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Process and Procedures

  • Date:
  • Update Date:
  • Hit:6502
  • Source:Higher Education Evaluation and Accreditation Council of Taiwan
  • Editor:hyweb

The procedure for the entire process of the on-site survey from its planning and site visit to the completion of the reports and procedure for determination of the result are as follows:

(note: TMAC site visits are held between October and December and therefore the writing of the reports and determination of the result occur in the following year)

Period +/-

Survey Visit

TMAC Activity

-7 to -6

months (Mar to Apr)

TMAC committee meeting is called to determine the team chairs of each survey team for that year.

-7 to -6 months

(Mar to Apr)

Schools under survey are notified to proceed with the self-study (schools are given six months’ of


-6 to -5 months

(Apr to May)

Survey teams are formed, surveyors participating in site visits have to comply with TMAC’s Code of Ethics for

Accreditation and sign the consent form for avoidance of conflicts of interest.

-4 to -5 months

(May to Jun)

Introductory sessions are held for schools being surveyed.

-3 months (June)

Council meeting is held to determine the list of surveyors.

-1 to -2 months

(Aug to Sep)

Schools being surveyed are contacted about the schedule for the site visit.

-1 month

Consensus camp is held for surveyors to orientate them about the procedure, code of ethics, determination of compliance with accreditation standards, writing of report, and practicalities concerning site visits.

-1 month (Sep)

Schools being surveyed submit their self-study reports and supporting documents.

Surveyors are sent a package containing the TMAC Accreditation Manual, the school’s Self-Study, past accreditation reports of the school, list of faculty, class schedule during the week of site visit, etc.


(Oct to Dec)

On-site visit (four days for full reviews and 2-3 days for follow- up review).

+2 weeks

Writing of reports by surveyors which will be submitted to the team chair who will then compile a draft report and make a recommendation on the accreditation.

+2 weeks

Compilation of the report by the team chair who will confirm that consensus is reached concerning its contents and recommended decision. Further discussions on items where there is disagreement among the surveyors are held to attain consensus.

+5 weeks

Submission of survey report to TMAC’s office for editing.

+3 to +4 months

(Mar to Apr)

Council meeting is held to review the first draft of the survey report and to vote on the decision. The number of council members eligible for voting is determined according to TMAC’s Regulations for the Accreditation Process and members with conflict of interest to the school being discussed have to recuse themselves. The result of the evaluation is decided upon by the same regulation.

+4 to +5 months

(Apr to May)

Drafts of survey reports are sent to each school; the latter has two weeks to appeal the contents and decision.

+5 to +6 months

(May to Jun)

Appeals are handled: survey team has to respond to the appeals and a council meeting is called by TMAC to discuss them. TMAC’s reaction to the appeals may be: (1) maintain the original decision, (2) accept appeal and modify contents of report accordingly, (3) accept appeal and change status to “compliance with standard”.

+ 6 to +7 months (Jun to Jul)

Accreditation decisions are reported to HEEACT’s Board of Trustees and sent to the MOE for filing for future reference.

+7 months (July)

Announcement on TMAC’s website of the accreditation decisions, appeals filed, and TMAC’s response to the appeals.

Note: The operating schedule will be adjusted accordingly, the actual timeline and schedule shall be based on the TMAC’s official notification.


    The schools being full reviewed or follow-up reviewed shall submit the self-study report to TMAC by mid of September of the accreditation year. The self-study is a process for which to collect all the ideas about the operation of school from all faculties, staffs and medical students, its main purpose is to self-review the education quality, and then seek solutions to improve and result in strengthening the school’s advantages.  

    For the schools being full reviewed, and follow-up reviewed, should prepare the self-study report based on the following rules:

  • For Schools being Full Reviewed: Write the self-study report, answering all narrative questions and tables under each standard and provide supporting documentation when necessary.
  • For Schools being Follow-up Reviewed: Describe the improvement of those standards were determined at last accreditation as “partially compliance with a need for monitoring” and noncompliance”, answered those narrative questions and fill in tables under those If the narrative descriptions and tables are not sufficient to present the improvement, please additionally describe the measures taken for improving, implementations of the measures, evaluation of the outcomes and difficulties encountered.

    Through the self-study process, the school being surveyed can review which part requires to be improved, some of the problems may not be able to achieve immediately (e.g., the implementation of graduate questionnaire); however, the questions and tables designed in the self-study are in response to the global medical education development, those can be deemed as the way forward for schools.

    According to the “Regulations for the Accreditation Process of the Taiwan Medical Accreditation Council”, the accreditation results and actions have the following four (4) types:

  1. Accredited, valid for 6 years: The institution must apply for a follow-up review of written reports describes its improvement implementations within 3 years after being accredited. If the institution passes the review, the certificate is valid for the remainder of the 6-year expiration period; near the expiration date, the TMAC conducts another full However, if the follow-up review determines that the institution exhibits major shortcomings that could substantially affect its education quality, TMAC may terminate the accreditation status of the institution.
  2. Accredited, valid for 3 years: A full review is conducted close to the end of the 3- year expiration period.
  3. On Probation: A follow-up visit must be conducted within 2 years to determine whether the institution has continued to improve and achieve favorable If the accreditation result of the follow-up visit is still “on probation,” a full-review must be conducted within the next 2 years.
  4. Nonaccredited: The institution must reapply for accreditation within a designated period. If the subsequent accreditation process determines that the institution is still nonaccredited, the TMAC recommends that the Ministry of Education provides guidance to the institution and review students’ rights according to Measures for Maintaining the Education Quality of Junior Colleges and Above.

As to the determination procedures of accreditation results, the surveyors write the survey report based on the content of the school’s self- study report and the findings observed during the site visit, while make determination of the compliance with standards he or she assigned with; for standards determined as “partially compliance with a need for monitoring” or “noncompliance” must be written with factual findings, together with his or her review process to make report to the team chair for compiling. The survey report composed by the survey team chair consists of four parts:

  1. Profile of school/department and the key points of the survey.
  2. Implementation Process of Survey Visit: Include the documentations provided bythe school, briefing made by the school, visit various facilities/teaching curriculums/meetings, verification of supporting documentation, interview with faculties (including attending physicians)/residents/students/ leadership of the medical education (dean of medical school, the chairman of the program, teaching vice dean of hospital, representative of board of trustees, curriculum coordinator), etc.
  3. Findings of Survey Visit (check the compliance with standards).
  4. Summary & Recommendation of Accreditation result.

    Basically each survey item will be checked/evaluated by two surveyors, the surveyors will require to discuss to reach consensus ; the survey report compiled by the survey team chair shall also be confirmed and reached consensus by the team members, and then propose the recommended accreditation result to TMAC. Lastly, the first draft of survey report will be reviewed by the TMAC committee and convening a committee meeting for deliberate discussion and vote for accreditation result, and send the draft survey report to the school.

    The reviewed school could response to TMAC against its draft survey report within two weeks from receiving the report, which process is regulated in the Taiwan Medical Accreditation Council Regulations for Response to the Survey Report (Appendix D). The TMAC shall, within 30 days after the deadline of claims applications, transfer the response to the site survey team for review and generating comments. Where necessary, the TMAC may request the institution to provide a written explanation to support their response. Then TMAC convene a committee meeting to review responses both from the school and the survey team, then makes final decision of the accreditation result, and provide the school a written response together with the finalized survey report. After sending the survey report and results to Ministry of Education for future reference, the survey report, school’s response and TMAC’s response comments will be announced on the TMAC website.