CNA - Guide 03 - 2021

Ministry of National Education Republic of Colombia

GUIDE 03

SELF-ASSESSMENT OF ACADEMIC

PROGRAMS AND HIGHER

EDUCATION INSTITUTIONSCOUNCIL MEMBERS

Iván Enrique Ramos Calderón Council Coordinator Technical and Technological Department

José William Cornejo Ochoa Council Member Health Sciences Department

Álvaro Acevedo Tarazona Council Member Social and Human Sciences Department

AD HOC COUNCIL MEMBERS

Álvaro Zapata Domínguez Economic, Administrative and Accounting Sciences Department Fernando Cantor Rincón Council Member Basic and Natural Sciences Department

Helmuth Trefftz Gómez Council Member Engineering Department

Carmen Amalia Camacho Sanabria Council Member Education Department

Franco Alirio Vallejo Cabrera Agronomy, Veterinary and Related Programs Department

FORMER COUNCIL MEMBERS

Guillermo Murillo Vargas

Álvaro Andrés Motta Navas

Jhoniers Guerrero Erazo

Álvaro Campo Cabal

Martha Vitalia Corredor Montagut

Fernando Chaparro Osorio

Edgar Díaz Puentes

José Uriel Giraldo Gallón

Pedro Pastor Polo Verano

Harold José Rizo Otero

Jaime Restrepo Cuartas

Bernardo Restrepo Gómez

Alberto Enrique Roa Valero

Guillermo Londoño Restrepo

Diana Elvira Lago de Vergara

Jaime Eduardo Bernal Villegas

Pedro Prieto Pulido

Álvaro Zapata Domínguez

Alberto Enrique Roa Valero

Guillermo Londoño Restrepo

Diana Elvira Lago de Vergara

Jaime Eduardo Bernal Villegas

Pedro Prieto Pulido

Álvaro Zapata Domínguez

María Lorena Gartner Isaza Franco Alirio Vallejo Cabrera

Carlos Augusto Hernández Rodríguez

Luis Enrique Orozco Silva

Diana María Ramírez Carvajal

Carl Henrik Langebaek Rueda

Emilio Armando Zapata

Jairo Alfonso Téllez Mosquera

Cecilia Dolores Correa de Molina

Guillermo Paramo Rocha

Emilio Aljure Nasser (+)

Darío Abad Arango (+)

Ramsés Hakim Murad (+)

Guillermo Hoyos Vásquez (+)

Jesús Virgilio Niño Cruz (+)

José Neftalí Revelo Revelo (+)

Rafael Serrano Sarmiento (+)

EDUCATION TEMPORARY

CHAMBER

Claudia Patricia Salazar Blanco

Gilma Mestre de Mogollón

Jorge Oswaldo Sánchez BuitragoTECHNICAL SECRETARIAT TEAM - CNA

Luis Enrique Silva Segura Technical and Academic Secretary

Patricia del Pilar Amórtegui Perilla Planning and International Certification Advisor

Jenny Patricia Martín Buitrago Legal Counsel

Judith Alexandra Rodríguez Meza Internationalization Advisor

Gina Marcela Parra Marín Communications Advisor

Yenny Paola Cadena Medina Accreditation Process Management

Carlos Campo Rodríguez SACES - CNA Application Manager

Catalina Jiménez Díaz

Internationalization Advisor

Gina Marcela Parra Marín Communications Advisor

Yenny Paola Cadena Medina Accreditation Process Management

Carlos Campo Rodríguez SACES - CNA Application Manager

Catalina Jiménez Díaz Specialized Professional - Administrative and Financial Management

Joshua Gutiérrez Peer Management Support Professional

Diana Carolina Wilches Pérez Technical Assistance Professional

Nydia Constanza Romero Technical Assistance Professional

Ludy Martínez Technical Assistance Professional

Marlly Estefanía González Peña Support Professional

Amparo Peñaloza Archive and Documentation Center Professional

Tatiana Guzmán General ServicesTABLE OF CONTENTS

INTRODUCTION ................................................................................................................................................................................... 5 INTRODUCTION ................................................................................................................................................................................... 6

1. PURPOSE ..................................................................................................................................................................................... 7

