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AOA Communication  |   March 2009
Evolution of Colleges of Osteopathic Medicine: A Discussion of the COCA's “Substantive Change” Policies
Author Notes
  • From the American Osteopathic Association's Department of Accreditation. 
  • Address correspondence to Konrad C. Miskowicz-Retz, PhD, CAE, Department of Accreditation, American Osteopathic Association, 142 E Ontario St, Chicago, IL 60611-2864. E-mail: kretz@ostopathic.org 
Article Information
AOA Communication   |   March 2009
Evolution of Colleges of Osteopathic Medicine: A Discussion of the COCA's “Substantive Change” Policies
The Journal of the American Osteopathic Association, March 2009, Vol. 109, 128-134. doi:10.7556/jaoa.2009.109.3.128
The Journal of the American Osteopathic Association, March 2009, Vol. 109, 128-134. doi:10.7556/jaoa.2009.109.3.128
Abstract

This article is the second in a series of discussions on the major activities of the American Osteopathic Association's Commission on Osteopathic College Accreditation (COCA), which is recognized by the US Secretary of Education as the only accrediting agency for predoctoral osteopathic medical education in the United States. Last year's article outlined the process that an educational institution undergoes to obtain accreditation status from the COCA and addressed the expansion of approved class sizes at the nation's colleges of osteopathic medicine. This year, the authors further describe US federal administrative regulations regarding “substantive changes” to institutional mission and programs. Class-size increases osteopathic medical schools, the most common form of substantive change requiring COCA approval, are once again detailed.

As of last March, the American Osteopathic Association's (AOA) Department of Accreditation1 has begun using the occasion provided by the The Journal's annual osteopathic medical education theme issue to address one topic that falls within its purview that may be of interest to the profession. In last year's article,1 we focused on key changes in the accreditation process for colleges of osteopathic medicine (COMs) in the United States and on the recent growth of new COMs. In the present article, we elaborate further on US federal administrative regulations regarding “substantive changes” to institutional mission and programs—the chief example of such change currently being class-size increases. 
Substantive Change
The Commission on Osteopathic College Accreditation (COCA) is recognized by the US Secretary of Education as the only accrediting agency for predoctoral osteopathic medical education. 
To maintain its recognition with the US Secretary of Education, the Commission is required to adhere to all federal laws2,3 and regulations4,5 associated with recognition of accrediting agencies. Included in these laws and regulations are specifications regarding “required operating policies and procedures” that mandate maintenance of an “adequate substantive change policy,” defined as one that: 

...ensure[s] that any substantive change to the educational mission, program, or programs of an institution after the agency has accredited or preaccredited the institution does not adversely affect the capacity of the institution to continue to meet the [accrediting] agency's standards.4

 
Therefore, Accreditation of Colleges of Osteopathic Medicine: COM Accreditation Standards and Procedures6 includes policies and provisions that require COMs to obtain COCA approval before implementing any of the following “substantive changes”: 
  • changes in the established mission or objectives of the institution
  • change of location
  • changes in the legal status or governance of the institution
  • modification of instruction (ie, content or delivery) that represents a significant departure from the curriculum reviewed at the last onsite evaluation
  • change from clock hours to credit hours or vice versa
  • substantial increase or decrease in the number of hours required to complete curriculum
  • establishment of an additional location that is geographically separate from the main campus
  • increase in class size
  • establishment of a branch campus
When planning such modifications, COMs must notify the Commission in writing at least 120 days before the date of implementation so that the proposal can be reviewed at the next regularly scheduled COCA meeting.6 
Meeting dates are posted online (http://www.aoacoca.org). Upcoming meeting dates scheduled for the current calendar year are as follows: 
  • Saturday, May 2, through Sunday, May 3
  • Saturday, September 12, through Sunday, September 13
  • Saturday, December 5, through Sunday, December 6
The Commission must receive notification of all substantive change requests at least 60 days before the COCA meeting during which the request will be reviewed.6 In addition, all documentation and materials in support of the substantive change must be submitted to the Commission at least 30 days before the date of the regularly scheduled COCA meeting.6 
Educational Mission or Objectives
Colleges of osteopathic medicine that propose changes in an established educational mission or their objectives must provide documentation to the COCA that addresses the following factors: 
  • rationale for the change
  • anticipated effect the change will have on learning outcome assessments, facilities, faculty, admissions policies and procedures, and curriculum
