CNA - Guide 04 - 2021

Ministry of National Education Republic of Colombia

GUIDE 04

FOLLOW-UP AND ASSESSMENT OF

THE IMPROVEMENT PLANS 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

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

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

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 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

1. INTRODUCTION ....................................................................................................................................................................... 6

2. OBJECTIVE OF FOLLOW-UP AND ASSESSMENT OF IMPROVEMENT PLANS FOR ACADEMIC INSTITUTIONS AND PROGRAMS ....................................................................................................................................................... 8

3. GENERAL GUIDELINES FOR THE IMPROVEMENT PLAN FOLLOW-UP AND ASSESSMENT PROCESS ........................ 10

4. PROCESS OF IMPROVEMENT PLAN FOLLOW-UP AND ASSESSMENT ........................................................................... 12 4.1 Follow-up and assessment timelines and planning ........................................................................................................ 125

Guide 04 - Follow-up and assessment of the improvement plans 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 Hi gher Education Quality Assurance System

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 Hi gher 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, 2020 of the National Higher E ducation 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 provi ded by leading national and international organizations 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 Spanish 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 purposes of 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 procedures in their different stages and enable their implementation by institutions within their communities and provide them with elements for the preparation 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:

implementation by institutions within their communities and provide them with elements for the preparation 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 timetables. • 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, "Follow -up and assessment of improvement plans of academic programs and higher education institutions", from the perspective of quality assurance, addresses the National Accreditation Council's decision to include the follow-up and assessment stages of improvement plans in the high quality accreditation model as part of the process for the renewal of accreditation, which, until this update of the model, was an assessment carried out at the end of the accreditation period, which did not allow the National Accreditation Council to assess the institutional commitment to the sustainability of strengths, or the progress made in structuring plans or projects that would account for the recommendations that were part of the administrative act by which accreditation or renewal was previously granted.

The inclusion of the follow -up and assessment of improvement plans also addresses the reflection on quality assurance systems in other countries, and to international trends in relation to accreditation processes.

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 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

1. INTRODUCTION

This guide details the activities to be carried out in the framework of the follow-up and assessment of improvement plans and is

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

1. INTRODUCTION

This guide details the activities to be carried out in the framework of the follow-up and assessment of improvement plans and is aimed at the institutions, as well as to the academic programs that have received high quality accreditation for any term (6, 8 or 10 years) and is part of the National Accreditation Council's function to promote the culture of self-assessment and continuous improvement, as a permanent task of the country's institutions and as an integral part of the high quality accreditation process.

A high quality institution is recognized for its capacity to plan its development and self-assess in a systematic and permanent manner, generating plans that address opportunities for improvement resulting from self-assessment processes and impact institutional decisions at all levels and areas of influence, in the development of institutional autonomy. To this end, it must have an internal quality assurance system in place, which has undergone a process of maturation and improvement as a result of the self-assessment and self-regulation processes. In this sense, the high quality of Institutions assumes that they have consolidated aspects such as [1]1:

• Development and appropriation of a solid culture of self-assessment and self-regulation aimed at continuous improvement, supported by an internal system of quality assurance to demonstrate the achievements and ongoing development of training, academic, teaching, scientific, cultural and extension activities. • Demonstration of the consistency between the declared objectives and the actions carried out to fulfill them, as discussed in their development plans or the programs serving as such, and in budget projection. • Effective articulation between administrative and academic processes, that highlights the institutional effort to ensure an efficient and effective mechanism to support the institutional mission. • Mechanisms for assessing and follow-up the Institution's administrative performance that show continuous improvement and actions that display institutional effectiveness. • Sufficient financial resources to ensure the adequate fulfillment of mission and supporting functions, both in investment and in operation in the short, medium and long term.

• Mechanisms for assessing and follow-up the Institution's administrative performance that show continuous improvement and actions that display institutional effectiveness. • Sufficient financial resources to ensure the adequate fulfillment of mission and supporting functions, both in investment and in operation in the short, medium and long term. • Transparency demonstrated in the promotion of the services offered by the Institutions in the performance of their educational, academic, teaching, scientific, cultural and extension activities.

