Assurance SectionUniversity of Arkansas for Medical Sciences
ASSURANCE SECTION
REPORT OF A COMPREHENSIVE EVALUATION VISIT
TO
University of Arkansas for Medical Sciences
Little Rock, Arkansas
April 2 – April 4, 2007
FOR
The Higher Learning Commission
A Commission of the North Central Association of Colleges and Schools
EVALUATION TEAM
Augustine O. Agho, Dean, School of Health Professions and Studies, University of Michigan-Flint, Flint, Michigan48502-1950. (Team Chair)
Susanne Darcy, Assistant Director for Operations, Center for Distance and Independent Study, University of Missouri-Columbia, Columbia, MO65211
Mary Kunes-Connell, Associate Dean of Academic and Clinical Affairs, CreightonUniversity, Omaha, NE68178
Bonnie L. Saucier, Professor, College of Nursing, Indiana State University, Terre Haute, IN47802
Gerard Stockhausen, S.J, President, University of Detroit Mercy, Detroit, MI48221-3038
John F. Williams, Jr., Provost and Vice President for Health Affairs, theGeorgeWashingtonUniversityMedicalCenter, Washington, DC20037
Contents
I. Context and Nature of Visit...... 3
II. Commitment to Peer Review...... 13
III. Compliance with Federal Requirements...... 14
IV. Fulfillment of the Criteria...... 14
a.Criterion One...... 14
b.Criterion Two...... 15
c.Criterion Three...... 18
d.Criterion Four...... 20
e.Criterion Five...... 23
V. Affiliation Status...... 25
VI. Additional Comments and Explanations...... 27
I. CONTEXT AND NATURE OF VISIT
A.Purpose of Visit
The visit to University of Arkansas Medical Sciences (UAMS) is for the purpose of conducting a comprehensive evaluation in response to the institution’s request for continued from the Higher Learning Commission of the North Central Association of Schools and Colleges.
B.Organizational Context
The University of Arkansas Medical Sciences (UAMS) is one of the public institutions in the University of Arkansas (UA) System, a system governed by a ten-member Board of Trustees who are appointed by the Governor. The mission of UAMS, the only academic health center in the State of Arkansas, is to teach, to heal, to search, and to serve. Included in the academic health center are: five colleges (i.e., Medicine, Pharmacy, Nursing, Public Health, and Health-Related Professions), Graduate School, Medical Center, six Centers of Excellence (i.e., Arkansas Cancer Research Center, Harvey and Bernice Jones Eye Institute, Donald W. Reynolds Institute on Aging, Myeloma Institute for Research and Therapy, Jackson T. Stephens Spine and Neurosciences Institute, and Psychiatric Research Institute), and seven Area Health Education Centers located throughout the State. UAMS is affiliated with Central Arkansas Veteran’s Healthcare Systems and the Arkansas Children’s Hospital.
The UAMS was first accredited by the North Central Association in 1924 and the last review for continued accreditation was in 1997. UAMS is accredited to offer education programs on its campus and at any of its Area Health Education Centers, and is approved to offer distance education programs.