  • confirmation of review and approval by the COM's governing body
  • documentation that the proposed change has been formally announced to stakeholders (ie, students, faculty, staff, alumni, public)6
If the Commission approves the institution's request for a substantive change in educational mission or objectives, monitoring of the approved change by the COCA is accomplished through progress reports in year 2 and year 4 of the change. These two progress reports will address any changes that have been observed with regard to the following elements, further described in COM Accreditation Standards and Procedures,6 as a result of the new mission or objectives: 
  • learning outcome assessment measures (Standard 1.3)
  • facility modifications (Standard 3.1)
  • faculty changes (Standard 4.1)
  • adjustments in admissions policies and procedures (Standard 5.1)
  • curriculum alterations (Standard 6.1)
The two progress reports will be reviewed by the COCA to determine whether these standards have been met and whether the COM is still in compliance with the guidelines specified in COM Accreditation Standards and Procedures.6 
Location
If a COM intends to change location and move to a new jurisdiction, that institution must provide the COCA with the appropriate charters, licenses, or approvals required to operate in the proposed location. 
For new or remodeled facilities, the COM must submit building or remodeling plans, budgets for initiating and completing the project—including estimated costs for moving and related expenses—and a timeline for project completion. 
In addition, evidence of review and approval by the COM's governing body is required with the documentation submitted to the COCA. 
The Commission requires monitoring in the form of an onsite visit to the new location “as soon as practicable,” but no later than 6 months before the move. In addition, a second onsite visit will be scheduled in year 2 of the move to evaluate institutional compliance with maintaining “adequate” provision in the following areas, as specified in COM Accreditation Standards and Procedures6: 
  • financial resources (Standard 2.3)
  • facilities (Standard 3)
  • faculty (Standard 4.1)
Legal Status and Governance
A change to a COM's legal status or form of control or ownership requires a substantive change request with documentation that demonstrates the institution's governing body has reviewed and approved the proposed change. 
New or amended articles of incorporation must be submitted to the COCA along with revised bylaws, administrative and organizational charts, and evidence that a formal announcement of the proposed changes has been issued to stakeholders. 
If the substantive change is approved, the Commission will initiate monitoring efforts in the form of an onsite visit to be conducted as soon as practicable, but no later than 6 months after the approved change, to review the following items outlined in COM Accreditation Standards and Procedures6: 
  • bylaws (Standard 2.1)
  • administrative and organizational structure vis-à-vis authority (Standard 2.1.1)
  • established policy regarding conflict of interest, due process, disclosure, nondiscrimination, confidentiality of records, and fiscal accountability, among other documents (Standard 2.1.2)
  • all necessary provisions as required by applicable law and regulations (Standard 2.1.3)
If these requirements are met during the onsite visit, no further monitoring is required by the Commission. 
Curriculum
Changes to curriculum that represent significant content differences or modified methods of delivery from the curriculum offered during the COCA's most recent onsite review are considered substantive changes and must be presented to the Commission for approval. 
The following documentation is required when a COM requests the approval of COCA for substantive curriculum changes: 
  • description of the curriculum change
  • analysis of additional resources (eg, financial, facilities, faculty) needed as a result of the change
  • curriculum committee discussion and approval
  • faculty governance discussion and approval
  • discussion and approval of the COM's governing body
If the COM is granted COCA approval for the curriculum change, for the next 4 years an annual progress report must be submitted by the school to the Commission to assist in monitoring efforts. Progress reports are expected beginning 1 year postimplementation and will include an analysis of the curriculum changes, noting positive and negative aspects. Likewise, these reports will address the financial, facility, and faculty resources affected by the curriculum change. Finally, data relating to student achievement will also be recorded in the annual progress reports. 
Lake Erie College of Osteopathic Medicine in Erie, Pa, received approval from the COCA for substantive change to curriculum in 1999. Readers may wish to review a description of these changes in the October 2007 issue of JAOA—The Journal of the American Osteopathic Association.7 
Educational Units or Length of Instruction
Colleges of osteopathic medicine that wish to change educational units from clock hours to credit hours or vice versa must provide detailed information to the Commission regarding their rationale for making this change. If the change is approved, no further monitoring is required by the COCA. 