2. GENERAL GUIDELINES FOR THE SELF-ASSESSMENT PROCESS ...................................................................................... 10 2.1 Preparation and Coordination of Teams ........................................................................................................... 12 2.2 Internal Quality Assurance System ..................................................................................................................... 13 2.3 Design of the Self-Assessment Model based on the Guidelines of the National Accreditation Council .. 14 2.4 Data Collection ....................................................................................................................................................... 15 2.4.1 Sources of information ......................................................................................................................................... 16 2.4.2 Instruments of the self-assessment process ..................................................................................................... 17 2.4.3 Issuing opinions ..................................................................................................................................................... 18 2.4.4 The Self-Assessment Report ................................................................................................................................ 19 2.4.5 Report Contents .................................................................................................................................................... 19 2.4.5.1 Introduction............................................................................................................................................................ 19 2.4.5.2 General aspects of the institution or academic program ................................................................................ 19 2.4.5.3 Result of the self-assessment .............................................................................................................................. 20

2.4.5 Report Contents .................................................................................................................................................... 19 2.4.5.1 Introduction............................................................................................................................................................ 19 2.4.5.2 General aspects of the institution or academic program ................................................................................ 19 2.4.5.3 Result of the self-assessment .............................................................................................................................. 20 2.4.5.4 Strengths and areas for improvement of the program and explicit opinion on its quality. ....................... 20 2.4.5.5 Improvement plan ................................................................................................................................................. 20 2.4.5.6 Annexes .................................................................................................................................................................. 20 2.4.5.7 Presentation of the Report to the National Accreditation Council ................................................................. 20

3. ACCREDITATION GUIDELINES FOR ACADEMIC PROGRAMS AND INSTITUTIONS .......................................................... 22 3.1 Factors and Characteristics for Academic Programs [8]. ................................................................................ 23 3.2 Factors and Characteristics for Institutions [9] ................................................................................................ 24

4. SUPPLEMENTARY INFORMATION AND MASTER TABLES.................................................................................................. 26

5. DEFINITIONS ............................................................................................................................................................................ 265

Guide 03 - Self-assessment of academic programs and higher education institutions

INTRODUCTION

The National Accreditation Council, throughout its 25 years of continuous operation, has conceptualized and built an accreditation model aimed at higher education institutions as part of a system that respects and recognizes university autonomy, diversity and the particularities of institutional contexts, which has allowed the development of guidelines for undergraduate academic programs, master's and doctoral programs, medical-surgical specializations and higher education institutions. As part of the updating of the Higher Education Quality Assurance System undertaken by the Ministry of National Education with the support of the National Higher Education Council (CESU), the National Accreditation Council (CNA), the National Intersectoral Commission for Quality Assurance in Higher Education (CONACES, for the Spanish original), the Permanent Quality Commission and the national academic community, the updating of the high quality accreditation model was consolidated through Agreement 02/July 1,

the National Accreditation Council (CNA), the National Intersectoral Commission for Quality Assurance in Higher Education (CONACES, for the Spanish original), the Permanent Quality Commission and the national academic community, the updating of the high quality accreditation model was consolidated through Agreement 02/July 1, 2020 of the National Higher Education Council, and, previously by the amendment of Decree 1075/2015 through Decree 843/2020.

The updating of the high quality accreditation model incorporates the most relevant international trends in accreditation matters and the recommendations provided by national and international organizations that serve as references in these matters, especially those contained in the external assessment reports received in compliance with good practices for certifying agencies, carried out by the National Accreditation Council before the International Network for Quality Assurance Agencies in Higher Education (INQAAHE, for the Spanish original) and the IberoAmerican Network for Quality Assurance in Higher Education (RIACES, for the Spa nish original). Similarly, it is based on the history and processes of assessment of high quality in the country, building on what is already in place, recognizing the diversity of institutions, the different modalities and levels of academic programs, and the standardization of the Higher Education Quality Assurance System.

For the implementation of Agreement 02/2020 by the National Accreditation Council and the internalization by higher education institutions, and in general by the academic and scientific community, procedural guidelines must be developed to guide the accreditation processes in their different stages and enable their implementation by institutions within their communities and provide them with elements for the construction of the documents that must support the specific stages that the institution shall go through. In order to facilitate the work of the institutions, the guides have been summarized in four documents:

• Guide 01 refers to the accreditation procedure and explains the steps and timelines. • Guide 02 provides guidelines for the initial conditions assessment of academic programs and institutions. • Guide 03 provides guidelines for the self-assessment of academic programs and institutions. • Guide 04 provides guidelines for carrying out assessment and follow-up visits regarding the improvement plans of both academic programs and institutions.

