Regardless of whether a COM's physical location is a new entity or a component of an existing entity (ie, a branch campus or an additional location), common principles apply. The first broad group of common principles is regulatory. For a new COM, the entity must show that it can legally conduct business (ie, that it is registered with the appropriate state authority as a corporation). This status is usually acquired through the secretary of state. The new COM must also show that it has the necessary certificates or licenses from that state's higher education authority to operate as an institution offering doctorate-level education. The location of this authority within the government varies from state to state.¹² Finally, at the municipal level, the COM must obtain appropriate permits, from constructing buildings to obtaining a certificate of occupancy, before it may proceed with new construction or remodeling to provide instruction for students. 

The second broad group of common principles deals with accreditation and accounts for the bulk of the AOA COCA accreditation requirements. The elements that most stakeholders are familiar with are sometimes referred to as the "3 Fs"—finances, facilities, and faculty. In addition to these better-known domains, domains for mission, student services, research, and graduate medical education (GME) outcomes comprise the 8 standard domains to which all COMs, additional locations, and branch campuses must adhere. Of these, the domain for GME outcomes is the newest, having been added in the July 2013 revision of The Standards.¹¹ 

It is important for any type of developing educational program to demonstrate the presence of resources and expectation of continuing to have those resources. However, current accreditation standards focus much more on the assessment of educational outcomes. Regardless of the type of entity, a new COM is expected to demonstrate planning and progress in establishing its clinical education resources, both at the predoctoral and postdoctoral level. 

The accreditation of a COM is viewed by the AOA COCA as an orderly process that begins with applicant status and ends with accreditation status, the highest level of accreditation that can be awarded by the AOA COCA. The development of a new COM is a deliberate process in which the evaluation elements increase along with correspondingly greater privileges. This process can be achieved in a minimum of 5 years. The AOA COCA believes that 5 years is the shortest possible period necessary for the development of a new COM and will not waive this timeline to speed up the process. The AOA COCA cautions developing COMs about business risks associated with new COM development and urges new COMs to factor in these risks when planning their development timelines. 

The initial stage of accreditation is applicant status, which is offered without any rights or privileges of accreditation. It does not initiate or indicate recognition by the AOA COCA. Applicant status is given to an entity attempting to establish a new COM when a formal request, usually by letter, from the entity's chief executive officer is received in the AOA COCA office. This letter will typically provide information about the location of the new COM; affiliation with a college, university, or health care institution, if pertinent; and the administrative staff that has been appointed or hired to guide the COM through the accreditation process and the opening of the COM. Information for new COMs is available on the AOA COCA website, www.aoacoca.org, under "Accreditation Services" and "For New and Developing COMs." Information can also be found in The Standards in "Chapter II: Applicant and Accreditation Procedures,"^11(p30) "Chapter VIII: Glossary,"^11(p81) and "Chapter IX: Tables."^11(p88) 

The AOA COCA replies to the request for applicant status by sending a letter to the new COM acknowledging receipt of its request, as well as by providing some information to the applicant COM about the next step in the accreditation process. The AOA COCA also provides the applicant COM with start-up cost estimates and a preaccreditation preparation timetable calculator. In addition, the AOA COCA refers the applicant COM to Table One in Chapter IX of The Standards, "Preliminary Timetable for Evaluation from Application Status to Initial Provisional Accreditation Status Decision."^11(p88) 

Preaccreditation is the next step for a proposed new COM seeking accreditation. When a new COM receives preaccreditation status, it has achieved the privilege of recognition by the AOA COCA and this status is announced publicly. In order to achieve this status, the new COM must show that it has the plans and resources that would allow them to proceed to provisional accreditation within 5 years. A COM that has been granted preaccreditation status cannot, however, recruit, accept applications from, or admit students. 

Applicants for preaccreditation must submit a feasibility study to the AOA COCA that assesses its sustainability as a new COM. The AOA COCA requires a new COM to hire a dean and a chief academic officer at least 6 months before it submits the feasibility study. The associate or assistant deans must be hired at the time that preaccreditation status is awarded. The chief academic officer must have a DO degree from an AOA COCA– accredited COM and be board certified. The dean is expected to guide the development of the feasibility study through all steps of the accreditation process. The AOA COCA reserves the right to not review a feasibility study if the COM cannot verify that the dean had a leadership role in preparing the document. 

