WF-05 — Accreditation and External Review Readiness

KPI 5.2 is the only KPI in the framework where a classification decision, taken in a spreadsheet by someone with no time, can cost three full points in either direction. Eligible and accredited scores 100. Eligible and unaccredited scores zero. Not eligible has the weight redistributed with no penalty at all. The middle case is the worst outcome available anywhere in Pillar 5, and it is reached by ticking a box carelessly rather than by any failure of quality. This workflow exists principally to make that one decision properly.

1. Purpose

To ensure that the international accreditation eligibility of every IoL programme is classified as a documented, dated, dual-signed decision rather than a spreadsheet default, that every accreditation IoL holds is valid and correctly recorded at the reporting date, and that IoL is permanently ready for an external review visit rather than preparing for one, so that the evidence a CAA reviewer asks for exists before the request is made.

2. Scope

Scope statement. This process manages external accreditation and review from the annual assessment of international accreditation eligibility, through the pursuit, maintenance, renewal and recording of accreditations held, to permanent readiness for CAA and other external review visits.

Applies to. PGDipHPE and MScHPE. Programmatic international accreditation, institutional accreditation as it bears on the programmes, CAA licensure and programme accreditation status, and readiness for any external review visit at which KPI 2.1 is produced.

Does not apply to. The design changes that might make a programme accreditable, which are WF-01. The production of the curriculum map that review readiness depends on, which is WF-02. Assessment repository and blueprinting, which are WF-09. The annual monitoring loop, which is WF-04. This workflow classifies, maintains and prepares; it does not redesign.

Applicable requirements. OBEF guide v11.5 KPI 5.2 and KPI 2.1; the CAA recognised list of international accreditation bodies; CAA Standards for Licensure and Accreditation; HEDB Data Dictionary 2026 definitions for Institute - Academic Programs.xlsx and Institute - Overview.xlsx; the HEDB lookup Inst Accreditation Entities.

The eligibility rule, stated exactly, because everything below depends on it. A programme is eligible for international accreditation if a specialised global programmatic accreditation body exists that accredits programmes of that kind in the language of instruction, and that body is recognised by the CAA. Three conditions, all required: a specialised body, programmatic rather than institutional; accreditation available in the programme's language of instruction; recognition by the CAA. Failing any one of the three makes the programme not eligible.

3. Trigger, boundary and endpoint

4. SIPOC

5. Accountability

Process owner. IoL lead for quality, or the role able to commit IoL to an accreditation process and to sign an eligibility classification jointly with the Programme Director.

Escalation.

6. Process steps

1. Establish the programme's classifying facts. Discipline, award level, and Language of Instruction from WF-01. [CAPTURE] the facts used, so the classification can be re-tested when any of them changes. Serves 5.2.

2. Search for candidate specialised programmatic accreditation bodies. Search actively rather than relying on what is already known. [CAPTURE] the bodies considered and the date of the search. A search that was never documented cannot later be shown to have been reasonable.

3. Test each candidate against the three conditions. For each: is it a specialised global programmatic body accrediting programmes of this kind; does it accredit in the language of instruction; is it recognised by the CAA. The guide names WASC, QAA, EQAR, AACSB, ABET and similar bodies on the CAA recognised list, and institutions may propose others to the Commission for consideration. [CAPTURE] the test result per candidate with reasons. Serves 5.2. Decision point. If a body meets the first two conditions but is not on the CAA recognised list, the option of proposing it to the Commission is open and should be considered explicitly rather than allowed to lapse by default.

4. Classify the programme. Eligible, or not eligible, with a written rationale that names the bodies considered and why each was or was not qualifying. [CAPTURE] the classification, the rationale, the date. Serves 5.2 and feeds Is the program eligible for International Accreditation (Y/N). This is a decision, not a data-entry task. It must never be produced by a spreadsheet default, an inherited value, or a blank cell.

5. Obtain two signatures. The Programme Director and Quality and IQA both sign, dated. [CAPTURE] the signed classification. The charter requires this separation for exactly this decision, because the person who benefits from a favourable classification should not make it alone.

6. Where the programme is eligible, decide whether to pursue accreditation, and record the decision. An eligible and unaccredited programme scores zero. That is a live loss of the full 3 points, and it persists every cycle until it is either accredited or the eligibility position genuinely changes. The decision not to pursue accreditation is legitimate, and it must be taken knowingly by curriculum governance with the point cost stated, not arrived at by inaction.