In turn, a high quality institution is recognized when it demonstrates that it carries out periodic accountability mechanisms to all its stakeholders and the academic community, through reflective, structured and documented processes, which allow an objective analysis of the commitments [2]2 and value propositions of the institutions and/or of the academic programs as well as the degree and manner in which they have been effectively fulfilled.

In terms of an academic program, high quality, from the accreditation perspective, is recognized by considering benchmarks on which it guides its action and involves highly demanding and complex challenges, recognizing the elements that constitute its identity, its mission, type and legal nature, as well as the level of education and the modality of the academic program. The high quality of an academic program involves considering the following aspects, among others [3]3:

• Response to the institution's internal quality assurance system, which demonstrates achievements in academic aspects and learning outcomes, interaction in the national and international environment, contributions in research, innovation, technological development and creation, associated with the academic program in accordance with the level of education thereof. • Alignment with a strong culture of institutional self-regulation and self-assessment aimed at continuous improvement, appropriated by the academic community with the participation of students, professors and graduates. • Contribution to the development of institutional good governance policies that ensure the stability of the academic program, and the generation of effective management systems that ensure fulfillment of the rights and duties of individuals and social accountability. • Capacity to impact society and, in particular, the public and private business sectors, and all other sectors that need to be considered in order to establish meaningful long-term relationships with the environment, through research and social outreach activities that show measurable results.

accountability. • Capacity to impact society and, in particular, the public and private business sectors, and all other sectors that need to be considered in order to establish meaningful long-term relationships with the environment, through research and social outreach activities that show measurable results.

[1] Subsection a) of Article 18 of CESU Agreement 02/2020. [2] Article 20 of CESU Agreement 02/2020. [3] Subsection a) of Article 15 of CESU Agreement 02/2020.7

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

OBJECTIVE OF FOLLOW-UP

AND ASSESSMENT OF

IMPROVEMENT PLANS FOR

ACADEMIC INSTITUTIONS

AND PROGRAMS8

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

2. OBJECTIVE OF FOLLOW-UP AND ASSESSMENT

OF IMPROVEMENT PLANS FOR ACADEMIC

INSTITUTIONS AND PROGRAMS

In order to demonstrate the institutional commitment to continuous improvement, the National Accreditation Council will carry out a follow -up and assessment of the improvement plans established by the institutions and academic programs as a result of the high quality accreditation process. The assessment shall be carried out midway through the accreditation period.

To this end, the institutions and academic programs are expected to have a culture of continuous improvement, to further strengthen the social and academic role of higher education, in order to achieve high levels of quality and maintain high quality accreditation based on the strength of their internal quality assurance systems.

The follow-up and assessment carried out by the National Accreditation Council has the following objectives:

a) Demonstrate both the progress and the soundness of the planning and management that support its execution. b) Describe how the improvement plans identified have been developed to involve the recommendations of

The follow-up and assessment carried out by the National Accreditation Council has the following objectives:

a) Demonstrate both the progress and the soundness of the planning and management that support its execution. b) Describe how the improvement plans identified have been developed to involve the recommendations of the most recent accreditation process and the innovative capacity demonstrated by the academic program or institution. c) Account for significant changes in continuous improvement with regard to the term of accreditation.

In addition, and as established in Article 47 of CESU Agreement 02/2020, in order to support the continuous improvement process, institutions may ask the National Accreditation Council to carry out follow-up and assessment visits [4]4 of the improvement plans of their academic or institutional programs.

4 Institutions may voluntarily request follow-up visits (Article 46 of Agreement 02/2020), whose purpose is for the institution to receive guidance on the high quality accreditation model, the culture of self-assessment and internal quality assurance systems.9

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

GENERAL GUIDELINES FOR

THE IMPROVEMENT PLAN

FOLLOW-UP AND

ASSESSMENT PROCESS10

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

3. GENERAL GUIDELINES FOR THE IMPROVEMENT

PLAN FOLLOW-UP AND ASSESSMENT PROCESS

The improvement plan refers to a set of systematic actions defined by the institution for the permanent improvement of management and quality assurance processes. It is based on the improvement actions identified in the comprehensive assessment carried out by the National Accreditation Council and those derived from the permanent self-assessment processes carried out during that period.