To assess the sustainability of a new COM, the feasibility study must address 9 criteria, which are described in detail in The Standards.^11(pp31-33) Initially, a financial pro forma statement must be provided by a nationally recognized accounting or management firm. The new COM must show the amount of support that they have from their community and state, including their state osteopathic association. The applicant COM must have an organizational structure and functioning governing body and, if part of a parent institution, show commitment to the COM's mission and objectives. Planning and progress for clerkship training must be evident. In addition, financial support must be adequate and account for construction costs, operating reserve, and an escrowed reserve fund that is "100% wholly owned assets of the COM or its parent institution."^11(p32) Finally, the new COM must show educational planning and progress in creating GME opportunities. To show that they comply with this criterion, and to ensure consistency in documentation, all new COMs are required to complete a clinical rotations and GME workbook that has been developed by the AOA COCA. 

When the feasibility study, along with a letter of application and a nonrefundable fee of $32,000, is received in the AOA COCA office, it will be reviewed by the AOA COCA Executive Committee, which comprises the AOA COCA chair, the AOA COCA vice chair, and 3 additional AOA COCA commissioners appointed by the AOA COCA chair. This review for technical completeness, usually done by means of teleconference, is to assure that if a site visit for preaccreditation were to be authorized, a site visit team would reasonably be able to assess whether the new COM was in compliance with AOA COCA standards and procedures. If the AOA COCA Executive Committee determines that the feasibility study is complete, a site visit is authorized and a team is assembled to visit the new COM. The AOA COCA Executive Committee can also authorize a site visit for preaccreditation but stipulate that 1 or more of the elements in the feasibility study need additional information, which could be obtained during the site visit. 

The site visit team for preaccreditation will review all elements of the feasibility study, as well as the following standards: 

The site visit team will conduct its visit and write a report, which will be delivered to the AOA COCA at its next scheduled meeting. At that time, the AOA COCA will make its decision of whether or not to grant preaccreditation status to the new COM. 

The AOA COCA reviews a new COM's preaccreditation status annually for up to 5 years. In addition, COMs with preaccreditation status are required to submit an annual report to be reviewed by the AOA COCA. The AOA COCA may continue the COM's preaccreditation status, withdraw the COM's preaccreditation status, or authorize another site visit. It is expected that a COM will attain provisional accreditation status during this 5-year period. Failure of a COM to reach provisional accreditation status during this 5-year period results in the AOA COCA's termination of the COM's preaccreditation status. 

At any time after a new COM has been granted preaccreditation status and before the 5-year period expires, the COM may request review for provisional accreditation status. At this time, the new COM must show that it meets, or will meet by the proposed start date for its education program, all of the accreditation standards listed in "Chapter I: COM Accreditation Standards" of The Standards.^11(pp13-30) 

When the new COM believes it is ready to be evaluated for provisional accreditation status, it submits an updated feasibility study that addresses all standard domains (1 through 8) to show its compliance with all standards.¹¹ The new feasibility study includes the proposed educational program to be implemented at the new COM through the graduation of its first class of students, the COM's plans for development, and verification of sufficient clinical sites to meet the clinical needs of the COM's proposed class size, along with affiliation agreements with those clinical sites. 

The AOA COCA staff conducts an initial review of the updated feasibility study to ensure that all requirements are present; any absent requirements are noted. The AOA COCA chair makes the final determination as to whether additional information is needed before authorizing a site visit or if the additional information can be provided onsite. If the updated feasibility study is determined to be complete, the site visit team will be identified and a first provisional accreditation site visit will be conducted. 

The site visit team is responsible for determining whether the information in the updated feasibility study is correct and whether the new COM is in compliance with all of the standards.¹¹ The team will produce a report of their findings, which will be sent to all AOA COCA commissioners to be reviewed at the next regularly scheduled AOA COCA meeting. The AOA COCA will then determine from the information contained in the report, as well as from testimony of the new COM's leadership, whether to grant provisional accreditation status to the new COM. 