However, any adjustment to curriculum length—whether an increase or decrease—must be approved by the COCA and requires ongoing monitoring. 
Detailed information regarding curriculum modifications with an analysis of resources needed (financial, facilities, and faculty) for implementation must be provided to the COCA for approval. Evidence of discussion and approval by the institution's curriculum committee as well as faculty and COM governing bodies must also be submitted. 
As noted, monitoring is required for curriculum length adjustments. An annual progress report must be submitted for 4 years postimplementation. Progress reports should include an analysis of the positive and negative results of the change, detailing the impact to financial, facility, and faculty resources as well as student achievement. 
Additional Location
The addition of a location that is “geographically apart” from the COM's main campus and offers at least 50% of an educational program to students is also considered a substantive change.6 
Unlike a branch campus, an additional location is defined primarily by the fact that it shares administrative and financial resources with the main campus—regardless of admissions processes that may matriculate new students directly to the new facility. Likewise, for institutions that have additional locations, currently enrolled students may have the option of selecting classes at the new location; this is not necessarily the case for students at branch campuses. 
The osteopathic medical school and its parent institution must not have accreditation with warning, accreditation with probation, or be subject to a show cause determination that could alter accreditation status from the COCA or the regional accreditor before requesting a substantive change for an additional location. 
To establish an additional location, a COM must notify the Commission in writing of its intent at least 18 months before the date it intends to begin offering instruction. In addition, the college must conduct and submit a feasibility study that addresses the following factors: 
  • An assessment of and documentation demonstrating support for the additional location from the community, county, and state, as well as relevant osteopathic professional associations—including a letter of comment from the state osteopathic association for each state in which the intended additional location will have clinical training sites.
  • Documentation with written verification regarding the availability of adequate clinical training sites. This documentation should include an assessment of the impact of the additional location's clinical sites on other, preexisting osteopathic training programs.
  • An evaluation of the ability of the parent COM to ensure a student recruitment and enrollment process that attracts and maintains “a qualified applicant pool,” as required by Standard 5.
  • A list of the faculty members who will provide instruction at the additional location.
  • A summary of projected revenues, expenditures, and cash flow.
  • A description of the operation, management, and physical resources that will be available at the additional location.
If the COM or its parent has regional accreditation from an agency recognized by the US Secretary of Education, a letter of approval for the additional location from the regional accreditor must be included with the substantive change request. 
An onsite focused COCA visit must be conducted 6 months before student recruitment at the additional location. The additional location can neither recruit students nor begin operations, including offering instruction, until it obtains the Commission's approval (ie, after the first onsite visit). 
In addition, an onsite focused visit will be conducted within 6 months after operations have begun to determine whether the financial, facility, and faculty resources are appropriate for the additional location.6 
The accreditation status of the parent COM will be extended to the additional location only after the second site visit to all sites and the site visit report is accepted by the COCA. Thereafter, when the parent COM has an onsite accreditation visit scheduled, the additional location will also undergo an onsite visit. 
Class Size Increases
A COM cannot admit additional students beyond its approved class size (Table). Planned class size increases are considered a substantive change. Institutions seeking a permanent class size increase must obtain COCA approval, as must schools seeking a one-time increase. Unplanned class size increases that are the result of admitting more students than a COM's approved class size must be reviewed by the Commission on a case-by-case basis. 
Table
American Osteopathic Association Commission on Osteopathic College Accreditation: Approved Class Sizes for US Colleges of Osteopathic Medicine, Academic Years 1999-2000 Through 2008-2009
 American Osteopathic Association Commission on Osteopathic College Accreditation: Approved Class Sizes for US Colleges of Osteopathic Medicine, Academic Years 1999-2000 Through 2008-2009
Table
American Osteopathic Association Commission on Osteopathic College Accreditation: Approved Class Sizes for US Colleges of Osteopathic Medicine, Academic Years 1999-2000 Through 2008-2009
 American Osteopathic Association Commission on Osteopathic College Accreditation: Approved Class Sizes for US Colleges of Osteopathic Medicine, Academic Years 1999-2000 Through 2008-2009 ×
Planned Class Size Increases—For the COCA to consider a request for a planned class size increase, a COM must submit information for review by the Commission demonstrating that the college has adequate faculty levels to manage the additional students. A full explanation of how this assessment was reached is also required. 
