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Plan for Assessing Program Effectiveness

The Middle States Commission on Higher Education (MSCHE), through accreditation, requires that member institutions meet rigorous and comprehensive standards, which are addressed in the context of the mission of each institution and within the culture of ethical practices and institutional integrity expected of accredited institutions. An institution is accredited when the educational community has verified that its goals are achieved through self-regulation and peer review.

A process of continuous assessment and improvement is expected as part of that. MSCHE requires that the institution systematically evaluates its educational programs and related programs and makes public how well and in what ways it is accomplishing its purposes.

Responsibility for the Upstate Medical University plan for program effectiveness is a function of the President’s University Executive Committee (UEC) through a new Committee on Institutional Effectiveness (CIE), and is supported by the Office of Accreditation and Compliance. The process includes the following:

  1. Periodic review of all academic programs and departments on a rotating basis through a self-study process
  2. Review by approximately 3-5 member Program Effectiveness Review Team
  3. Presentation to the UEC for review, recommendations and approval
  4. Communication of recommendations by the CIE to academic program or administrative department

Although the content of these reports will vary according to the mission of the program/ department, an Internal Review Self-Study Template will be used to ensure linkage to the university mission, goal-setting, an evaluative process, and a plan for improvement. The process is designed to be formative and promote the effectiveness of planning, resource allocation, institutional renewal processes, and availability of resources.

Committee on Institutional Effectiveness

Membership includes:

  • VP, Academic Affairs
  • VP, Research
  • VP, Operations & Chief of Staff
  • Project & Strategic Planning Administrator
  • CEO, University Hospital
  • Coordinator, Accreditation & Compliance
  • Senior VP, Finance and Administration
  • Senior VP, Strategic Planning
  • Chair, Faculty Council
  • Director, Evaluation, Assessment & Research
  • Director, Accreditation & Compliance

Program Effectiveness Review Teams

Each Program Effectiveness Review Team will consist of approximately 3-5 reviewers. Review team members will be identified based on expertise as well as representation from faculty, administration, and students. The Review Team Chair will be responsible for convening the team, finalizing the report and presenting to UEC.


Each academic program and administrative department is required to complete an assessment and be reviewed at least once every five years. Reviews are conducted on a rotating schedule. Volunteers will be accepted and other programs/departments will be assigned via a lottery or random number assignment. The UEC will review 12-15 academic programs and administrative departments per year (~1 per month).


  • Program/department prepares and submits Internal Review Self-Study Template (8 weeks)
  • Program Effectiveness Review Team members review self-study and develop summary response (4 weeks)
  • Program/department receives summary and submits response (2 weeks)
  • Summary of review presented to Committee on Institutional Effectiveness (CIE) by Review Team Chair, and CIE approves or modifies recommendations (quarterly meeting)
  • UEC gives final approval
  • Program/department receives the review team report and approved recommendations

Summaries of Self-Studies Completed in 2017

Unit/Program Adopt Upstate's
Mission as
Unit's Mission
Reviewed by
Review Team
and CIE
Admissions & Financial Aid X X X
Sponsored Programs & Contracts X X X
Graduate Medical Education X X X
University Police X X X
Payroll X X X
Library X X X
Registrar & Student Information Services X X X
Student Life (Campus Activities, Disability Services, Housing, Judicial Affairs, Multicultural Affairs, Student Support, Student Counseling) X X X
Patient Experience X X X
Research Policies and Guidelines/Research Compliance X X X
Foundation and Alumni organizations X X X
Diversity & Inclusion X X X
Human Resources X X X
Clinical Skills Center and Simulation Center(s) X X X
Neuroscience X X