Once provisional accreditation status has been granted, the COM is able to solicit applications and admit students based on their approved class size, offer medical instruction according to their approved curriculum, and announce that they have been granted provisional accreditation status. Provisional accreditation is reviewed annually for renewal by the AOA COCA at the end of the first, second, and third academic class years of the COM. The annual review process includes a site visit and a self-study submitted by the COM before each visit to show that they are in compliance with all AOA COCA standards. 

To be compliant with the USDE regulations at 34 CFR 602.16(a)(2), provisional accreditation status may not exceed 5 years.¹⁰ Therefore, provisional accreditation becomes effective on July 1 of the year it is approved, and it is intended to end when the new COM graduates its first class in May or June 5 years later. It is expected that COMs with provisional accreditation status will request an initial comprehensive accreditation visit during the winter or early spring of the year their inaugural class of students will graduate. During this visit, the COM is evaluated for the first time on the outcomes of all 4 years of its curriculum. All standards are reviewed during the first comprehensive visit for accreditation status, and the team findings from this visit are presented to the AOA COCA at a regularly scheduled spring meeting in late April or early May (ie, before the end of the academic year). At that time, the AOA COCA makes its decision to grant or not grant the COM accreditation status. 

Accreditation status (ie, "full" accreditation) is the highest level of accreditation awarded to a COM. It gives the COM all rights and privileges of accreditation. After receiving accreditation status, a COM is placed on a 7-year cycle for review. Every 7 years, a COM must submit a self-study addressing all AOA COCA standards and undergo a site visit by a team of AOA COCA evaluators to ensure that the COM is in compliance with all standards to renew accreditation status. The AOA COCA has the ability to authorize a shorter review cycle for a COM if necessary. Accreditation status is held by a COM unless it is withdrawn by either the AOA COCA or by a request from the COM itself. 

Branch campuses and additional locations have many similarities and are evaluated against the same 10 criteria, which will be discussed in the following sections. In fact, to the casual observer, to students, and to those who are unfamiliar with the nuances of the regulations of the USDE, a branch campus and an additional location may appear to be interchangeable. Branch campuses and additional locations are quite different from separate COMs, however. 

First, branch campuses and additional locations derive their accreditation from their "parent" COMs; they are not stand-alone entities. Stated another way, the accreditation status of a COM applies to its branch campus or additional location and vice versa. Therefore, if an accreditation problem arises in any component of the parent COM or its satellites, it can cause a reduction in the accreditation status of the entire entity. 

Second, unlike with the establishment of a new COM, the "education risk" associated with the establishment of a new branch campus or additional location is spread over the entire entity, including the parent COM. Therefore, the AOA COCA does not require the establishment of an operating reserve or an escrowed teach-out reserve for new branch campuses and additional locations. 

Third, because branch campuses and additional locations are being developed by established, fully accredited COMs, the initial evaluation period is shorter. However, the evaluation is no less rigorous than that of a new COM and, like a new COM, it requires a successful on-site evaluation before the AOA COCA grants permission to the entity to admit students and offer instruction. 

Despite their similarities, branch campuses and additional locations are actually defined as 2 separate entities by the USDE.¹⁰ All accrediting agencies recognized by the USDE are required to have procedures to evaluate and approve substantive changes, one of which is the development of an additional location as defined at 34CFR602.22(a)(2)viii.¹⁰ Those accrediting agencies that have "institutional" accrediting authority, or those that accredit entities that may participate in financial aid programs under Title IV of the Higher Education Act,⁹ are also required to evaluate and approve the establishment of a branch campus as defined at 34CFR602.24(a).¹⁰ The AOA COCA is a programmatic accreditor for all COMs to which it grants recognition. In addition, the AOA COCA has limited "Title IV" authority only for those COMs that are stand-alone institutions, which is the reason that the AOA COCA has separate procedures to evaluate the establishment of branch campuses and additional locations. These procedures are found in "Chapter VI: USDE Requirements" in The Standards.^11(pp63-76) 

All COMs that have the AOA COCA as their institutional accreditor have the option to open a branch campus. These COMs are single-purpose institutions that offer the DO degree and that are not part of a larger institution. They have no other programs that would necessitate regional or other programmatic accreditation. A branch campus is a permanent location of the COM at another site that offers the same or a similar educational program that leads to a DO degree. The branch campus has its own faculty, administrative body, budget, and clinical sites. 

