An assessment study of quality model for medical schools in mexico

404 Chapter 16 An Assessment Study of Quality Model for Medical Schools in Mexico Silvia Lizett Olivares Olivares Tecnologico de Monterrey, Mexico Mildred Vanessa López Cabrera Tecnologico de Monterrey, Mexico Alejandra Garza Cruz Tecnológico de Monterrey, Mexico Alex Iván Suárez Regalado Tecnologico de Monterrey, Mexico 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) DOI: 10.4018/978-1-5225-0672-0.ch016 Copyright © 2017, IGI Global Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited  An Assessment Study of Quality Model for Medical Schools in Mexico Excellence in healthcare delivery is only possible by addressing the quality issues in medical education 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) 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’ expectations 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: principles, 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 405  An Assessment Study of Quality Model for Medical Schools in Mexico 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 defective 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 accreditation 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 processes across departments considering several organizational levels Instead of linear processes, 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, productivity, 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 importance 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 406  An Assessment Study of Quality Model for Medical Schools in Mexico 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 education provided in schools of medicine (Fernández González, 2007) This report encouraged medical 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 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 standards and parameters for healthcare institutions In 1961, Avedis Donabedian made great contributions 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 quality 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 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 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 arguments, whose responses may be ranked in five levels of maturity (start, development, standardization, innovation and sustainability), which are represented on the outer layer 407  An Assessment Study of Quality Model for Medical Schools in Mexico Figure Components of the Quality Model for Medical Schools 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 408  An Assessment Study of Quality Model for Medical Schools in Mexico 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 according 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 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, excellent 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 objective, 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: clinical 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 409  An Assessment Study of Quality Model for Medical Schools in Mexico Leadership 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 development 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 Standardization 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 410  An Assessment Study of Quality Model for Medical Schools in Mexico Figure Quality Model for Medical Schools 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: 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 411  An Assessment Study of Quality Model for Medical Schools in Mexico 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), leadership 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 indicators aligned with organizational objectives to measure, follow trends and compare results with leading institutions 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: 412  An Assessment Study of Quality Model for Medical Schools in Mexico 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 qualifications for medical school d Determine educational strategies to develop both disciplinary and generic competences to perform with professionalism, quality and patient safety, and social responsibility For example: 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 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 learning group of faculty, students and other scientific members 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 413  An Assessment Study of Quality Model for Medical Schools in Mexico Table 12 Evaluation process: Assessment and Continuous Improvement Start Procedures are established to assess students learning Programs are defined to award high performance students with scholarships and internal awards Development Internal collegiate bodies are established to define students’ assessment criteria Mechanisms are designed for monitoring graduate performance and results Standardization Innovation Sustainability Standardized assessments are defined and validated for students (individual and entire class) There are mechanisms to assess and improve the curriculum and support services in the institution, derived from outcomes described by students, alumni, faculty and administrators Projects are defined for the improvement of students’ academic performance For the assessment of students’ performance, standardized test and instruments are used These tests are developed and validated by collegiate bodies from different institutions Students’ performance assessment is based on international standardized tests Alumni results evidence impact in healthcare context Table 13 Evaluation process: Results Start Development Standardization Innovation Sustainability Key performance indicators are designed Key performance indicators monitor students’ development Staff turnover, improvement projects and intellectual contributions are