• Guide 02 provides guidelines for the initial conditions assessment of academic programs and institutions. • Guide 03 provides guidelines for the self-assessment of academic programs and institutions. • Guide 04 provides guidelines for carrying out assessment and follow-up visits regarding the improvement plans of both academic programs and institutions.

This guide, "Self -assessment of academic programs and higher education institutions," from the perspective of quality assurance, provides guidelines for institutions to carry out their self -assessment process and structure the corresponding report, in order to undergo external assessment as part of the high quality accreditation process.

The National Accreditation Council explicitly recognizes the different areas and people of the higher education sector, the Minister, the Vice-Minister of Higher Education, the Directorate of Quality, the National Council of Higher Education, the CONACES Chambers, and the Permanent Quality Commission, among others, for their support throughout this process of updating the high quality accreditation model.6

Guide 03 - Self-assessment of academic programs and higher education institutions

INTRODUCTION

In higher education, self -assessment should be a permanent practice that enables a critical look at the way institutions assume the development of all the processes involved, in order to systematically monitor the fulfillment of their mission objectives, to analyze the conditions that affect their development and to implement measures for continuous improvement, so as to ensure the quality of the service they offer; in this sense, self -assessment is the central stage of the accreditation process.

The self-assessment process and the corresponding report must be the result of a participatory, responsible and critical endeavor of the members of the academic community and other stakeholders, in order for the great institutional and academic program efforts to be legitimate, serve the purposes of continuous improvement and ensure the commitment to the high quality of the institution and the academic programs.

In this sense, this Guide for self -assessment of academic programs and institutions provides suggestions to facilitate the self -assessment processes for high quality accreditation of academic programs and institutions that decide to move forward in the accreditation process. Given that this is a voluntary and autonomous act, the

In this sense, this Guide for self -assessment of academic programs and institutions provides suggestions to facilitate the self -assessment processes for high quality accreditation of academic programs and institutions that decide to move forward in the accreditation process. Given that this is a voluntary and autonomous act, the recommendations provided herein are ind icative in nature and therefore constitute a flexible basis from which to draw elements both for developing assessment instruments with characteristics of relevance, validity and reliability, and for consulting the required sources.7

Guide 03 - Self-assessment of academic programs and higher education institutions

1. PURPOSE

The purpose of this guide is to instruct institutions in the development of the self -assessment process of academic programs and institutions for high quality accreditation and the renewal of accreditation in accordance with the guidelines and aspects to be assessed of academic programs and institutions, as well as for the preparation of the respective report.

The guidelines provided by the National Accreditation Council for the development of self -assessment processes will enable institutions to identify strengths and areas for improvement that will guide the implementation of improvement plans, and in this way, they will have elements that will enable them to support the high quality roadmap of their academic programs and the institution in the accreditation or renewal of high quality accreditation procedures, and in the preparation of the respective report.

It is important to mention that the National Accreditation Council does not intend for this guide to be the only way to implement the self-assessment processes, but rather to provide suggestions that may contribute to the institution's progress in the process, either by using its own model or, if it so wishes, by following the recommendations of the National Accreditation Council. In both cases it is essential to articulate it with the internal quality assurance system.

However, in compliance with the provisions of paragraph a) of Article 34 of Agreement 02/2020 issued by the National Council of Higher Education, and as part of the high quality accreditati on model, this guide discusses the essential components that the institution must develop in the self-assessment report for the purpose of high quality accreditation of an academic program or the institution.

National Council of Higher Education, and as part of the high quality accreditati on model, this guide discusses the essential components that the institution must develop in the self-assessment report for the purpose of high quality accreditation of an academic program or the institution.

The high quality accreditation process, in accordance with the stages established in the current regulations (Article 2.5.3.3.7.3 of Decree 1075/2015, as amended by Decree 843/2020), includes:

a) Assessment of initial conditions: this is required when the institution expresses its interest in accrediting academic programs or the institution for the first time [1] 1. b) Self-assessment carried out by the academic program or institution and the submission of the corresponding self-assessment report to the National Accreditation Council. c) External assessment conducted by academic peers appointed by the National Accreditation Council. d) Comprehensive assessment of the National Accreditation Council, which issues the opinion on the quality of the academic program or institution and recommends the high quality accreditation to the Ministry of National Education, if applicable. Resolution granting or renewing the high quality accreditation issued by the Ministry of National Education in the event that the National Accreditation Council has recommended accreditation. If the academic program or institution has not reached the high quality conditions to achieve accreditation, the National Accreditation Council will send an opinion with recommendations for improvement directly to the institution or academic program.

