Accreditation Guidelines

Uniform Criteria /Guidelines for Accreditation of Training Institutions

BASIS: The College recognizes that the training of specialist requires

1. Qualified and experienced personnel

2. Appropriate infrastructure

3. A well-structured training programme that recognizes modern trends of training and assessments

4. Opportunities and evidence of acquisition of skills

5. Access to up-to-date information

6. Regular feedback and evaluation from trainers and trainees

PHILOSOPHY:   The process must be:-

Fair – Done when the institution is ready
Transparent – What is being assessed and persons assessing is known to all
Objective – Minimal bias in the choice of the accreditors – usually not from the institution of affiliates
Instructive – Feedback given to heads of Institutions
Monitored – Reaccreditation done after a clearly defined period – 5 years (Full), 2 years (Partial)



1..Qualified personnel

The basic qualification for training is the Fellowship of College (by examination or election but not honorary). The individual must have had at least 5 years’ experience working in a training institution and must be financially up-to-date. It is also expedient that departments in Institutions should have a good mix of the College training in the country so that trainees will have the maximum benefits of current rules and regulations governing their training. Weighting should be 15% of total accreditation score

2. Appropriate Infrastructure

This is a major pillar without which training cannot take place. What is appropriate will be defined by Faculties. But facilities must be well constructed and maintained with the basic amenities

  1. Light
  2. Water
  3. Waste disposal

Available and with adequate backup. These includes

  1. Wards
  2. Out patients clinic
  3. Laboratories
  4. Theaters
  5. Radiological suites, etc

The weighting shall be a minimum of 10% of total accreditation scores. This can be sub-divided into core infrastructure (5%) and support infrastructure (5%)

3. Equipment

Equipment is an essential component in the acquisition of skills and competence. The minimum equipment needs will be determined by Faculties and the procedure/log book will be necessary in assessing this component. The weighting shall be a minimum of 20% of total accreditation score.

4. Structured training programme:

The College has approved curricula and required competencies that trainees are expected to acquire. It is expected that institutions have a well-publicized (every trainee should have it in writing) structured programme which faithfully implemented and evaluated by a departmental residency committee. This programme must be seen by the accreditation team. Weighting should be 15% of total accreditation score.

5. Opportunities/ Evidence of skill acquisition

In recognition that our profession is an apprenticeship, all trainees must be provided with the opportunities of acquiring the necessary skills to be competent as a specialist. Records of such must be seen. This includes a procedure registrar, theater list and log book. Weighting should be 15% of total accreditation score.


6. Access to new information

This is a crucial element in making our trainees lifelong learners. It is therefore expected that there should be institutional support for trainees to attended updates, revisions, conference and seminars. It is also expedient that trainees acquire the skills at making presentation at departmental meetings and other scientific of professional. The library and the internet are veritable sources of information and it is expected that training institutions have such facilities accessible to the trainees. Evidence of all these must be seen. Weighting should be 15% of total accreditation score

7. Regular feedback and evaluation:

Evaluation is an important aspect of training. It is recognize that assessment can be formative /continues or summative. The College traditionally have carried out summative examinations at the end of each part.  However, training requires regular feedback from trainers to trainees and vice versa. Mentorship builds on the concept of  regular evaluation, feedback, appropriate guidance and counseling of trainees. A good training programme must have these inbuilt and faithfully carried out. Weighting should be 10% of total accreditation score.

Total score is 100% or 100 points

8. Table of Requirement and Grading

No Requirement Inadequate Partially Adequate Full Adequate Total
1. Qualified and experienced personnel (15 points)
a.  Prescribed number (full time/Part    time
b. prescribed trainers: trainees ratio
c. support personnel
2. Appropriate infrastructure  (10 points)
a.  basic:  water, light, sewage etc
b.  core departments presents
c. support departments presents
3. Equipment  (20  points)
a. core equipment
b. support equipment
4. Well-structured training programme  (15 points)
a. seen by all
b. content (lectures, tutorial , bedside sessions )
5. Opportunities/ Evidence of skill acquisition (15 point)
a.    Procedure Registrar
b.    Theater List
c.     Log Book
6. Access to new information(15 point)
a. library
b. Internet
7. Regular feedback and evaluation(10 point)

8. Effectiveness/function/role of visiting Consultants

  • A visiting Consultant should have a minimum of 5 years post Fellowship experience
  • No training should take place in any institution without permanent consultants on ground
  • There must be documented evidence of activities of a visiting Consultant that residents are being supervised by him/her.
  • For the purpose of accreditation the full time equivalent should be as follows:

           2 visiting Consultants to 1 Full time Consultant.

9. Period of Accreditation

  • Partial accreditation should last for 2 years. Within the period of the Partial accreditation, one monitoring visit should be made to the institution.
  • Full accreditation should last for 5 years. Within the period of the Full accreditation, two monitoring visits should be made to the institution.

10. Effective Date of Accreditation

The effective date for existing accreditation should be with effect from the date of visitation, irrespective of the time the Senate approves the report.

The effective date for new accreditation should be from the date of Senate approval.

11. Trainers/trainee ratio

The ratio of Residents to consultants should be minimum of 3:1 or Maximum 4:1. That is, One (1) Senior Registrar and Two (2) Registrars OR Two (2) Senior Registrars and Two (2) Registrars to one Consultant.

12.  The number of Consultants is not the sole determinant for accreditation status, either as partial or full.

Every other criteria are taken into account to arrive at the verdict of either Partial or Full accreditation.

13.  For any re-accreditation visit, the report of the previous accreditation visit should be made available to the current nominated panel member, to enable them to compare notes and ensure that progress is being made.