the integrity of the site visit process, following each site visit, the program receives site visit survey instruments for completion by the program's director, faculty, staff and students to evaluate the site visit process and the performance of individual site visitors on such factors as professionalism; competence; collegiality; knowledge; fairness; objectivity, etc. To protect confidentiality, completed surveys are not shared with the site visitors and are reviewed solely by Commission staff to evaluate and improve the site visit process. If the Commission receives credible complaints regarding the conduct of individual site visitors, that information is actively used to assess whether to remove that individual from the Commission's list of site visitors. The survey results are also used to make improvements to the site visit review process.
Site visit teams prepare a written report of findings. A copy of that report is submitted to the Commission and to the program. Programs are permitted, but not required, to file a written response to the site visit report to correct any perceived errors of fact, procedural irregularities or disagreement with team findings relative to compliance with the Commission's accreditation standards. The site visit report, the program's written response to that report, and the school catalog and financial statements are placed in the Commission's agenda books for Commission review. Although most accrediting agencies render accreditation decisions based on a written record alone, in addition to the written record, the Commission also conducts public hearings on accreditation and candidacy reviews that provide program representatives the opportunity to provide oral testimony relevant to the Commission's consideration of accreditation or candidacy status. Members of the public are also provided an opportunity to attend these hearings and to offer any comment bearing on the program being reviewed. Following the public hearings, the Commission deliberates on the candidacy or accreditation status of each program in executive session. ACAOM's public hearing process for school reviews is truly unique among accrediting agencies. Compared to other agencies, the Commission's accreditation review process provides for maximum public visibility and input, which is rare among members of the accreditation community.
Accreditation standards of any accrediting agency can only be effective if they emerge from the collective wisdom of the broad-based constituencies affected by the accreditation process. A participatory effort in ACAOM's accreditation standards development process is critical if those standards are to be accepted by practitioners, colleges, state regulatory agencies, professional associations in the field and others who rely on the accreditation process to assure the quality of education and training for the next generation of practitioners. The Commission ensures this in a number of ways.
Proposed new accreditation standards or amendments to existing standards are generated through internal suggestions by commissioners and staff, as well as suggestions by practitioners, colleges, students, faculty, professional associations, regulatory agencies, and others. Each of these suggestions is considered by the full Commission. If deemed appropriate, the Commission will publish the proposal(s) in its newsletter inviting public comment and will conduct public hearings on those proposals. Based on input from all sources, the Commission may adopt the proposal as a "trial standard" or "trial amendment" for a one-year period, during which time programs are encouraged (but not required) to comply with the trial standard(s). Proposals that are adopted as "trials" are also published in the Commission newsletter, inviting both written comment and oral testimony during public hearings. Based on the public comment received on the trial standard(s), the Commission may modify the language of the trial standard(s) or adopt the standard(s) as permanent. Standards adopted as permanent are published in the ACAOM Accreditation Handbook; programs must demonstrate compliance with those standards.
In addition to the above process, the Commission also periodically conducts surveys on the validity, reliability, clarity and effectiveness of selected accreditation standards to ensure that those standards keep pace with developments and growth within the field. The Commission recently conducted a comprehensive, national on-line survey of practitioners, professional organizations, regulatory boards, college presidents, school faculty, school administrators, students and others on its standards addressing purpose and educational objectives; legal organization; governance; administration; program of study (curriculum); and financial stability. The Commission considered the report of its statistical consultant on the survey at its Summer 2001 Retreat. Based on this input, the Commission will be proposing changes to many of its accreditation standards in these areas.
Clinical Doctor Programs
A clear example of the Commission's participatory process in the development of its standards relates to the inclusive process utilized by the Commission in developing accreditation standards for clinical doctoral programs in Oriental medicine. To ensure that the Commission would not develop a proposal for a doctoral program for the field in a vacuum, the Commission established a Doctoral Task Force to develop a "blueprint" to be used as the basis for developing accreditation standards for reviewing the quality of doctoral programs. The task force was composed of persons who have significant experience in educational standards, admissions and credentials review, and who are experienced practitioners and educators. Four representatives (all of whom are practitioners) were appointed by the two national professional organizations in the field (the American Association of Oriental Medicine and the Acupuncture and Oriental Medicine Alliance); four were appointees of the Council of Colleges of Acupuncture and Oriental Medicine (including school administrators, faculty and practitioners); and three were appointed by the Commission (one ACAOM public member of the Commission; one ACAOM practitioner member; and one ACAOM staff person). The task force also included a higher education consultant who helped established the recognized model for "clinical doctoral programs" in the field of psychology and who has served in leadership roles with the accreditation committee of the American Psychological Association. The Commission held four public hearings on each of the task force's revisions to their report seeking input from educators and practitioners throughout the country.