C.Unique Aspects of Visit
None
D.Sites or Branch Campuses Visited
None
E.Distance Education Reviewed
None
- Interactions with Constituencies
Dean, GraduateSchool (GS)**
Dean, College of Health Related Professions*(CHRP)*
Dean, College of Medicine*(COM)*
Dean, College of Nursing*(CON)*
Dean, College of Pharmacy**(COP)
Dean, College of Public Health*(CPH)*
Immediate Past President, Academic Senate
President, Associated Student Government
President, House of Delegates
Vice Chancellor for Academic Affairs & Research Administration
Vice Chancellor for Regional Programs
Assistant Dean for Curriculum Development, Coll. of Medicine*
Assoc. Dean for Baccalaureate Education, College of Nursing
Associate Vice Chancellor for Communications & Marketing
Director, Enterprise Resource Planning System (SAP), IT
President, Academic Senate
Accreditation Project Director
Accreditation Project Manager
Accreditation Steering Committee:
Area Health Education Centers (AHEC) Librarian, via Access Grid from Fayetteville
Director, Rural Hospital Program and Associate Director, AreaHealthEducationCenters*
Arkansas Children's Hospital Librarian
Assistant Dean, GraduateSchool
Assistant Director, Grants Accounting†
Assistant Professor, College of Nursing
Assistant Professor, Environmental & Occupational Health, College of Public Health
Assistant Vice Chancellor for Communications & Marketing†
Assistant Vice Chancellor for Employee Relations†
Assistant Vice Chancellor for Human Resources*
Associate Dean for Academic Affairs, College of Pharmacy*
Associate Dean for Administrative Affairs, College of Health Related Professions
Associate Dean for Development and Professional Affairs, College of Pharmacy
Associate Dean for Faculty Affairs, College of Medicine
Associate Dean for Student Affairs, College of Pharmacy
Associate Dean for Translational Research, COM
Associate Dean/Student & Acad. Affairs, Coll. Of Pub. Health*
Associate Dean/Undergraduate Medical Education, Coll. of Medicine*
Associate Director of Construction Management
Associate Director, ResearchSupportCenter
Associate Director, UAMS Library*
Associate Professor & Interim Chairman, Imaging & Radiation Sciences, College of Health Related Professions
Associate Professor, Neurobiology & Developmental Science Department, College of Medicine
Associate Professor, Pharmacy Practice, College of Pharmacy
Associate Vice Chancellor for Academic Services
Associate Vice Chancellor, Development & Alumni Affairs†
Associate Vice Chancellor, Finance*
Associate. Dean for Academic & Student Affairs, College of Health Related Professions*
Chair, Neurobiology and Developmental Science Department, College of Medicine
Chairman, UA Board of Trustees
Chancellor
Clinical Instructor, College of Nursing
Associate Dean for Academic Affairs, College of
Dean, GraduateSchool and President, Research Council**
Director of Construction Management †
Director of Recruitment for Diversity
Director, Academic Administration & Informatics, College of Nursing
Director, Academic Computing*
Director, Academic Computing, Academic Affairs and Research Administration
Director, AHEC Foundation Fund, Regional Programs
Director, Center for Clinical Skills Education
Director, Center for Diversity Affairs & Assoc. Dean for Minority Affairs, College of Medicine*
Director, Client Services, IT*
Director, Div. of Medical Humanities and Chairman, UAMS Ethics Consultation Service
Director, Governmental Affairs
Director, Human Resources Administration
Director, IT Client Services, Information Technology Division
Director, Office of Budget and Planning*
Director, Office of Educational Development
Director, Office of Research and Sponsored Programs, Institutional Review Board (IRB)
Director, Physical Plant
Director, Research Compliance
Director, Research Systems (ARIA System and FacFacts), IT
Director, Student Activities and Housing
Director, Student Mental Health Service
Director, Telecommunications
Director, UAMS Financial Aid Office*
Director, UAMS Library*
Executive Associate Dean, College of Medicine
Foundation Fund Board Member
House of Delegates Parliamentarian
House of Delegates President
House of Delegates President-elect
Immediate Past President, Academic Senate
Lead Therapist, Student Mental Health Services