The COM must also demonstrate that its finances are adequate to meet its stated mission and objectives with the increased number of students. 
In addition, the COM must demonstrate that it has sufficient classroom and laboratory space to accommodate additional students and that the library and study space available will likewise meet their needs. 
An adequate number of year 3 and year 4 clinical rotation slots must also be secured for the additional students. The COM must also demonstrate planning and progress in generating additional postdoctoral clinical training slots for an increased number of graduates. 
Monitoring for an approved class size increase requires a single onsite focused COCA visit during the first year of implementation and annual progress reports for the next 3 years (ie, years 2-4). These reports should evaluate institutional compliance with maintaining adequate provision in the following areas, as specified in COM Accreditation Standards and Procedures6: 
  • financial resources (Standard 2.3)
  • facilities (Standard 3)
  • faculty (Standard 4.1)
Unplanned Class Size Increases—As previously noted, an unplanned class size increase must also be approved by the COCA. An unplanned class size increase occurs when there is a matriculation rate in excess of 8% of the approved class size of a COM (ie, more than “permitted variance”). 
Colleges with a matriculation rate in excess of this permitted variance will not be allowed to request a planned class size increase for 3 years. 
In addition, the COCA reserves the right to review the accreditation status of any institution that (1) exceeds its approved class size for 2 consecutive years, or (2) knowingly misrepresents its class size to the Commission. In such instances, the COCA reserves the right to implement appropriate remedial measures, including reduction or withdrawal of accreditation. 
To allow on-time graduation for students, COMs are permitted to request a class size increase for 3 years after the initial report and request for approval is submitted to the Commission. Once COCA approval is granted for an unplanned class size increase, the COM has approval for a class-size increase for that matriculating class only. The COM can admit only the approved number of students for subsequent matriculating classes. 
Postapproval monitoring of unplanned class size increases requires at least two onsite focused COCA visits, with the first such visit occurring in year 1 and the second in year 3. As is the case for planned class size increases, both onsite visits for unplanned increases are undertaken with the goal of assessing the adequacy of financial resources (Standard 2.3), facilities (Standard 3), and faculty (Standard 4.1).6 
In addition, four annual progress reports are expected and should address these same three basic requirements, as outlined in COM Accreditation Standards and Procedures.6 In the years when an onsite visit is planned for monitoring purposes (ie, year 1 and year 3), the written annual progress report is due 60 days before the scheduled COCA visit. 
Branch Campus
The addition of a branch campus is considered a substantive change. A free-standing COM with accreditation status from the Commission as its institutional accreditor may seek COCA approval for a branch campus. Alternatively, a COM that has received programmatic accreditation from the COCA can submit an application for new a COM or for an additional location; it cannot seek Commission approval to establish a branch campus. 
To establish a branch campus, the COM must submit written notification to the Commission at least 18 months prior to the date that instruction is planned to begin. All the feasibility study materials required when a COM seeks COCA approval for establishing an additional location (see page 130) are required for creating a branch campus—beginning with approval from the relevant state agencies, a charter, and evidence of support for approval to grant the degree of Doctor of Osteopathy (DO) or Doctor of Osteopathic Medicine (DOM).6 The administrative and organizational charts, however, must clearly illustrate the relationship between the parent COM and the proposed branch campus. 
The standards from COM Accreditation Standards and Procedures6 used at the parent campus will be applied to the branch campus with regard to faculty, staff, facilities, student services, curriculum, and research. 
Figure.