7. Where accreditation is held, verify validity. [CAPTURE] Name of Int'l Accreditation Agency, Date of current Int'l Accreditation, Int'l Accreditation valid until. Accreditations must be valid, not expired, during the reporting cycle. An expired accreditation is excluded, not carried forward. Serves 5.2.

8. Where a branch-campus inheritance is claimed, evidence it. A parent institution's programme accreditation may be accepted for a branch only where it is demonstrated that the parent's accreditation review also covered the branch. [CAPTURE] the evidence of coverage. [IoL to confirm whether any branch-campus consideration applies to MBRU or to IoL's programmes. The assumption in this document is that it does not.]

9. Set the accreditation attribute set. [CAPTURE] Is the program eligible for International Accreditation (Y/N), Has the program received International Accreditation(Y/N), the agency, the dates, Accredited by CAA, and Language of Instruction. At institution level, populate Overview_Accreditation_Body, Date_international_accreditation and International_accreditation_expiration. Serves 5.2 at both levels.

10. Confirm the KPI 5.2 institutional denominator counts eligible programmes only. Hand this to WF-26 as cross-KPI assertion C8. Using all programmes understates the institutional percentage.

11. Maintain permanent review readiness for KPI 2.1. The review visit is not scheduled around the OBEF cycle, so the only workable posture is continuous. Hold ready, at all times: the curriculum map from WF-02 for each academic year; the assessment repository from WF-09; mark distributions per assessment; student numbers per assessment; and the ability to produce a representative, randomised and reliable sample of marked, graded student assessments spanning a variety of assessment types and, if asked, several years. [CAPTURE] the readiness position, tested rather than assumed.

12. Rehearse the evidence production at least annually. Pick an academic year at random, ask for a stratified sample, and time it. A readiness position that has never been tested is an opinion.

13. Reconcile before every submission. Confirm no null eligibility flag, no expired accreditation claimed, and no eligible-and-unaccredited programme that has not been escalated.

7. OBEF data generated

Capture rule. One thing here cannot be reconstructed after the fact and is worth more than the rest of the table combined: the eligibility rationale as it stood when the classification was made, including which bodies were considered and why each failed. A year later, the classification is a letter in a cell and the reasoning is gone. Under an Appendix B request or a review question, the letter alone is not a defence, and reconstructing the reasoning after the fact looks exactly like inventing it.

Reproducibility test. A second analyst can read the accreditation attribute set and the certificates without asking anyone. They cannot reproduce or check the eligibility classification unless the rationale register exists, because eligibility is a judgement about the state of the world rather than a value in a system. On the assumption that no such register currently exists at IoL [IoL to confirm], that is the capture defect this workflow closes, and it is the one that decides between 100, zero and redistribution.

8. Max-score design

The asymmetry, drawn out, because it is the whole design problem. Three outcomes, and their expected values are not symmetric:

What this workflow must do to reach the target.

1. Classify eligibility actively, annually, in writing, with two signatures, for every programme.
2. Never leave Is the program eligible for International Accreditation (Y/N) null. Nulls default badly.
3. Where a programme is eligible, force an explicit governance decision on whether to pursue accreditation, with the 3-point cost of inaction stated.
4. Monitor validity dates and never claim an expired accreditation.
5. Confirm the institutional denominator counts eligible programmes only, as assertion C8.
6. Hold permanent, tested review readiness for KPI 2.1 rather than preparing when a visit is announced.

[REDESIGN] actions.

The sequencing point. R1 is worth up to 3 points, takes about a month, requires no curriculum change and no external approval, and is currently unresolved. There is no cheaper significant action anywhere in the pilot. It should not wait for anything.

9. Indirect strategy where data cannot be collected

Category 3 applies: the activity genuinely does not exist. If no specialised global programmatic accreditation body accredits postgraduate health professions education programmes in the language of instruction and is recognised by the CAA, then IoL's programmes are not eligible, the KPI is not counted for them, and its 3% weight is redistributed across the remaining Pillar 5 KPIs. This is what the framework instructs and it carries no penalty. The Score Maximisation Plan models this position in both scenarios and describes it as a deliberately conservative assumption that has not been verified. Verifying it is action R1.