Linda Stone, Senior Director of Development Operations†
MBA, Chief Information Officer
President, University of Arkansas for Medical Sciences
Professor & Chair, Audiology & Speech Pathology, College of Health Related Professions
Professor of Anatomy and Partners in Health Sciences Program Director
Professor, Pharmaceutical Sciences, College of Pharmacy
Program Manager, Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS)†
Representative at large, Academic Senate
WebCT Specialist, Office of Educational Development
Secretary, UA Board of Trustees
Senior Dir./Development Services & Comprehensive Campaign Coordinator†
Space Allocation Coordinator
Student Financial Services
UA General Counsel
UAMS Diversity Manager
UAMS Ethnic and Racial Health Disparities Taskforce Member
UAMS Library Advisory Committee Members
Vice Chancellor for Administration
Vice Chancellor for Development
Vice Chancellor for Finance/Chief Financial Officer
Vice Chancellor for Institutional Compliance
Vice Chancellor for Research
Vice Chancellor, Campus Operations*
Vice Chancellor/Research & Chairman, Conflict of Interest Committee
Vice President for Academic Affairs
Vice President for Finance and Administration
Vice President, Associated Student Government, College of Medicine
G.Principal Documents, Materials, and Web Pages Reviewed
UAMS Institutional Self Study February 2007UAMS Institutional Snapshot February 2007
Criterion Committee 1 Minutes Notebook
Criterion Committee 2 Minutes Notebook
Criterion Committee 3 Minutes Notebook
Criterion Committee 4 Minutes Notebook
Criterion Committee 5 Minutes Notebook
Steering Committee Minutes Notebook
Criterion Committee Notebook – SAMPLE
Steering Committee Notebook – SAMPLE
Accreditation Staff Notebook
Focus Group & Interviews
Survey Results & Instruments
1997 NCA Self-study
1997 NCA Basic Institutional Data Forms and Audits
NCA Team Visit Report 1997
NCA 96 Fin Admin Resource Survey
NCA 1996 UAMS I Believe Statements
Academic Affairs and Research Administration Annual Report 2005 & 2006
ACHRI Scientific Report 2004
ACRC Annual Report 2005
AHEC Annual Report 05
ANGELS Program Annual Report 2004
Arkansas Aging Initiative Annual Report 2005
Arkansas Biosciences Institute Annual Report 2005
ArkansasCenter for Health Improvement Annual Report 2005
Campus Operations Annual Report 2005
CHRP Annual Report 2005
Clinical Skills Center Annual report 2006
COM Annual Report 2005
CON Annual Report 2005
COP Annual Report 2005
COPH Annual Report 2005
GraduateSchool Annual Report 2005
Information Technology Annual Report 2005
Jones Eye Ophthalmology Dept Annual Report 2005
Reynolds Annual Report 2005
Rural Hospital Program Annual Report 2005
Stephens Spine Annual Report 2005
UA Development and Alumni Affairs Annual Report 2005
UAMS Annual Report 2000-2001
Vice Chancellor for Finance Division Annual Report 2005
COM Accreditation Self-Study
COP Accreditation Self-Study
CON Accreditation Self-Study
CHRP Accreditation Dates and Programs
CHRP Accreditation Self-Studies
Audiology Speech Pathology
Cytotechnology
Dental Hygiene - Volume I
Dental Hygiene - Volume II
Dental Hygiene - Volume III
Diagnostic Medical Sonography
Dietetics and Nutrition
Emergency Medical Sciences
Genetic Counseling
Health Information Management
Medical Dosimetry
Medical Technology
Nuclear Medicine Imaging Sciences
Ophthalmic Technologies
Radiation Therapy
Radiologic Imaging Sciences - Little Rock
Radiologic Imaging Sciences – Fayetteville
Radiological Imaging Sciences – Texarkana
Radiologist Assistant
Respiratory Therapy
Respiratory Care
Surgical Technology
COPH Accreditation Self-Study – 2004
COPH Accreditation Self-Study – 2006
Educational Accreditation Bodies Table
COM Catalogs
COP Catalogs
CON Catalogs
CHRP Catalogs
COPH Catalogs
GraduateSchool Catalog
COM Student Handbook
COP Student Handbook
CON Student Handbook
CHRP Student Handbook
COPH Student Handbook
GraduateSchool Student Handbook
COM New Faculty Orientation Notebook
CON Faculty Handbook 2005-2006
COP Faculty Handbook 1-30-06
Women's Faculty Development Caucus Unofficial Faculty Handbook
College Promotional Brochures
Budget - Legislative Council
Budget Office Overview
Budget Process
Budget Request 07-09
Campus Summary Budget 04-05