The authors outline the variety of substantive changes made by colleges of osteopathic medicine (COMs) that require approval from the American Osteopathic Association's Commission on Osteopathic College Accreditation (COCA) before implementation: changes in the established mission, objectives, or location of the institution; changes in the legal status or governance of the COM; significant modification of instruction representing a significant departure from the curriculum reviewed at the last onsite evaluation; change from clock hours to credit hours or vice versa; a substantial increase of the number of hours awarded for completion of the curriculum; substantial increases or decreases in the length of the curriculum; establishment of an additional location that is geographically separate from the main campus; increase in class size; and establishment of a branch campus. Between January 2004 and December 2008, the COCA received 42 requests for substantive change from 16 different COMs. During this time, no substantive change requests were submitted to the COCA regarding major modifications to institutional mission or objectives. Likewise, no requests were filed by COMs regarding substantive changes to credit units or length of instruction.
Figure.
The authors outline the variety of substantive changes made by colleges of osteopathic medicine (COMs) that require approval from the American Osteopathic Association's Commission on Osteopathic College Accreditation (COCA) before implementation: changes in the established mission, objectives, or location of the institution; changes in the legal status or governance of the COM; significant modification of instruction representing a significant departure from the curriculum reviewed at the last onsite evaluation; change from clock hours to credit hours or vice versa; a substantial increase of the number of hours awarded for completion of the curriculum; substantial increases or decreases in the length of the curriculum; establishment of an additional location that is geographically separate from the main campus; increase in class size; and establishment of a branch campus. Between January 2004 and December 2008, the COCA received 42 requests for substantive change from 16 different COMs. During this time, no substantive change requests were submitted to the COCA regarding major modifications to institutional mission or objectives. Likewise, no requests were filed by COMs regarding substantive changes to credit units or length of instruction.
At least 6 months prior to the start of instruction at the branch campus, an onsite evaluation visit will be conducted to guarantee compliance with all relevant accreditation requirements.6 The branch campus cannot recruit students or begin operations—including offering instruction—until the site visit report is accepted and approved by the COCA. 
Unless directed by the Commission, no additional monitoring is required for new branch campuses. Once the COCA determines that the branch campus meets all of the guidelines specified in COM Accreditation Standards and Procedures,6 it is included in the parent institution's accreditation and will undergo regular onsite accreditation visits on the same schedule as its parent institution. 
Recent Substantive Change Activity
Between January 2004 and December 2008, the COCA has received 42 requests for substantive change made by 16 different COMs (Figure). Thirty-five (83%) of the requests for substantive change have been approved, 6 (14%) have been denied, and 1 (2%) has been deferred until additional information requested by the COCA has been submitted. 
Although planned class size increases have been the most frequent substantive change requested (25 [60%]), 5 requests for unplanned class size increases (12%) have been received during this 4-year timeframe making it the second most popular kind of substantive change request received, tied with curriculum changes (5 [12%]). Four substantive change requests for curriculum modifications have been approved by the COCA; one was denied. 
This 4-year period has also seen 3 requests for additional locations (7%) submitted to and approved by the COCA, with the same number of requests for branch campuses (3 [7%]) submitted and approved. 
One substantive change request (2%) for COM governance has also been submitted and approved during this time. 
Recent Changes to Approved Class Sizes
A list of COCA-approved class sizes for the past 10 academic years demonstrates a steady increase. During the 1999-2000 academic year, 19 COMs operating on 19 campuses received 2813 matriculants. During the current academic year, 4599 new students were received at 25 COMs, 3 of which have a branch campus making a total of 28 campuses (Table). 
This 1786-student (64%) increase since the 1999-2000 academic year total of 2813 is, in large part, accounted for by the addition of 6 new COMs and their combined 745 students (42%). 
The remaining 1041 students (58%) of the 1786-student increase were the result of formal class size increases granted by the COCA to 14 COMs. These class size increases include the development of new program tracks and 3 branch campuses. 
During the 10-year period under investigation, the net increase in approved positions ranged from 0 in the 2000-2001 academic year to 411 in the 2007-2008 academic year—a 10.8% increase compared to the 2006-2007 academic year's total of 3793. 
In the current academic year, a total of 175 new students were added to the matriculating class at 3 schools (Table) for a 8.6% increase compared to the 2007-2008 academic year's total of 4204 students: 
  • 110 (63%) — Midwestern University/Arizona College of Osteopathic Medicine in Glendale
  • 40 (23%) — Ohio University College of Osteopathic Medicine in Athens
  • 25 (14%) — Edward Via Virginia College of Osteopathic Medicine in Blacksburg
Conclusion
Because growth and change are commonplace in US medical education, a primary role for accrediting agencies such as the COCA is to ensure that the necessary evolution complies with existing standards and procedures for accreditation and that the osteopathic medical profession, their patients, and the wider public will be kept well informed. 