The follow-up and assessment of the improvement plans by the National Accreditation Council is understood as the

of management and quality assurance processes. It is based on the improvement actions identified in the comprehensive assessment carried out by the National Accreditation Council and those derived from the permanent self-assessment processes carried out during that period.

The follow-up and assessment of the improvement plans by the National Accreditation Council is understood as the verification of the progress and soundness achieved by the academic program or institution in order to strengthen the culture of self-assessment and continuous improvement. They also contribute to the development of institutional strategic plans and associated financial management processes to ensure their execution in line with the objectives and expected impacts, the way in which the public education service is provided, as well as the achievements attained and the impacts created.

The aspects to be followed up and assessed are as follows:

Improvement plan progress report • This report must include the commitments, projects and activities carried out to consolidate its strengths and the actions being taken or planned to be taken in the short, medium and long term to develop its opportunities for improvement. Projects must include activities, management indicators and goals for monitoring their development, timetable, responsible parties and resources for their implementation. Institutional planning • Institutional planning must be articulated with the improvement plans of each of the programs. This report includes the progress made in the consolidation of the internal quality assurance system and how this system supports the projects and actions defined to address the recommendations made by the National Accreditation Council in the most recent accreditation process. Continuous improvement • Continuous improvement can be described as addressing quality in a continuous, structured and systematic manner in terms of its maintenance, improvement and sustainability. High quality must strive for continuous improvem ent and sustainability over time, supported by internal quality assurance systems that ensure compliance and demonstrate their commitment to the culture of high quality.11

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

quality.11

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

PROCESS OF IMPROVEMENT

PLAN FOLLOW-UP AND

ASSESSMENT12

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

4. PROCESS OF IMPROVEMENT PLAN

FOLLOW-UP AND ASSESSMENT

The organization and planning of the improvement plan follow -up and assessment process allow the assessment to be carried out within the timelines referred to in this guide. CESU Agreem ent 02/2020 establishes that the institution must report the progress of the improvement plan midway through the accreditation period, both for academic and institutional programs.

4.1 Follow-up and assessment timelines and planning

As part of the commitment of the institution or academic program, upon being granted the high quality accreditation, it must provide the National Accreditation Council with the consolidated timetable of the improvement plan established by the institution to address the r ecommendations resulting from the self -assessment, the external assessment and those included in the administrative act by which the accreditation was granted or renewed, issued by the Ministry of National Education. The improvement plan must be duly approved by the competent area of the institution and submitted to the National Accreditation Council within six (6) months following the notification of the administrative act issued by the Ministry of National Education.

Subsequently, no later than midway through the term of the institutional or academic program accreditation, following the execution of the administrative act that recognizes the high quality accreditation, a report on the progress made in the improvement plan must be submitted to the National Accreditation Council, through the Higher Education Quality Assurance System (SACES -CNA, for the Spanish original) or its equivalent, accompanied by a communication from the Institution's Registered Agent. The National Accreditation Council shall analyze and reflect

progress made in the improvement plan must be submitted to the National Accreditation Council, through the Higher Education Quality Assurance System (SACES -CNA, for the Spanish original) or its equivalent, accompanied by a communication from the Institution's Registered Agent. The National Accreditation Council shall analyze and reflect on the different aspects of the improvement plan, its relevance, achievements and results.

In the event of adjustments to the commitments of the improvement plan initially formulated, the institution must provide the rationale and objective evidence to justify the changes implemented. If significant differences are found in the commitments and goals set forth in both the progress report of the improvement plan and the improvement plan initially submitted, the National Accreditation Council may schedule a follow -up and assessment visit to verify and learn the details of the actions carried out, in order to determine, objectively, whether the plan has the necessary conditions for its proper development.

