Abstract
This article is the third 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. The 2008 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. The 2009 article described the regulations of the US Secretary of Education regarding “substantive changes” to an institution or its programs. This year, the authors further describe the COCA's regulations pertaining to continuous evaluation of accredited institutions and programs. The article concludes with a review of class sizes of the accredited colleges of osteopathic medicine.
The American Osteopathic Association (AOA) Commission on Osteopathic College Accreditation (COCA) is recognized by the US Secretary of Education as the only accrediting agency for colleges of osteopathic medicine (COMs), through which all predoctoral osteopathic medical education occurs.
To maintain its recognition, the COCA is required to adhere to all federal laws
1,2 and regulations
3,4 associated with accrediting agencies. For example, all accreditors must adhere to requirements for monitoring the institutions and programs that they accredit.
5
Therefore,
Accreditation of Colleges of Osteopathic Medicine: COM Accreditation Standards and Procedures6 includes policies and provisions that assess several components of COM performance during the periods between regularly scheduled comprehensive visits at 7-year intervals for fully accredited COMs. These visits occur annually for COMs with preaccreditation or provisional accreditation.
With the reorganization of T
he J
ournal's annual osteopathic medical education theme issue beginning in March 2008, the AOA's Department of Accreditation has prepared a series of articles to address one major area of the COCA that may be of interest to the profession and the many stakeholders in the accreditation process. In the March 2008 article
7, we focused on key changes in the accreditation process for COMs in the United States
6 and on the recent growth of new COMs. In the March 2009 article,
8 we addressed COCA procedures regarding “substantive changes” to institutional missions and programs—the chief example of such change currently being class-size increases. This year's article discusses the following procedural areas:
annual reports and related COM evaluation tools (eg, annual class size survey, progress reports, ad hoc reporting, and interim mission reports)
complaints
The complaint review process is emphasized in the present report because a complaint may be submitted by any stakeholder in the COM accreditation process, including students, faculty, and members of the public.
A related question, but not a complaint per se, is that pertaining to alleged conflict of interest within the COCA commissioners and staff. A detailed conflict of interest policy is available in the
Commission on Osteopathic College Accreditation: Handbook,
9 which is available on the COCA's Web site (
http://www.aoacoca.org).
The present article concludes with an update on COM growth.
Annual Reports
The COCA and the accrediting body before it have continually sought to minimize the burden of the annual reporting process. To do so, the COCA works closely with the annual reporting process of the American Association of Colleges of Osteopathic Medicine (AACOM) to minimize the duplication of data submission. As a result, AACOM shares its annual report with the COCA. However, information sharing between the two organizations is not all encompassing. For example, the COCA has no standards addressing the compensation of faculty and staff members of a COM; therefore, the COCA does not receive salary information from AACOM.
Similarly, in its role as an accreditor, the COCA needs information that is not part of the AACOM Annual Report. For this reason, there is a COCA supplemental narrative report that directly addresses accrediting information needs.
6 The information is organized into the following four domains:
Faculty resources—How does the COM determine that it has sufficient faculty?
Curriculum—How does the COM address core clinical competencies?
Clinical education—Define the clinical core rotations and any changes in the COMs clinical education sites.
Financial audit—A copy of the COM's or its parent institution's most recent audited financial statement is provided with their supplemental report.
Each of the COM annual and supplemental reports is reviewed by two COCA commissioners according to a prepared set of guidelines and evaluation instruments with two principle questions: (1) Is additional written information needed? and (2) Is a focused site visit necessary?
The reviewers' comments and their recommendations are reviewed by the entire COCA at its April/May meeting. After deliberation and decision, the COCA releases its findings to each individual COM. The number of COMs for which additional written information is required varies from year to year, typically between 20% and 40% of the COMs. The additional written information is received and reviewed by the entire COCA at its August/September meeting in the same calendar year.
Class Size Survey
An annual class size enrollment report form is sent to each COM every fall.
6 The class sizes are reviewed by the entire COCA at its December meeting. Findings of an excess of students beyond that allowed will be considered an unplanned class size increase.
