The Influence of International Education Accreditation on a Graduate Health and Hospital Program

The overriding objective was to compare the influence of Assurance of Learning (AoL), on several graduate students’ pedagogical outcomes before and after an international accreditation program. A self-administered questionnaire was employed to collect data from subjects enrolled in a graduate program. Out of 122 graduate students who voluntarily participated in the pretest (2015), only 88 students participated in the posttest (2017). Overall, the students expressed effective AoL in many pedagogical outcomes based on the post-accreditation process. A high positive correlation was observed between the overall effectiveness of AoL and communication skills (r = 0.875, p = 0.01). Of the pre-accredited group, 56.2% reported effective AoL outcomes; this percentage increased to 77.8%. The pretest and posttest results indicated significant differences in AoL (p < 0.01). Health programs accreditation provides effective outcomes on academic as well as personal leadership levels. Continuous implementation and assessment of AoL must be monitored periodically to ensure its successful contribution to health programs and business schools.

One of the major roles of educational programs is to improve the candidates' performance based on their individual capacity through potential outcomes (Darling-Hammond et al., 2005).Program accreditation is a formal process of ensuring that a program meets the minimum quality standards of the profession for which that program prepares graduates for.Hence, accreditation focuses on ensuring an effective program design, achieving the educational objectives, making the student outcomes measurable, creating the rubrics, and analyzing the assessment data (Crawley et al., 2007;Hale, 2011).The emphasis of current educational accreditation lies on improving the overall learning outcomes of students by enhancing innovative assurance of learning (AoL) techniques (Eschenfelder, Bryan, and Lee, 2014;Trifts, 2012).Recently, pedagogical policies are implemented worldwide to reflect the effect on end users.One of the concurrent approaches in assessment involves the process of implementing course content, engaging the stockholders, and involving the experts, particularly in health programs.
While setting up a health program, the overriding role of the academe is to identify the intended learning outcomes.This role primarily ensures that each course, and consequently the program, meets the learning outcomes through specific AoL outcomes in health education.In some science courses like engineering, there is a value of accreditation as suggested by Byrne and others (Byrne et al., 2013).However, the literature proving the effectiveness of graduate health programs after accreditation is scattered and not practically approved.Thus, the current research aimed to compare a graduate program before and after international accreditation by assessing its AoL outcomes.

Learning Outcomes
What a learner is expected to know, understand, and/or be able to do at the end of a period of an intended learning course is simply known as AoL.In health education programs in Saudi Arabia (SA), AoL has been under consideration, particularly after the inception of the National Commission for Academic Accreditation and Assessment (NCAAA) in 2004.AoL represents central standards that any accredited program must undergo to maintain effective performance.Thus, AoL has become one of the most frequently discussed topics in tertiary education today (Rubin and Martell, 2009).Learning outcomes have also started to gain importance at the leadership level, consequently driving the development of the national qualifications framework (Zocco, 2011).Learning outcomes gradually lead to a student-centered paradigm, which is the mission of many schools and could be achieved through many ways.Practically, to meet and maintain the program objectives, employers may share better understanding of the acquired knowledge, skills, and competencies to recruit the most competent candidates.Learning outcomes could increase the transparency and comparability among qualification standards.In other words, the AoL mainly examines the high level of knowledge outcomes, but with a particular focus on the academic study results.

Quality and Health Education Program Accreditation
The urgent need to improve the performance and quality of healthcare organizations was raised by the Institute of Medicine a long time ago; specifically, the Institute argued that initiatives should commence from healthcare professionals and their schools (Chassin and Galvin, 1998).However, Hirose and other researchers proposed that an accreditation system is a remedy element in maintaining standardized healthcare services to practically increase the cohesiveness and coherence of any healthcare system (Hirose et al., 2003).
In a systematic approach, Greenfield and Braithwaite analyzed the nature of health research studies.They found that the professional's attitude toward accreditation was the dominant subject within recent research literature among 10 other scopes of studies (from 2007 onward) (Greenfield and Braithwaite, 2008).The alignment of the course objectives and competencies has been addressed, particularly in communication skills (Brink and Costigan, 2015).When incorporating the essential parts of accreditation, AoL content is always presented.For example, a student engagement model was proposed within the Taiwanese educational system to ensure effectiveness (Hu, Ching, and Chao, 2012).Meanwhile, critical thinking as a major outcome and building quality of culture are indispensable components that ensure learning (Cortese, 2003).

Accreditation as Triangulation
Demonstrating educational accountability requires valid course content, students' engagement, and stockholders' contribution.Batalden and others highlighted the need to address competency and communication skills within clinical programs, but did not provide a clear model on how to foster such needs (Batalden et al., 2002).The aim behind acquiring such competency is fundamentally based on patients' centeredness philosophy and accurate data collection from the patient experience (Greenfield and Braithwaite, 2008;Makoul, 2003).In addition to other essential domains, such as student engagement, self-learning, and critical thinking, many health programs implement quality culture within the educational system (Adel, 2016;Salmi, 2017).
When conducting accreditation, once the utilization of AoL content is in progress, the successful use of such systems depends extensively on how well those contents integrated within the delivery of pedagogical activities.With the support of the program mission, the educational health programs have the potential to make a significant difference in building effective educational culture, enabling healthcare professionals to perform on logic and scientific bases, and in increasing efficiencies and cost savings for the healthcare system.In SA, after the inception of NCAAA, the culture of education has been initiated by setting up basic education requirements, such as course specification, course reports, and AoL (Alebaikan, 2010;Telmesani, Zaini, and Ghazi, 2011).