In the event that there is no s ignificant progress in the improvement plan, the report issued by the National Accreditation Council shall include recommendations in order for them to make adjustments to the plan or its implementation process, bearing in mind that the ultimate goal is to strengthen the continuous improvement process in terms of quality.

The follow-up of the improvement plans is an additional guarantee to advance in the accreditation renewal process and, therefore, it is recommended that the self -assessment report for ren ewal report on the progress of the improvement plan.

It is also possible for the institutions, on a voluntary basis, to ask the National Accreditation Council for follow -up and assessment visits of their improvement plans as a mechanism to support their self-assessment and continuous improvement processes.

The follow-up and assessment of the improvement plans shall be carried out in the following phases:13

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

a) Presentation of the improvement plan progress report

Midway through the term of the accreditation granted to the institution or academic program, the institution must submit a document demonstrating the progress made in the improvement plan, in order to ensure continuous

academic programs and higher education institutions

a) Presentation of the improvement plan progress report

Midway through the term of the accreditation granted to the institution or academic program, the institution must submit a document demonstrating the progress made in the improvement plan, in order to ensure continuous improvement and sustainability over time of high quality, supported by its internal quality assurance systems, which must contain at least the following information:

1. Data identifying the program or institution such as: • SNIES Code of the institution • Creation data. Number and date of the regulations and issuing area • Name of program, modality(ies) and place(s) of development • SNIES Code of the program • Degree awarded • Number of credits • Modality • Level of Education • Administrative act by which high quality accreditation was granted or renewed. • Administrative act by which qualification certification was granted or renewed. • Administrative acts authorizing modifications to the program, subsequent to the date on which high quality accreditation was granted or renewed, as the case may be. • Report of the modifications to the quality conditions, reported to the Ministry of National Education.

2. An executive summary that: • Lists the main recommendations in the previous administrative act of accreditation provided and the approach to improvement by the institution, giving an account of the mechanisms, achievements, actors and resources involved. • Reports the challenges for the implementation of these changes (faced or expected). • Lists the expected effects and results of these changes in the short, medium and long term. • Indicates how this process has pr omoted the institution's reflection on its activities and the improvement of its substantive functions. • Lists the commitments for improvement resulting from the self-assessment and external assessment processes.

3. Description of the actions of the improvement plan Actions of the improvement plan that the institution has implemented in accordance with the recommendations made in the corresponding administrative act of accreditation. This description must provide the following, with their respective analyses: • Compliance indicators, in relation to objectives and expected impacts. • Achievements. • Actions taken up to the cut-off date of the report.

made in the corresponding administrative act of accreditation. This description must provide the following, with their respective analyses: • Compliance indicators, in relation to objectives and expected impacts. • Achievements. • Actions taken up to the cut-off date of the report.

4. Characterization of associated projects

• Objectives • Goals • Actions - Activities • Resources (human, physical and financial, among others)
• Timetable

5. Description and line of reasoning of performance levels • The factors and characteristics that have changed significantly with respect to the previous accreditation process and the effects, achievements and results expected from these changes in the short, medium and long term.

6. Annexes • Documents or information that provide evidence of the progress achieved.14

Guide 04 - Follow-up and assessment of the improvement plans of academic programs and higher education institutions

b) Verification of the information provided

Once the request has been filed by the institution, the Technical Secretariat of the National Accreditation Council will be responsible for reviewing the completeness thereof, within ten (10) business days, to confirm that the structure defined for the report has been fully discussed.

If the documentation submitted is incomplete or the requirements are not fully complied with, the institution shall be notified within five (5) business days, so that it can be corrected within a period of no more than thirty (30) calendar days.

c) Follow-up and Assessment of the Progress of the Improvement Plan

Once it has been verified that the request is complete, a council member shall be appointed to serve as speaker and the request shall be scheduled for consideration at the following meeting of the General Accreditation Chamber. In accordance with the previous study carried out and the report submitted by the assigned council member, it will be determined whether the information is sufficient to demonstrate that the institution or academic program is making structural and consistent progress in t he consolidat