assessed Social impact, satisfaction of students, faculty, staff, residency programs, and local community is measured The results from the institution are comparable with average performance of other schools of medicine, according to the rankings Results show that the school excels in rankings in the national context Results put the medical school in the first places in international rankings ing results from the self-assessment applied by the medical schools The media was calculated for each criterion as well as the average by process type The quality level for each criterion and by process type was determined according to the Incremental Quality Model (IQM) Table 14 presents results of each criterion and its level achieved The overall media of schools of medicine in Mexico is 3.07 (Table 14) According to the IQM this corresponds to the third level (Standardization) The medical schools represented on the study are focused on accreditation standards for their medical program Van Zanten, McKinley, Durante Montiel & Pijano (2012) mention that accreditation systems are used to ensure the quality of education Furthermore, Davis & Ringsted (2006) state that the purpose of using the accreditation systems is the improvement of quality in healthcare For a medical school, according to the applied instrument, being at this level means that the organization has mission, vision and objectives, evaluation and faculty development, mechanisms to assess and improve students’ satisfaction, tracking performance of both students and graduates, a structured method for program design, formal agreements with other institutions for the exchange of students, intention for research, interactive spaces, annual planning, and mechanisms to promote social responsibility on students 425  An Assessment Study of Quality Model for Medical Schools in Mexico Table 14 Mean results by criteria Process Type Strategic Core Support Evaluation Criteria Media Level Achieved Leadership and Planning 3.35 (3) Standardization Program design 3.04 (3) Standardization Research 2.89 (2) Development Students 3.00 (3) Standardization Integral Education 2.80 (2) Development Faculty 3.07 (3) Standardization Learning facilities 3.26 (3) Standardization Administration 3.15 (3) Standardization Networks with other institutions 3.15 (3) Standardization Assessment and continuous improvement 2.89 (2) Development Results 3.11 (3) Standardization 3.07 (3) Standardization Overall Leadership and Planning The Leadership and Planning criteria obtained a 3.35 media, which corresponds to the third level of quality, Standardization The schools of medicine were distributed by level of the IQM in: (0%) Start, (9%) Development, (61%) Standardization, (13%) Innovation, and (17%) Sustainability According to the developed instrument, it means that an operation structure and an ethic code are in place There are some teams oriented for high performance according to values and institutional philosophy Mission and vision statements are declared, and objectives are defined and known by administrators, students, faculty and staff They declare the application of systematic self-assessment The diagnosis coincides with the quality cycle of Deming, which states that it is necessary to create and disseminate to all employees the statement of the objectives and purposes of the company or organization (Evans & Lindsay, 2008) As mentioned before, most medical schools (61%) are on the third level of the IQM In order to advance to the next level which is Innovation, it will be necessary to increase the commitment to quality at organizational and individual level visualizing and managing goals for a longer time (See Table 3) Program Design In the Program Design criteria a media of 3.04 was obtained, which corresponds to the third level of quality, Standardization or continuous improvement The schools of medicine were distributed by level of the IQM in: (4%) in Start level, (9%) development, (70%) Standardization, (4%) innovation, and (13%) Sustainability According to the diagnosis, 4% of the medical schools have only completed the Start level, which implies to have defined an entry and graduate profile, as well as a curricular structure with appropriate content and materials for medical education On the second level (Development), 9% of schools have also a curriculum design based on a regional context analysis and approved by collegiate groups This level relates to a control stage 426  An Assessment Study of Quality Model for Medical Schools in Mexico Most of the schools (70%) achieved the level of Standardization, which indicates that their curricula fosters the development of disciplinary and generic skills considering professionalism, quality and safety practices and social responsibility among others On Innovation, only 4% of the participants consider their medical schools as a role model for other institutions According to Elizondo-Montemayor, Cid-García, Pérez-Rodríguez, Alarcón-Fuentes, Pérez-García and David (2007) and Castañeda Rincón (2002), curriculum design and educational model are the main elements to be distinguished from other programs and institution On the other hand, 13% of participants from medical schools consider themselves as sustainability for having participation of healthcare leading institutions Bordage and Harris (2011) affirm that a leading edge program must look beyond the evidence from literature reviews, incorporating aspects from diverse future visions and backgrounds Research In this category, a media of 2.89 was obtained, that corresponds to the second level of IQM, Development The schools of medicine were distributed by level of the IQM in: (11%) in start level, (22%) development, (41%) standardization, (7%) innovation, and (20%) sustainability According to results, schools of medicine may be stratified into two