The task force's structure, in addition to the public comment process for its reports, ensured that practitioners and educators played a direct role in shaping the final model for a doctoral program in the field. For example, based on input from the practitioners on the task force and from practitioner public comment and testimony considered during public hearings, the doctoral program included special admissions provisions that would specifically accommodate the special needs of existing practitioners wishing to obtain a doctoral degree; distance learning was incorporated into the program to allow practitioners to earn the degree without causing undue disruptions to their personal and professional lives; clinical training in settings that require interaction with allopathic medical providers was included; and biomedical assessment knowledge and narrative report writing skills, including Western physical exams and related laboratory tests, were included. The principle focus of the program on advanced clinical training was directly influenced by the input received by practitioners. Similarly, the recommendation of one of the AAOM representatives on the task force that the doctoral program be a "free standing" program independent of master's level program requirements directly resulted in the adoption of a footnote articulating the Commission's intent to eventually adopt standards for a free standing doctoral program not tied to master's level education. The footnote makes it clear that even under the existing doctoral standards, colleges can elect to offer comprehensive integrated doctoral programs in which students receive both a master's degree and a doctoral degree upon completion of both programs. There are countless additional examples as well.
The Commission subsequently established a doctoral committee to draft proposed accreditation standards based on the final Doctoral Task Force report. The doctoral committee included: Theresa J. Rapida, ACAOM public member who serves on the faculty of Portland State University's public administration program; Pamela Lee, ACAOM practitioner member who is a private practitioner and past president of both the California Council of Acupuncture and Oriental Medicine Associations ("CAOMA") and the California Society of Oriental Medicine (formerly the California Acupuncture Association); and Stanley Leung, prior ACAOM institutional member who is a private practitioner and serves as Chief Academic and Clinical Advisor for the American College for Traditional Chinese Medicine in San Francisco. Based on the work of the ACAOM Doctoral Committee, and following extensive public comment and numerous public hearings, the Commission in May 2000 adopted final accreditation standards for a clinical doctoral program in Oriental medicine. The product of this participatory effort was the development of accreditation standards for a practitioner, professionally-oriented doctoral degree for the field. Although no schools currently offer clinical doctoral programs in Oriental medicine, the Commission is now beginning to accept applications from colleges wishing to offer such programs.
ACAOM's Future Development
ACAOM has seen tremendous growth since its establishment in 1982. There are now 47 ACAOM-accredited and candidate programs throughout the U.S. and Canada. The majority of states with licensure laws and regulations for the field now require graduation from an ACAOM accredited or candidate program to be eligible for licensure, and the National Certification Commission for Acupuncture and Oriental Medicine now requires graduation from an ACAOM accredited or candidate program to be eligible for NCCAOM certification. The Commission's new accreditation standards for clinical doctoral programs in Oriental medicine have been established, and the Commission has just begun receiving its first round of applications from colleges wishing to begin offering doctoral programs. The Commission was recently reviewed by the Department of Education relative to federal requirements for accrediting agencies and received the DoE's maximum five-year recognition period. This constitutes a major achievement, and reflects DoE's professional assessment that ACAOM substantially meets federal requirements that ensure the Commission conducts its operations with the integrity expected of Department-recognized accrediting agencies considered reliable authorities for quality of education and training in a given field.
To accommodate the increasing number of colleges in the accreditation process, the Commission will be hiring an additional staff person to help review programs seeking accreditation and candidacy status, including the review of doctoral program applications. The Commission recently moved to larger office space in Greenbelt, Maryland to help accommodate its significant growth. In addition, the Commission is increasingly relying upon technology to ensure that it can continue to provide effective services to the public and the practitioner and educational communities it serves. Not only has the Commission upgraded its computer and telecommunication resources; ACAOM is currently in the process of developing a website to provide ready consumer access to its accreditation standards, procedures and forms for the accreditation process, as well as news and other information.
The Commission has come a long way since its establishment. While ACAOM's functions will continue to pose challenges, we continue to be committed to high quality accreditation services and welcome any ideas and suggestions for improvement from the public and the acupuncture and Oriental medicine community.
Editor's note: Anyone with questions about ACAOM or the accreditation process should feel free to contact the Commission at: ACAOM, 7501 Greenway Center Drive, Suite 820, Greenbelt, MD 20770, Tel: (301) 313-0855.