6 As previously described,
8 COCA approval for unplanned class size increases applies to that matriculating class only.
Progress Reports
When the COCA determines that a standard for accreditation is not being met—usually on the basis of the findings from within a site visit report—a requirement is generated for a progress report to demonstrate compliance with a standard.
6
Progress reports, like annual reports, are reviewed by two COCA commissioners, who transmit their findings in writing to the entire COCA for deliberation and decision. A COM always has the right to have representatives present by telephone or in person to offer testimony in support of the COM's progress reports. Also, the COCA may invite specific representatives of a COM to be present at the consideration of a site visit report. Such an invitation would occur in the original accreditation action.
Beginning July 1, 2008, the COCA requires COMs to prepare an interim progress report on compliance with their mission. As noted in standard 1.1.1, This report is to occur with the Annual Report in the fourth year since the previous comprehensive site visit for review of accreditation status.
6 The purpose of the report is to provide a “mid-course” look at COM achievement and compliance with its current mission. It should be noted that a change in mission would constitute a substantive change and require review and approval by the COCA before implementation.
Ad Hoc Reports
The COCA is continually receiving information about the COMs. Based on credible information that is brought to the attention of the COCA between its regularly scheduled meetings, the COCA chair may direct the COCA staff to invite specific representatives of a COM to be present to address selected topics at the COCA's next regularly scheduled meeting. These types of discussions are considered ad hoc reports that may lead to request for further information, including a written report or focused site visit.
Complaints
The COCA understands it is responsible for providing complainants with a means to express their specific allegations against a COM as well as to provide a way to review and resolve allegations against the COCA or administrative staff. Therefore, the complaint procedures developed by the COCA are in place to ensure the continued compliance of the
Accreditation of Colleges of Osteopathic Medicine: COM Accreditation Standards and Procedures as they are associated with approved COMs. All accrediting agencies recognized by the US Secretary of Education are required to have a complaint resolution process.
10 The complaint procedures may be used by individuals, organizations, or other stakeholders as a means of bringing any areas of noncompliance with COCA accreditation standards to the attention of the accrediting agency. Such noncompliance issues may be evident in COM proceedings or programs. The complaint policies and procedures of the COCA, as outlined in the following paragraphs, are periodically reviewed by the US Department of Education.
Individuals or groups who file a complaint against a COM generally include osteopathic medical students, individuals or institutions affected by COM accreditation on either an academic or professional level, other members of the osteopathic community, and the public. The filing or acceptance of complaints, however, is not limited to any particular group.
A complaint about a COM must be in writing and signed by the complainant (or complainants) before it is submitted to the COCA assistant secretary. Complaints not in writing and not signed by a complainant will not be accepted. The complainant must address the concern regarding a COM's violation (or violations) of an accreditation standard or procedure. The complaint must be in narrative form and must be based on truthful and reliable information. Allegation of a COM standard or procedure violation must be supported with accurate information as well as documentation. In addition, the complainant must provide evidence regarding his or her attempts to resolve the violation through appropriate COM channels and how these attempts failed to resolve the problem.
After the written and signed complaint has been received by the COCA assistant secretary, copies of the complaint will be sent within 10 business days to the COM's chief executive officer (CEO) or chief academic officer (CAO) for the COM's response within 15 business days. The response is sent back to the COCA assistant secretary addressing the allegations made by the complainant. When the COM response is received, both the original complaint and the response from the COM are forwarded to the COCA chair for a decision. The COCA chair determines whether the complaint should be brought before the entire COCA or if an ad hoc subcommittee needs to be appointed to determine the merits of the complaint and whether further investigation is needed.
If the COCA or ad hoc subcommittee finds that the complaint does not have merit, the complainant and the COM will be notified in writing regarding this decision. If, however, it is determined that the complaint has merit, an investigation will be conducted. The timeframe for conclusion of this part of the process is 15 business days with written notification of the investigation to both the complainant and the COM.
A warranted investigation will initiate a formal review by the COCA assistant secretary, in cooperation with the AOA corporate council and the ad hoc subcommittee within 30 business days from the decision that the investigation is warranted. The appropriate method of review and manner of investigation are decided by the ad hoc subcommittee and are dependent on the type of complaint that has been received. Review and investigation could include further requests for information from both parties, interviews of the complainant and specific COM personnel, and an on-site visit to the COM.