Capital Campaign Prospectus DRAFT
Capital Funding
Classified / Non-Classified FTE
Construction Growth Maps 1984-2013
Development Office Policies and Procedures
Endowed Chairs List
Facilities Audit Program 3-14-02
Financial Statements 2005 & 2006
Five Year Financial Forecast 2006-2011
Functional Classification of Expense
Funding for CancerResearchCenter 042506
Grants Awarded 2005 & 2006
Hospital Budget FY07
Investment Income Jan 06
MISC Income 06-07
Peer Survey Revenues
Request for Legislative Appropriations 06-07
Special Language Bills 05-07
State Funding Analysis 06-07
State Percent Funding
Tentative Budget Schedule 2006-2007
Tuition Forecast 06-07
UA Foundation Financial Statement 2005
University of Arkansas 2007 Budget
UAMS Foundation Member List 2007
UAMS Fund List
Joint Commission on Accreditation of Health Org (JCAHO) Letter 2006
Patient Bill of Rights
Press Ganey Patient Satisfaction Surveys
Chancellor's Presentation Index
Here's to Your Health Topics 2005
KUAR Radio Spots
The 125 Anniversary Celebration Hall of Fame Video & Brochure Oct 2 '04
Brochures
Posters
College of Medicine Magazine
Video's & Vignettes
House Call Magazine
Newsletters
"I AM" Promotion
AHEC Continuing Education Trends
COM Continuing Education
COP Continuing Education
CON Continuing Education
CHRP Continuing Education
COPH Continuing Education
Black History Month Announcement 2005
Desegregation and Minority Recruitment Progress Reports
Diversity and Health Disparities Task Force Brochure
Diversity Committee Brochure
Diversity Training
Diversity Week
Hispanic Growth Arkansas Democrat Gazette Article
Medical Interpreter Training
Racial and Ethnic Health Disparities Taskforce
Admin Policies Governing Faculty Service
Board Policies Governing Faculty Service
Associate Deans Retreat Results
Chancellor's Faculty Teaching Awards 2005
COM Faculty Grievance Procedure
COM PBIC Faculty Survey May 06
Faculty Awards Offered by Colleges
Faculty Performance Reviews
Faculty Rosters & Appointments
Faculty Survey
Incentive Plans
Promotion & Tenure Guidelines
Promotion & Tenure Policy
Promotion & Tenure Workshops COM
Teaching Scholars Program
Teaching w Technology Symposium
Associated Student Government
Board Policies on Governance
Bylaws - Alumni Associations
Bylaw - Board Policy on Medical Staff Bylaws
Bylaws - Faculty Governance
Bylaws – Miscellaneous
House of Delegates Information
Organization Charts
Leadership Institute Information
UAMS Campus Assembly Constitution
UAMS Role and Scope Document
Board Policy - Tuition Waiver
Employee Stats for Campus by Division
Employee Survey Information
Employees by CountyMap
Employees Wellness Screening Report
New Employee Orientation
Staff Handbook 2002
Turnover Analysis, UAMS, FY 2006
Admin Policies for IT and Computer Usage
Admin Policy Library Services
Annual Security Report 2005-2006
CON Support Services Survey
General Facilities Assigned for Undergraduate Education
Instructional Equipment Plan
IT List of Systems
IT Survey Recap 2005-2006
Library Friday at Noon Conferences 2005-2006
Most Wired Hospital Information
Net Assignable Sq Ft by Division 6-30-2005
Parking Committee Proposal
Physical Plant Maintenance Policies
Student Information Systems List
Support Units Focus Group Summary
Admin Policies on Integrity-Ethics-Compliance
Conflict of Interest
Quality Assurance Unit Established
End-of-Life Policy
College and University Mission and Vision Statements
UAMS Vision and Mission Statement
Mission Survey
UAMS Update January 2001 Mission
ACHI Legislation
Adjunct Faculty / Preceptors
Advisory Council / Groups
Affiliations
AHEC & Regional Programs
Alumni Materials
ANGELS Program
CHRP Recruitment Report 2005-2006
COP Opportunity Enhancement Program
Distant Site Library Resources and Services
Evidence Based Rx Program Quarterly Report
Good Neighbor Policy
Nuclear Education Online Overview
Outreach Activities – List
Outreach Database and Reporting System Assessment
Outreach Map
PIBHS Program Numbers, Summary
PoisonControlCenter
RAND Report July-December 2005
Rural Hospital Program
UAMS Statewide Compressed Video Network
Arkansas Times NW Expansion Article
Chancellor and Deans Interviews
Chancellor's State of Campus Address 2005
Construction Plans Campus
Economic Impact Study, UAMS 2003