Formal entry into the National Accreditation System shall only be granted when the institution receives an opinion of compliance with the initial conditions and achieves high quality accreditation of at least one academic program for one of its places of development.

An academic program is accreditable if it complies with the requirements established in subsection a) of section 2.3 of Article 2 of CESU Agreement 02/2020, which determines that: “An academic program is accreditable if it is authorized to be offered and provided by the institution and has been operating for at least eight (8) continuous years, verifiable in the National Information System for Higher Education (SNIES, for the Spanish original). The

authorized to be offered and provided by the institution and has been operating for at least eight (8) continuous years, verifiable in the National Information System for Higher Education (SNIES, for the Spanish original). The

[1] When the Institution has High Quality Institutional Accreditation, it is not required to carry out the initial conditions assessment for undergraduate academic programs.8

Guide 03 - Self-assessment of academic programs and higher education institutions

academic programs of the professional t echnical, technological, university, master, medical -surgical specialty and doctoral levels of education are considered to be accreditable.”

A higher education institution is accreditable when it complies with the requirements established in subsections c ) and d) of Article 34 of Agreement 02/2020:

a) In the case of accreditation by place of development, the institution must have accredited at least thirty percent (30%) of its accreditable academic programs, regardless of the level and modality, in each of the places of development to be included in the accreditation process. b) In the case of multicampus accreditation, the institution must have accredited at least thirty percent (30%) of its accreditable programs at all of its places of development in which ac ademic offerings have been authorized.

When applicable, once the initial conditions assessment stage has been passed, if the institution decides to go on to the self-assessment stage of one or more of its academic programs or of the Institution, it must s ubmit to the National Accreditation Council the corresponding self -assessment report within one year following receipt of the communication of the opinion of compliance with the initial conditions.

The institutional self-assessment process and the submiss ion of the corresponding report must be the result of a participatory, responsible and critical endeavor of the members of the academic community and other stakeholders, in order for the great institutional and academic program efforts to be legitimate, serve the purposes of continuous improvement and ensure the commitment to the high quality of the institution and the academic programs.9

Guide 03 - Self-assessment of academic programs and higher education institutions

in order for the great institutional and academic program efforts to be legitimate, serve the purposes of continuous improvement and ensure the commitment to the high quality of the institution and the academic programs.9

Guide 03 - Self-assessment of academic programs and higher education institutions

GENERAL GUIDELINES FOR

THE SELF-ASSESSMENT

PROCESS10

Guide 03 - Self-assessment of academic programs and higher education institutions

2. GENERAL GUIDELINES FOR

THE SELF-ASSESSMENT PROCESS

The consolidation of a culture of quality assessment is a basic premise of all higher education institutions committed to continuous improvement and the pursuit of high quality. In this sense, self -assessment must be a permanent practice that provides a critical view of the way in which institutions and academic programs undertake the development of all processes, in order to ensure the quality of the service they offer.

The success and seriousness of a self-assessment process requires the institution to take the lead of the process and encourage the broad participation of the academic community (students and professors) and other stakeholders such as graduates, employers and any others defined by the institution. It should be considered that in this internal view, the self-study should be undertaken exhaustively, that is, by means of a one by one assessment of the training, academic, teaching, scientific, cultural and extension work, and of the supporting processes, with the fundamental purpose of identifying strengths and weaknesses, and proposing improvement plans that aim to improve the quality of the institution or of the academic program undergoing the accreditation process and assuring society and the State that the highest levels of quality are being fulfilled, in accordance with its purposes and objectives.

High quality accreditation is a voluntary mechanism for the constant pursuit of the highest levels of quality by the institutions that join the system. It is based on guidelines approved by the National Council of Higher Education (CESU), in accordance with the recommendations of the National Accreditation Council, which have been

High quality accreditation is a voluntary mechanism for the constant pursuit of the highest levels of quality by the institutions that join the system. It is based on guidelines approved by the National Council of Higher Education (CESU), in accordance with the recommendations of the National Accreditation Council, which have been previously agreed upon with the national academic community in line with international recommendations and international benchmarks. Compliance with these parameters should lead to continuous improvement and not be merely a reflection of the quality achieved so far. Accreditation is not an oversight and monitoring mechanism to be exercised by the State and, therefore, does not replace it.