Findings from the investigation are forwarded to the COCA for action at the next regularly scheduled meeting. The COCA may decide on either of the following actions as a result of these findings:
dismiss the complaint and report that the COM is in compliance with the accreditation standards
notify the COM in question that, on the basis of the investigation, the COCA has determined that the COM is failing to meet the accreditation standards
There are several methods of review that can be taken if the COM is found to be out of compliance with the accreditation standards as a result of the complaint investigation. The COM may be required to submit a report to the COCA with its plans to address the compliance deficiencies. In addition, a progress report documenting the COM's planning and implementation of the plans to meet the deficient standards may be required. Finally, if believed appropriate, an on-site visit may be recommended to decide whether the COM's accreditation status should be changed.
When a COM is found to be out of compliance with the standards by the COCA as a result of a complaint investigation, the COM must be notified in writing within 15 business days of that decision. As in any accreditation decision issued by the COCA, the COM can ask for a reconsideration of the decision or appeal the decision according to the written appeals procedures of the COCA.
6
Complaints may also be submitted by stakeholders, osteopathic medical students, academic professionals, the osteopathic community, and the public against the COCA or COCA administrative staff. These complaints, again, must be in writing and signed by the complainant before they can be received and reviewed. All complaints of this nature should be submitted to the COCA assistant secretary and will be presented by the COCA assistant secretary, in conjunction with the AOA corporate counsel, to the COCA chair, vice-chair, and secretary. When applicable, it will also be presented to the affected staff members. The COCA chair will appoint a subcommittee to initiate a formal review of the complaint and draft a response to the complainant. The reviewing and response process for the subcommittee must be completed and forwarded to the COCA within 30 business days of the date that the subcommittee is convened.
At the next regularly scheduled meeting of the COCA, the complaint and response will be considered. An invitation will be made to the complainant to appear before the COCA to present the complaint and to attempt to reach a resolution. The COCA's final action will be sent to the complainant within 30 days from the date that the complaint was heard by the COCA.
The COCA requires all COMs to keep a record of complaints made by students that relate to accreditation standards and procedures, including information on the investigation and resolution of these complaints. It is recommended by the COCA that a COM should utilize these complaints in their performance improvement process. The COCA standard 5.7 addresses this topic as follows
6:
The COM, and/or its parent institution, must publish policies and procedures regarding student complaints related to accreditation standards and procedures, and must maintain records of the receipt, adjudication, and resolution of such complaints.
Guideline: The COM should utilize student complaints in its ongoing performance improvement processes, as appropriate.
All complaints, as mentioned above, should be directed to the Assistant Secretary of the COCA, AOA, 142 E Ontario St, Chicago, IL 60611-2864. Complaints will only be accepted and reviewed if they are in writing and signed by the individual or individuals who are submitting the complaint. Questions about complaints may be directed to
predoc@osteopathic.org. Information about the COCA complaint procedures may also be found on the COCA Web site,
http://www.aoacoca.org.
Recent Changes to Approved Class Sizes
The COCA-approved class sizes for the past 10 academic years have steadily increased. During the 2000-2001 academic year, 19 COMs operating on 19 campuses were approved for 2813 matriculants. During the current 2009-2010 academic year, 4933 students were approved for the aggregate class sizes at 25 COMs, 3 branch campuses, and 3 additional locations for a total of 31 sites (
Table). The full names and locations of these COMs are provided in
Appendix 1 on pages 195-197.