Facilities Master Plan
Preparing for the Future Survey
Planning Documents
Student Growth Plans
SWOT Analyzes
Workforce Studies
Workforce Study, 2006
ABI 2006 Performance Measures
ACH Research Agreement
ACHRI Research Agreements
Admin Policies on Research
ARIA Overview
BRIN Mentor Program Brochure
COM Research Survey
CON Research Day
Deans Research Forum Presenters 05-06
Extramural Research Collaborations
Office of Research Compliance Course Evaluation 05-06
Outgoing Research Subcontracts 3-17-06
Present Core Research Facilities
Tobacco Settlement
Student Research Week
AHEC Residents Policy Procedure Manual 2006
Board Policies on Students
College Competencies
CHRP Program List 1-06
COM Graduate Surveys
CON Graduate & Alumni Surveys
COP Graduate Surveys
CHRP Graduate Surveys
GraduateSchool Exit Survey
Postdoctoral Society Information
Student Demographic Data 96 thru 06
Student Enrollment / Headcounts
Student Grievance Procedures
Student Housing
Student Organizations
Students Remaining in Arkansas
Student Survey
Student Wellness Brochure
II. COMMITMENT TO PEER REVIEW
A.Comprehensiveness of the Self-Study Process
Based on the review of the membership of the self-study Steering Committee and various Criterion Committees, the team was able to determine that the self-study process was very comprehensive and inclusive.
B.Integrity of the Self-Study Report
The team found the self-study report to be well-organized and comprehensive. The concerns of the 1997 NCA Team were addressed. The Resource Room was organized to facilitate the work of the review team and the staff responded to requests for additional information and data in a timely manner. The team commends the institution for using this self-study to examine its strengths, highlight accomplishments, and identify areas of improvement.
C.Adequacy of Progress in Addressing Previously Identified Challenges
The team considers the response of the organization to previously identified challenges and recommendations to be adequate.
- Notification of Evaluation Visit and Solicitation of Third-Party Comment
On February 21, 2007, UAMS sent a press release to 57 media outlets for the purpose of inviting written public comments on UAMS request for continued accreditation. The team received and reviewed one (1) third-party comment. The comment was supportive of UAMS’ request for continued accreditation.
III. COMPLIANCE WITH FEDERAL REQUIREMENT
The team reviewed and determined that UAMS is in compliance with the required Title IV compliance areas and the student complaint information.
IV. FULFILLMENT OF THE CRITERIA
CRITERION ONE: MISSION AND INTEGRITY. The organization operates with integrity to ensure the fulfillment of its mission through structures and processes that involve the board, administration, faculty, staff, and students.
1.Evidence that Core Components are met
a.UAMS’ mission, mission statement, and vision statement are published extensively in print and on its website. They are reviewed during the Chancellor’s retreat every two years and form the base[EB1] for each strategic planning cycle. Unit mission statements flow from UAMS’ missionand are reviewed regularly to ensure continued linkage. The commitment to providing health care and health care education inmeeting the needs of the state of Arkansas is clearly embraced at all levels of the institution up to the University of Arkansas System Board of Trustees. This commitment is reflected in its publications and promotional materials as well.
b.UAMS recognizes the diversity of the people it serves, especially in Arkansas. UAMS’ mission statement is inclusive and emphasizes the dignity and worth of each individual. The strategic plan includes an objective to increase the enrollment and graduation rates of its underrepresented and underprivileged students. UAMS has a detailed Anti-Discrimination Policy and addresses diversity awareness in its Basic Code of Conduct Policy. Since 1993, UAMS has had a Diversity Committee whose duty it is to highlight the values of diversity. UAMS also has a Minority Student Recruitment and Retention Committee and a Center for Diversity Affairs. UAMS’commitment to diversity and its committees are matched at the unit level as well.