groups The ones that identify possible research opportunities for the institution (11%), and the others that have established formal programs for the development of research skills of faculty and students (22%) On Standardization, 41% of the medical schools promote the involvement of students and faculty in research activities as formal part of the program Controversially, 20% of participants assess their schools as having relevant research activities and encourage students and teachers to produce research to improve education (See Table 5.) Students In the Students criterion a media of 3.00 was obtained, which corresponds to the third level of quality, Standardization or continuous improvement The schools of medicine were distributed by level of the IQM in: (0%) in start level, (9%) development, (61%) standardization, (13%)innovation, and (17%)sustainability At this level, medical schools implement quality assurance models through feedback from graduates and students There were none responses at the Start level The 9% of participants referred a Development level for having preventive actions to failure and dropout Most of the schools (61%) are oriented to the third level for referring effective policies and procedures to ensure academic progress according to a competency based on education At Innovation level, 13% of participants from medical schools perceive that their institutions involve students in strategic decisions, such as the development of the mission, vision, policies, curriculum assessment and educational model At Sustainability level, 17% of participants refer having favorable results on knowledge generation (See Table 6) Integral Education In this criteria, the mean was 2.80 that corresponds to the second level, Development The schools of medicine were distributed by level of the IQM in: (9%) in start level, (33%)development, (33%) standardization, (4%)innovation, and (22%) sustainability According to the diagnostic, 9% of schools of medicine provide tutoring, counseling and orientation, community service program, cultural and sport 427  An Assessment Study of Quality Model for Medical Schools in Mexico activities Additionally, 33% of the participants perceive that their institutions also have student groups who participate for the benefit of institution and their context On the next level, 33% refer that medical schools develop entrepreneurs and they have formal processes to develop professionalism, quality and safety and social responsibility skills (See Table 7) Faculty In this criteria, a mean of 3.07 was obtained, which corresponds to the third level of quality, Standardization or continuous improvement The schools of medicine were distributed by level of the IQM in: (7%) Start, (7%) Development, (65%) Standardization, (4%) Innovation, and (17%) Sustainability The starters (7%) have formal processes for faculty selection and recruitment A 7% have also implemented a faculty development program On Standardization (65%), schools have indicators to recognize high teaching performance On Innovation (4%), faculty collaborates with colleagues from other institutions to collaborate on innovative projects Lieff et al (2012), Quraishi et al (2010) and Siddique et al (2011) consider measuring faculty satisfaction as a crucial factor as institutional practice, since correlates with loyalty, attraction and retention of talent (See Table 8) Learning Facilities This criteria, obtained a mean of 3.26, placing the result at the third level of quality, Standardization The schools of medicine were distributed by level of the IQM in: (4%) Start, (11%) Development, (50%) Standardization, (11%) Innovation, and (24%) Sustainability According to the diagnosis, medical schools have a clear alignment between infrastructure, bibliographic and library resources (50% at Standardization) On Innovation, (11%) schools of medicine provide spaces to nurture active learning for self-directed learners (See Table 9) Administration This criteria obtained a 3.15 media, placing the schools in the third level of quality, Standardization The schools of medicine were distributed by level of the IQM in: (4%) in start level, (20%) development, (46%) standardization, (13%) innovation, and (17%) sustainability According to the instrument, 4% of schools at Start level offer adequate administrative and support services On Development (20%), schools also define a budget plan for the academic year At Standardization level (13%), additional use of systematic assessment is needed to prepare resources, and to incorporate important elements to the teaching-learning process At Innovation level (13%), medical schools must develop valuable proposals to have the essential resources according to best higher education practices Finally, 17% of participants considered that their financial planning adapts agilely and flexibly according to a changing environment (See Table 10) Networks with Other Institutions A mean of 3.15 was obtained in this category, corresponding to Standardization level The schools of medicine were distributed by level of the IQM in: (2%) Start, (24%) Development, (37%) Standardization, (7%) Innovation, and (30%) Sustainability According to the study, medical schools at Start level (2%) 428  An Assessment Study of Quality Model for Medical Schools in Mexico have identified key institutions for agreements The 24% have already formalized those agreements The 37% of participants considered that their networking strategy offers valuable propositions to the public, private and social sector On Innovation (7%), schools refer to have agreements with local and foreign institutions for the exchange of students On Sustainability (30%), it is considered that they develop long term favorable alliances with healthcare organizations and government for the continuous development of health