Table
COCA-Approved Class Sizes by COM and Academic Year, 2000-2010
|
Academic Year†
| | | | | | | | | |
|---|
COM*
| 2000-2001
| 2001-2002
| 2002-2003
| 2003-2004
| 2004-2005
| 2005-2006
| 2006-2007
| 2007-2008
| 2008-2009
| 2009-2010
|
|---|
| ▪ ATSU/SOMA | NA | NA | NA | NA | NA | NA | NA | 100 | 100 | 100 |
| ▪ DMU-COM | 205 | 205 | 205 | 205 | 205 | 205 | 205 | 205 | 205 | 205 |
| ▪ KCOM | 140 | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 160 |
| ▪ KCUMB-COM | 220 | 220 | 220 | 220 | 220 | 250 | 250 | 250 | 250 | 250 |
| ▪ LECOM (LDP) | 144 | 144 | 144 | 144 | 144 | 144 | 144 | 180 | 180 | 180 |
| □ LECOM (PBLP) | NA | 40 | 40 | 40 | 40 | 40 | 40 | 40 | 40 | 40 |
| □ LECOM (Independent Study Program) | NA | 30 | 30 | 30 | 30 | 30 | 30 | 30 | 30 | 30 |
| □ LECOM-Bradenton† (PBLP) | NA | NA | NA | NA | 150 | 150 | 150 | 150 | 150 | 150 |
| □ LECOM-Seton Hill‡ | NA | NA | NA | NA | NA | NA | NA | NA | NA | 104§ |
| ▪ LMU-DCOM | NA | NA | NA | NA | NA | NA | NA | 150 | 150 | 150 |
| ▪ MSUCOM | 185 | 185 | 185 | 200 | 200 | 200 | 200 | 200 | 200 | 200 |
| □ MSUCOM-DMC‡ | NA | NA | NA | NA | NA | NA | NA | NA | NA | 50§ |
| □ MSUCOM-MUC‡ | NA | NA | NA | NA | NA | NA | NA | NA | NA | 50§ |
| ▪ MWU/AZCOM | 125 | 125 | 140 | 140 | 140 | 140 | 140 | 140 | 250 | 250 |
| ▪ MWU/CCOM | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 206§ |
| ▪ NSU-COM | 180 | 180 | 180 | 200 | 200 | 230 | 230 | 230 | 230 | 230 |
| ▪ NYCOM | 260 | 260 | 260 | 260 | 260 | 260 | 260 | 260 | 260 | 260 |
| □ NYCOM (Émigré Physicians Program) | 40 | 40 | 40 | 35 | 35 | 35 | 35 | 35 | 35 | 35 |
| ▪ OSU-COM | 88 | 88 | 88 | 88 | 88 | 88 | 88 | 88 | 88 | 97§ |
| ▪ OU-COM | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 140 | 140 |
| ▪ PCOM | 250 | 250 | 250 | 250 | 250 | 250 | 250 | 250 | 250 | 250 |
| □ GA-PCOM† | NA | NA | NA | NA | NA | 80 | 80 | 80 | 808 | 0 |
| ▪ PCSOM | 60 | 60 | 60 | 75 | 75 | 75 | 75 | 75 | 75 | 75 |
| ▪ PNWU-COM | NA | NA | NA | NA | NA | NA | NA | NA | 70 | 70 |
| ▪ RVUCOM | NA | NA | NA | NA | NA | NA | NA | NA | 150 | 150 |
| ▪ TouroCOM | NA | NA | NA | NA | NA | NA | NA | 125 | 125 | 125 |
| ▪ TUCOM-CA | 100 | 125 | 125 | 125 | 125 | 125 | 125 | 125 | 125 | 125 |
| □ TUNCOM† | NA | NA | NA | NA | 125 | 125 | 125 | 125 | 125 | 125 |
| ▪ UMDNJ-SOM | 75 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 150§ |
| ▪ UNECOM | 115 | 115 | 115 | 115 | 115 | 115 | 115 | 115 | 115 | 115 |
| ▪ UNTHSC/TCOM | 115 | 115 | 115 | 125 | 125 | 125 | 175 | 175 | 175 | 200§ |
| ▪ VCOM | NA | NA | NA | 150 | 150 | 150 | 150 | 150 | 175 | 175 |
| ▪ WesternU/COMP | 176 | 176 | 176 | 176 | 176 | 176 | 176 | 176 | 176 | 176 |
| □ WesternU/COMP (NWT) | NA | NA | NA | NA | 30 | 30 | 30 | 30 | 30 | 30 |
| ▪ WVSOM | 75 | 75 | 75 | 96 | 96 | 96 | 200 | 200 | 200 | 200 |
| ▪ Total | 2,813 | 2,953 | 2,968 | 3,194 | 3,499 | 3,639 | 3,793 | 4,204 | 4,599 | 4,933 |
| □ Change from previous year, No. (%) | 0 | 140 (5) | 15 (0.5) | 226 (7.6) | 305 (9.5) | 140 (4) | 154 (4.2) | 411 (10.8) | 395 (9.4) | 334 (7.3) |
Table