Design
This cohort study incorporated a pretest and posttest design.Prior to accreditation in 2016, a group of graduate students participated in indicating their daily experiences concerning the basic course content based on the accreditation criteria.Then, the same group was surveyed about the impact of such results.

Procedure
Targeting convenience sample, Master 's degree program candidates were invited to participate in a web survey.Details about their experiences were saved until the next year.After the program accreditation, the same candidates were emailed the same survey, yielding 88 valid results.

Sample
Students who registered in the academic year 2015 were invited to participate in the study voluntarily.They are enrolled in the Master degree Program of Health and Hospital Administration (MHHA) in the College of Business Administration in one of the tertiary educational universities in SA.

Tool
The web survey contains demographic and academic profiles of the sample.Then, nine domains were assessed based on the five-point Likert scale containing 45 factors.The tool was periodically distributed manually among program quality coordinators to assess the implementation of AoL at the college level.The tool is valid and reliable.

Analysis
First, basic demographic characteristics were analyzed using descriptive analysis.Each of the two categorical measures was aggregated into one measurement.Then, using SPSS-19, inferential analysis was employed, including Pearson correlation.

Ethical Approval
This research study was conducted after obtaining the approval of the IRB and the liaison with the concerned departments.

Results
Among over 135 graduate students registered in 2015, only 122 voluntarily participated in this survey, yielding a response rate of about 90%.In 2015, respondents were almost consistent in their experience when it came to appreciating the value of accreditation.However, in 2017, a slight change in the activities of AoL was observed, as shown in Table (2).

Discussion
In this study, the question of whether the promise of an effective AoL process was helpful in delivering health programs was addressed.The results were categorized by various factors depending on the overall objectives of AoL and students' acquisition.The overall findings of the results were not different from that identified in the literature.Most of the reports on the subjects identified effective and worthwhile outcomes in many pedagogical aspects.However, two influential areas were observed: an area with a strong effect and an area with less or no effect.
Communication skills, a fundamental competency among healthcare professionals, exhibited a rational effect in this research (Makoul, 2003).This result is consistent with those presented in many studies (Bylund, 2016;Bylund et al., 2017;Kissane et al., 2012).Evidently, communication skills cannot be achieved without referring to leadership commitment and faculty support in developing a quality program with continuous improvement elements.This skill-set is also an important consideration for academics.This effect is rather unique as the rate of medical errors is also associated with communication skills, but interpersonal and communication skills still result in effective information exchange and team building with patients, their families, and other health professionals (Makoul, 2003).This could be explained by two main issues.The first issue is related to the nature of the candidates as they normally graduate from a health school, and the second issue is related to the endeavors of the faculty to meet the program objectives based on the program objectives.
Enhancing the cognitive skills of the candidates is the major objective of any educational institution, particularly a graduate health program (Greenfield and Braithwaite, 2008;Hollin et al., 2008).As a result of competitive and accreditation demands, the utilization of rapid technology, the philosophy of education, and the growing knowledge transformation have had a profound effect on the students and faculty members, particularly the social media, whether as a result of national or international requirements (Otara, 2014).
As the results indicated no or minor relationships with several domains, such as course syllabus and self-learning, evidence shows that such domains have already become the major parts of the education process in the SA educational system (Al-Asmari, 2005;Bendania, 2011).Still, utilizing the AoL within the healthcare program context faces certain challenges.For example, results showed that competency and student engagement were not well affected by accreditation.Again, what is needed from the accreditation body is to ensure a shift toward an evolutionary effect on the student rather than the program, though accreditation is helpful tool to well performance (Almasabi and Thomas, 2016).However, this study did not identify any clue that competency was well addressed, based on the student experience.Institutional emphasis on research output rather than traditional academic values may increase the chasm while assessing the value of accreditation in health and business schools (Ryan and Guthrie, 2009).In response to this, some studies have proposed that several graduate schools may modify their practice and school mission based on overall educational strategy (Dawson, Burnett, and O'Donohue, 2006;Engebretsen, Heggen, and Eilertsen, 2012).Such principles are considered important in the field of academics, but how to increase its significance is still a major concern and may need further investigation.The opportunities for better learning outcome in the higher education sector still need to be thoroughly discussed from students' perspectives (Alonazi et al., 2016).

Conclusion
This paper presented the survey results obtained from cohort studies on quality assurance and learning outcomes, which were part of the MHHA program mission.The management of the health program periodically assessed the achievement of such a standard through qualitative and quantitative approaches, which addressed the question of what stakeholders expect from quality assurance in educational initiations in co nnection with learning outcome.This study defined the role that should be played by learning outcomes in external quality assurance and how they should be considered within the scope of external quality assurance.Finally, health policies may contribute to the assessment of the content of accreditation, particularly those related to program management and academic professional engagement

Limitations
Some of the limitations of this study included the limited sample, tailored survey design, and specific period of the data collection.Further research studies may focus on actual health college candidates rather than the program itself.The influence of accreditation on gender in the health education program should be further investigated.

Table 2 .
Dichotomy analysis of the respondents toward the influence of accreditation on the program A correlation analysis was conducted to investigate the relationships among the domains of AoL.Table4provides the Pearson correlation matrix among students' overall assimilation scale scores and the nine domain ratings.

Table 4 .
Pearson correlation matrix among the domains associated with AoL