It is important to emphasize that in the process of high quality accreditation, the National Accreditation Council gives its opinion taking into consideration the self -assessment of the academic program or institution, the external assessment report by the academic peers appointed by the National Accreditation Council and the comments made by the Registered Agent regarding this report. Based on the comprehensive assessment, the National Accreditation Council issues an opinion that, if it concludes that the academic program or institution has demonstrated high quality, will recommend the recognition or renewal of accreditation to the Ministry of National Education.

The National Accreditation Council takes the opinion of high quality as the basis for the theoretical, conceptual and methodological model of assessment. This concept refers to the characteristics and aspects to be improved that make it possible to recognize the high quality of an academic program or an institution. As part of the framework of the diversity, legal nature, identity, mission and typology of the institution, these considerations lead to the creation of an opinion regarding its capacity for continuous improvement to promote a better way of providing an effective public education service, achieve the expected results and result in the proposed impacts. Thus, the quality of an institution or academic program refers to the universal characteristics of higher education in general, to the generic characteristics corresponding to the ideal historically defined for that type of institution or academic program, and to the specific characteristics that are specific to it, according to its legal nature, identity, mission, typolo gy in the case of institutions and the levels of training and modalities in the case of academic programs.

characteristics corresponding to the ideal historically defined for that type of institution or academic program, and to the specific characteristics that are specific to it, according to its legal nature, identity, mission, typolo gy in the case of institutions and the levels of training and modalities in the case of academic programs.

The concept of high quality, which is part of the updating of the accreditation model, not only considers capabilities and processes, but also includes achievements and results. Quality, thus understood, implies the continuous effort of institutions and academic programs to comply responsibly with the educational, academic, teaching, scientific, cultural and extension activities, as well as with the s upporting functions: financial management, academic resources, organization, administration and management, and wellbeing, among others.11

Guide 03 - Self-assessment of academic programs and higher education institutions

The elements required for the institution to carry out the self -assessment process for the purpose of academic or institutional program accreditation include:

Table 1. General guidance components

GENERAL GUIDANCE COMPONENT DESCRIPTION Leadership and participation The directors of the institution and the academic program must take the lead and promote the participation and commitment of the different stakeholders in the selfassessment activities, to ensure the legitimacy of the process and of the improvement actions derived therefrom. They must also commit to financially support the self-assessment process and the implementation of the quality improvement proposals resulting from this process. Clarity and transparency The institution and the academic programs must have policies in place to explain the purposes and objectives of the self-assessment process to the entire academic community. It is important for there to be clarity and transparency in the execution and development of the self-assessment process, in order to create a climate of trust and security and to provide a critical and responsible view of all the components of the process. Organization and coordination As part of the framework of the internal quality assurance system, it is advisable to define those in charge of planning, directing and coordinating the selfassessment process, reviewing the final report and supporting each academic

the components of the process. Organization and coordination As part of the framework of the internal quality assurance system, it is advisable to define those in charge of planning, directing and coordinating the selfassessment process, reviewing the final report and supporting each academic program or the institution for the purpose of guiding the development of the selfassessment process, drafting the final report, finding solutions and coordinating strategies to support and introduce the changes required to improve quality. Training It is essential that the individuals involved in the self-assessment process for institutional and academic program accreditation purposes, especially those who lead the process, be familiar with the contents of the high quality accreditation model defined in Agreement 02/2020, the "Guidelines and aspects to be assessed of Academic Programs", the "Guidelines and aspects to be assessed of Institutions" and the guidelines and technical documents issued by the National Accreditation Council, as the case may be. Articulation with planning It is essential that the institution and the academic programs use the results of the self-assessment process to develop and implement quality improvement plans and projects, which are incorporated into institutional planning and are duly articulated with the internal quality assurance system. Information quality The development of the self-assessment process requires sufficient, reliable, valid, transparent and relevant information to issue an opinion regarding compliance with the characteristics and to make decisions on quality improvement.

For the sole purpose of facilitating the self -assessment process, the National Accreditation Council deems it advisable to offer the following suggestions for the consi