COCA-Approved Class Sizes by COM and Academic Year, 2000-2010
|
Academic Year†
| | | | | | | | | |
|---|
COM*
| 2000-2001
| 2001-2002
| 2002-2003
| 2003-2004
| 2004-2005
| 2005-2006
| 2006-2007
| 2007-2008
| 2008-2009
| 2009-2010
|
|---|
| ▪ ATSU/SOMA | NA | NA | NA | NA | NA | NA | NA | 100 | 100 | 100 |
| ▪ DMU-COM | 205 | 205 | 205 | 205 | 205 | 205 | 205 | 205 | 205 | 205 |
| ▪ KCOM | 140 | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 160 |
| ▪ KCUMB-COM | 220 | 220 | 220 | 220 | 220 | 250 | 250 | 250 | 250 | 250 |
| ▪ LECOM (LDP) | 144 | 144 | 144 | 144 | 144 | 144 | 144 | 180 | 180 | 180 |
| □ LECOM (PBLP) | NA | 40 | 40 | 40 | 40 | 40 | 40 | 40 | 40 | 40 |
| □ LECOM (Independent Study Program) | NA | 30 | 30 | 30 | 30 | 30 | 30 | 30 | 30 | 30 |
| □ LECOM-Bradenton† (PBLP) | NA | NA | NA | NA | 150 | 150 | 150 | 150 | 150 | 150 |
| □ LECOM-Seton Hill‡ | NA | NA | NA | NA | NA | NA | NA | NA | NA | 104§ |
| ▪ LMU-DCOM | NA | NA | NA | NA | NA | NA | NA | 150 | 150 | 150 |
| ▪ MSUCOM | 185 | 185 | 185 | 200 | 200 | 200 | 200 | 200 | 200 | 200 |
| □ MSUCOM-DMC‡ | NA | NA | NA | NA | NA | NA | NA | NA | NA | 50§ |
| □ MSUCOM-MUC‡ | NA | NA | NA | NA | NA | NA | NA | NA | NA | 50§ |
| ▪ MWU/AZCOM | 125 | 125 | 140 | 140 | 140 | 140 | 140 | 140 | 250 | 250 |
| ▪ MWU/CCOM | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 160 | 206§ |
| ▪ NSU-COM | 180 | 180 | 180 | 200 | 200 | 230 | 230 | 230 | 230 | 230 |
| ▪ NYCOM | 260 | 260 | 260 | 260 | 260 | 260 | 260 | 260 | 260 | 260 |
| □ NYCOM (Émigré Physicians Program) | 40 | 40 | 40 | 35 | 35 | 35 | 35 | 35 | 35 | 35 |
| ▪ OSU-COM | 88 | 88 | 88 | 88 | 88 | 88 | 88 | 88 | 88 | 97§ |
| ▪ OU-COM | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 140 | 140 |
| ▪ PCOM | 250 | 250 | 250 | 250 | 250 | 250 | 250 | 250 | 250 | 250 |
| □ GA-PCOM† | NA | NA | NA | NA | NA | 80 | 80 | 80 | 808 | 0 |
| ▪ PCSOM | 60 | 60 | 60 | 75 | 75 | 75 | 75 | 75 | 75 | 75 |
| ▪ PNWU-COM | NA | NA | NA | NA | NA | NA | NA | NA | 70 | 70 |
| ▪ RVUCOM | NA | NA | NA | NA | NA | NA | NA | NA | 150 | 150 |
| ▪ TouroCOM | NA | NA | NA | NA | NA | NA | NA | 125 | 125 | 125 |
| ▪ TUCOM-CA | 100 | 125 | 125 | 125 | 125 | 125 | 125 | 125 | 125 | 125 |
| □ TUNCOM† | NA | NA | NA | NA | 125 | 125 | 125 | 125 | 125 | 125 |
| ▪ UMDNJ-SOM | 75 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 150§ |
| ▪ UNECOM | 115 | 115 | 115 | 115 | 115 | 115 | 115 | 115 | 115 | 115 |
| ▪ UNTHSC/TCOM | 115 | 115 | 115 | 125 | 125 | 125 | 175 | 175 | 175 | 200§ |
| ▪ VCOM | NA | NA | NA | 150 | 150 | 150 | 150 | 150 | 175 | 175 |
| ▪ WesternU/COMP | 176 | 176 | 176 | 176 | 176 | 176 | 176 | 176 | 176 | 176 |
| □ WesternU/COMP (NWT) | NA | NA | NA | NA | 30 | 30 | 30 | 30 | 30 | 30 |
| ▪ WVSOM | 75 | 75 | 75 | 96 | 96 | 96 | 200 | 200 | 200 | 200 |
| ▪ Total | 2,813 | 2,953 | 2,968 | 3,194 | 3,499 | 3,639 | 3,793 | 4,204 | 4,599 | 4,933 |
| □ Change from previous year, No. (%) | 0 | 140 (5) | 15 (0.5) | 226 (7.6) | 305 (9.5) | 140 (4) | 154 (4.2) | 411 (10.8) | 395 (9.4) | 334 (7.3) |
×