Miskowicz-Retz KC, Williams A. New colleges of osteopathic medicine: steps in achieving accreditation. J Am Osteopath Assoc. 2008;108:121-125. Available at: http://www.jaoa.org/cgi/content/full/108/3/121. Accessed March 5, 2009.
Higher Education Opportunity Act, Pub L No. 110-315, 122 Stat 3078.
Higher Education Act of 1965, 20 USC §1001 (1965).
Substantive change. Fed Regist. 1999;64(122):34465-34485. To be codified at 34 CFR §602.22.
Additional procedures certain institutional accreditors must have. Fed Regist. 1999;64(202):56611-56626. To be codified at 34 CFR §602.24.
Commission on Osteopathic College Accreditation. Accreditation of Colleges of Osteopathic Medicine: COM Accreditation Standards and Procedures. Chicago, Ill: American Osteopathic Association; 2008. Available at: https://www.do-online.org/pdf/SB03-Standards%20of%20Accreditation%20July%202008.pdf. Accessed March 5, 2009.
Ferretti SM, Krueger WA, Gabel LL, Curry JJ. Lake Erie College of Osteopathic Medicine's preclinical problem-based learning pathway program: an alternative medical school curriculum design. J Am Osteopath Assoc. 2007;107:443-449. Available at: http://www.jaoa.org/cgi/content/full/107/10/443. Accessed March 5, 2009.
Figure.
The authors outline the variety of substantive changes made by colleges of osteopathic medicine (COMs) that require approval from the American Osteopathic Association's Commission on Osteopathic College Accreditation (COCA) before implementation: changes in the established mission, objectives, or location of the institution; changes in the legal status or governance of the COM; significant modification of instruction representing a significant departure from the curriculum reviewed at the last onsite evaluation; change from clock hours to credit hours or vice versa; a substantial increase of the number of hours awarded for completion of the curriculum; substantial increases or decreases in the length of the curriculum; establishment of an additional location that is geographically separate from the main campus; increase in class size; and establishment of a branch campus. Between January 2004 and December 2008, the COCA received 42 requests for substantive change from 16 different COMs. During this time, no substantive change requests were submitted to the COCA regarding major modifications to institutional mission or objectives. Likewise, no requests were filed by COMs regarding substantive changes to credit units or length of instruction.
Figure.
The authors outline the variety of substantive changes made by colleges of osteopathic medicine (COMs) that require approval from the American Osteopathic Association's Commission on Osteopathic College Accreditation (COCA) before implementation: changes in the established mission, objectives, or location of the institution; changes in the legal status or governance of the COM; significant modification of instruction representing a significant departure from the curriculum reviewed at the last onsite evaluation; change from clock hours to credit hours or vice versa; a substantial increase of the number of hours awarded for completion of the curriculum; substantial increases or decreases in the length of the curriculum; establishment of an additional location that is geographically separate from the main campus; increase in class size; and establishment of a branch campus. Between January 2004 and December 2008, the COCA received 42 requests for substantive change from 16 different COMs. During this time, no substantive change requests were submitted to the COCA regarding major modifications to institutional mission or objectives. Likewise, no requests were filed by COMs regarding substantive changes to credit units or length of instruction.
Table
American Osteopathic Association Commission on Osteopathic College Accreditation: Approved Class Sizes for US Colleges of Osteopathic Medicine, Academic Years 1999-2000 Through 2008-2009
 American Osteopathic Association Commission on Osteopathic College Accreditation: Approved Class Sizes for US Colleges of Osteopathic Medicine, Academic Years 1999-2000 Through 2008-2009
Table
American Osteopathic Association Commission on Osteopathic College Accreditation: Approved Class Sizes for US Colleges of Osteopathic Medicine, Academic Years 1999-2000 Through 2008-2009
 American Osteopathic Association Commission on Osteopathic College Accreditation: Approved Class Sizes for US Colleges of Osteopathic Medicine, Academic Years 1999-2000 Through 2008-2009 ×