To have a branch campus approved by the AOA COCA, the COM must request a substantive change and have it approved by the AOA COCA. The COM must submit a feasibility study to the AOA COCA addressing the 10 criteria that have been established for the approval of a branch campus substantive change request, as described in "Chapter VI: USDE Requirements" of The Standards.^11(pp73-74) These criteria include approval from the institution's regional accrediting agency and the state authority of higher education where the additional location will be established; community support; clinical training and GME availability, planning, and placement; provision for student services; adequate faculty; physical resources; necessary revenues; and management. After the branch campus has been approved, the AOA COCA monitors the program by conducting an onsite visit to the branch campus before students are accepted and instruction begins at the branch campus. Site visits are also conducted for the first 4 years that the branch campus is in operation. During year 1 and year 2, the AOA COCA evaluation team reviews all AOA COCA standards. In year 3 and year 4, the clerkship training standards in domain 6 and Standards 8.1, 8.2, and 8.3 are reviewed.¹¹ The branch campus will be included in the accreditation status of the parent COM when it is determined that all accreditation standards have been met. 

An additional location is geographically separated from the main campus of a COM that has the AOA COCA as its programmatic accreditor but is part of a larger institution of higher education or offers multiple degree-granting programs and has regional accreditation. At least 50% of a student's medical education must be offered at the new site in order for it to be considered and approved as an additional location. Unlike the branch campus, the additional location does not need to have its own independent administration or budget. 

A COM making a substantive change request to the AOA COCA for an additional location must meet the 10 criteria established by the AOA COCA as described in "Chapter VI: USDE Requirements" of The Standards.^11(pp68-69) These criteria are identical to those for a branch campus. The approved additional location is included in the parent institution's accreditation after it is determined that the additional location meets all accreditation standards. 

Both the additional location and the branch campus are included in the accreditation status of the parent COM and have all rights and privileges of the accredited parent COM. The additional location and branch campus are included in the 7-year accreditation cycle of the parent COM and must be included in the COM's self-study addressing compliance with all AOA COCA standards. Additional locations and branch campuses are included as part of the comprehensive visit by the team of AOA COCA evaluators when it is time to renew the accreditation status of a parent COM. 

For the past 10 academic years, AOA COCA–approved class sizes have steadily increased. During the 2005-2006 academic year, 20 COMs operating on 24 campuses were approved for 3614 total new students. During the current 2014-2015 academic year, the aggregate class sizes were approved for 6477 new matriculates at 30 COMs, 4 branch campuses, and 6 additional locations, for a total of 40 campus sites (Table). 

The aggregate number of authorized matriculates in the approved class sizes increased by 2863 over the academic years 2005-2006 through 2014-2015, inclusive, for a 79% increase since the 2005-2006 academic year. The larger fraction of this increase—1834 authorized positions (64%) of the 2863 increase—was the result of the establishment of 16 new campuses authorized by the AOA COCA. The remaining 1029 new authorized positions (36%) are accounted for by the expansion of class sizes at 18 existing COM campuses. 

During the 10-year period under discussion, the net increase in approved positions ranged from 134 in the 2010-2011 academic year (2.7% more than the previous year) to 565 in the 2013-2014 academic year (10.1% more than the previous year). In the 2014-2015 academic year, a total of 0 new approved positions were added to the approved class sizes at the existing COM campuses (Table) for a 0% increase compared with the 2013-2014 academic year's total number of 115 approved new positions at the existing COM campuses. 

Growth of COM campuses continues to occur both by the development of new COMs and by the development of branch campuses and additional locations. The accreditation processes for these different entities vary in their appearance but include the evaluation of the same elements with the same rigor. 

We thank Chantel Moore, MM, Data Analyst Accreditation Specialist in the Department of Accreditation for providing the analysis in the Table.