The aggregate number of approved class sizes increased by 2120 students over the academic years 2000-2001 through 2009-2010, inclusive, for a 75.4% increase.
The larger fraction of this aggregate 2120-student increase—1375 students (64.9%)—was the result of formal class size increases granted by the COCA to 14 COMs. These class size increases corresponded to the development of new program tracks, 3 branch campuses, and 3 additional locations. The remaining fraction of the aggregate 2120-student increase—745 students (35.1%)—is accounted for by the addition of 6 new COMs.
During the 10-year period under discussion, 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 students.
In the current academic year, a total of 334 new students were added to the approved class sizes at 4 COMS and 3 additional COM locations, as follows:
104 (31.1%)—Lake Erie College of Osteopathic Medicine-Seton Hill (additional location) in Greensburg, Pennsylvania
50 (15.0%)—Michigan State University College of Osteopathic Medicine Detroit Medical Center (additional location) in Detroit
50 (15.0%)—Michigan State University College of Osteopathic Medicine Macomb University Center (additional location) in Macomb County
46 (13.8%)—Midwestern University Chicago College of Osteopathic Medicine in Downers Grove, Illinois
9 (2.7%)—Oklahoma State University College of Osteopathic Medicine in Tulsa
50 (15.0%)—University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine in Stratford
25 (7.5%)—University of North Texas Health Science Center—Texas College of Osteopathic Medicine in Fort Worth
These increases, which are also noted in the
Table, resulted in a 7.3% class size increase compared to the 2008-2009 academic year's total of 4599 students.
Conclusion
Although accreditation agencies rely on on-site evaluation as the “gold standard” for making decisions about recognition—whether initial award, continuing award, reduction in status, or withdrawal of status—assurance of continued compliance with accreditation standards also requires a systematic ongoing review with written reporting and opportunity for stakeholder input.
Higher Education Act of 1965, 20 USC §1001 (1965).
Higher Education Opportunity Act, Pub L No. 110-315, 122 Stat 3078. To be codified at 20 USC §1001.
The Secretary's Recognition of Accrediting Agencies; Final Rule. Fed Regist. 1999;64(122):34465-34485. Codified at 34 CFR §602.
Institutional eligibility under the Higher Education Act of 1965, as amended, and the Secretary's Recognition of accrediting agencies. Fed Regist. 2009;74(206):55414-55435. To be codified at 34 CFR §602.
Monitoring and reevaluation of accredited institutions and programs. Fed Regist. 1999;64(202):56611-56626. Codified at 34 CFR §602.24.
Williams A, Miskowicz-Retz KC. Evolution of colleges of osteopathic medicine: a discussion of the COCA's “substantive change” policies.
J Am Osteopath Assoc. 2009;109(3):128-134.
http://www.jaoa.org/cgi/content/full/109/3/128. Accessed March 3, 2010, 2009.
Operating procedures all agencies must have. Fed Regist. 1999;64 (202): 56611-56626. Codified at 34 CFR §602.23(c).