professionals, and develop specific collaboration projects (See Table 11) Assessment and Continuous Improvement In this criteria, a mean of 2.89 was obtained which means schools are located on the second level of the IQM, Development The schools of medicine were distributed by level of the IQM in: (4%) Start, (28%) Development, (41%) Standardization, (0%) Innovation, and (26%) Sustainability According to the study, schools of medicine at Development level (28%) have collegiate bodies to define assessment criteria for students, as well as procedures to provide the same follow up to alumni’s performance once they graduate At Standardization (41%) refers to assess their students through standardized tests and student outcomes per student and class generation According to Benjamin et al (2012) and Norcross et al (2009), a comprehensive evaluation system includes internal and external standardized tests that compare results with other benchmark universities From this study, 26% refer to have in place an International standardized assessment for students (See Table 12) Results In the Results criteria, a media of 3.11 was obtained, placing the medical schools in the third level of the IQM, Standardization The schools of medicine were distributed by level of the IQM in: (4%) Start, (17%) Development, (50%) Standardization, (9%) Innovation, and (20%) Sustainability According to the self-assessment, medical schools at Development level (17%) have key indicators to monitor students, turnover, continuous-improvement projects and intellectual contributions At Standardization level (50%) of the schools also assess their social impact and students ‘satisfaction, faculty, employers, residency programs and local community; and its results are comparable to the average ranking of medical schools On Innovation, 9% of participants refer that their medical schools excel on national rankings Figure shows the overall results by process type The highest level of quality was obtained in the Support (3.19), Strategic (3.09) and Evaluation (3.00) processes, where a third level of Standardization was achieved The lowest score was obtained in the core processes (2.96) with a level of Development According to results from this study, the averages of medical schools in Mexico are at Standardization level Feisel (2009) remarks that this status corresponds to a focus on outcomes to guarantee the professional profile defined and declared The mean of medical schools refers to have evidence of the establishment of standardized internal processes which have been accredited by external agencies However, there is a group of participants from this study which refers to have sustainable evidence that their medical schools collaborate internationally to produce knowledge and impact on healthcare system indicators This group considers that its quality systems have an impact that transcends organizational boundaries, through students, graduates, institutions and employers The presented exploratory study shows the quality level of medical schools as perceived by their leaders It is desired to apply the complete guide by certified examiners to increase scores reliability The 429  An Assessment Study of Quality Model for Medical Schools in Mexico Figure Results by process type detailed criteria from the proposed QMMS should become a guide for systematic assessment, management and planning, to achieve improved and transformative results FUTURE RESEARCH DIRECTIONS The presented Quality Model for Medical Schools represents the guide to implement quality systems oriented to impulse institutions to innovation and sustainability levels from the Incremental Quality Model Accreditation quality models are designed to homogenize practices through standards In contrast, quality awards pretend to impulse organizations to excellence and unlimited achievements As future project and research initiative, the AMFEM has as strategic plan to create a quality award based on the criteria and assessment process presented here As a preparation phase, it is required to design a training program for examiners and representatives from medical schools, to define a steering prize committee and to formally implement an evaluation process similar as the established on the national quality awards CONCLUSION The world is facing technological, epidemiological and social transitions The educational contents for the future are vague and uncertain It is imperative that medical schools commit to improve their quality systems to develop sustainable organizational models which impulse their leaders to create excellence in the training of medical doctors that will safeguard society’s health and quality of life The study presented here shows contrasting results among medical schools Despite the fact that a minor group has outstanding research and pedagogical methods, other institutions struggle to have the proper infrastructure and minimum requirements to attend mandatory regulations Several actors may contribute to close this gap: ministry of health, accreditation agencies, medical boards and associations and healthcare institutions 430  An Assessment Study of Quality Model for Medical Schools in Mexico ACKNOWLEDGMENT We would like to thank the Mexican Association of Faculties and Schools of Medicine (AMFEM) for all their support in the development of this study REFERENCES Abell, D F (2006) The future of strategy is leadership Journal of Business Research, 59(3), 310–314 doi:10.1016/j.jbusres.2005.09.003 Alles, M A (2006) Dirección estratégica de recursos humanos: gestión por competencias (2nd ed.) 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An Assessment Study of Quality Model for Medical Schools in Mexico Figure Components of the Quality Model for Medical Schools A synthetic self -assessment instrument was designed to know the quality