The eligibility asymmetry, and why it deserves an explicit warning. In most of the framework, an inaccurate classification costs roughly what the activity is worth. Here it does not. Consider the two error directions:

• Classifying as eligible a programme that is not. The programme moves from redistribution, which carries no penalty, to a score of zero on 3 points. The error costs the full 3 points and gains nothing. It is the most likely error, because it is what a null, an inherited value or an over-cautious tick produces.
• Classifying as not eligible a programme that is. The programme gains redistribution it is not entitled to. This is outside the boundary and must not be done.

Say the second one plainly, because the temptation is structurally obvious. Redistribution is financially better than a zero, and the classification is made by IoL, and the evidence for "no recognised body accredits this in this language" is an absence rather than a document. Asserting an ineligibility that is not true, in order to trigger redistribution, is outside the boundary. The charter puts it in the right-hand column of its legitimacy table in as many words: "asserting an eligibility status that is not true in order to trigger redistribution" sits opposite "classifying eligibility and redistribution accurately, with documented reasoning". There is no version of this that is a judgement call. The safeguard is the register at R2: a classification that names the bodies considered and the reason each failed can be checked by anyone, and a classification that names nothing cannot be defended by anyone.

And note that redistribution is reallocation, not free money. As the Score Maximisation Plan demonstrates for KPIs 5.3 and 6.2, weight that redistributes flows to the other KPIs in the pillar and raises their contribution. A programme that could genuinely hold an international accreditation is always better off holding it and scoring 100 than being excluded and having 3% spread across 5.1, 5.3 and 5.4. Redistribution protects against a penalty; it does not manufacture points.

Category 1 also applies, to the KPI 2.1 half of this workflow. The Ministry holds the instrument: external experts score the assessment quality rubric during a CAA review visit, and MBRU cannot compute the number. The lever is the input, and the input is evidence quality and evidence availability. The charter's phrase for the correct posture is worth repeating: be permanently review-ready rather than review-prepared. A visit that is not scheduled around the OBEF cycle cannot be prepared for on notice, which is why step 12 rehearses production rather than assuming it.

A genuine ambiguity in the guide, flagged rather than resolved. The programme-level rule says a programme "or its college" holding a valid international accreditation scores 100. For a programme sitting inside an institute within a university, it is not stated what counts as the college for this purpose, whether an institutional accreditation held at MBRU level can satisfy a programme-level claim, or what degree of coverage the accrediting body's review must have had of the specific programme. The branch-campus rule offers an analogy, since it requires demonstrating that the parent's review actually covered the branch, and the safe reading is to apply the same test: claim an institutional or college accreditation at programme level only where the review demonstrably covered that programme. Record the reading used and put the question to MoHESR.

Boundary check. This workflow must never:

• record a programme as not eligible in order to trigger weight redistribution, where a specialised body recognised by the CAA in fact accredits programmes of that kind in the language of instruction;
• record a programme as eligible without having tested the three conditions, since a careless Yes converts a no-penalty position into a zero;
• leave Is the program eligible for International Accreditation (Y/N) null;
• claim an accreditation that has expired or that expires before the end of the reporting cycle;
• inherit a parent institution's accreditation for a branch, or an institutional accreditation for a programme, without evidence that the review actually covered it;
• count all programmes in the KPI 5.2 institutional denominator when the guide specifies eligible programmes only;
• allow a single person to sign the eligibility classification;
• assert review readiness that has never been rehearsed.

10. Service standards

11. Records and evidence

Appendix B readiness. Appendix B's requirement for KPI 5.2 is a complete list of records or certificates issued by international accreditation bodies, which IoL could produce within 15 working days for anything it holds. The record it could not produce today is the eligibility rationale, because on the stated assumption none exists. That matters more than the certificates: a certificate proves an accreditation, but only the rationale explains why a programme claiming not to be eligible is not eligible, and that is precisely the claim a reviewer would probe. For KPI 2.1 there is no 15 working day window at all, which is why section 10 sets a two working day standard and step 12 tests it.

12. Risks and controls

13. Performance measures

The last measure is the one that matters. A classification nobody can check is a classification nobody can defend, and this KPI is decided entirely by a classification.

14. Change control